Cranioskeletal Traction for the Management of Trauma to the Cervical Spine

h1 class=”calibre8″>5 Cranioskeletal Traction for the Management of Trauma to the Cervical Spine

Robert F. Heary, Raghav Gupta, and Sanford E. Emery

Abstract

Cranioskeletal traction is a treatment modality by which traumatic cervical fractures or dislocations can be reduced allowing reconstitution of the normal cervical spine alignment. In doing so, the neural elements are freed of any ongoing compression from displaced vertebral or disc material. This method was reportedly first used by the Greeks in the 4th century B.C. for the management of thoracic dislocations. Multiple devices have since been invented which can be used to apply traction to the cervical spine; the two most commonly utilized devices are the Gardner–Wells tongs and the halo apparatus. In the present chapter, we consider the primary indications for use of these two devices. We further describe how these devices are applied and the common complications encountered in the clinical setting when using either of these devices. Finally, we summarize data from previous studies delineating the clinical outcomes in patients who underwent closed reduction and/or cervical spine stabilization with either of these two devices.

Keywords: cranioskeletal traction, Gardner–Wells tongs, halo fixation, cervical spine trauma, indications, clinical outcomes

5.1 Introduction and Origins of Cervical Traction

Cranioskeletal traction is a treatment modality that can be used for the reduction and stabilization of cervical spine fractures or dislocations. It may also be used for immobilization of the cervical spine following trauma. When used alone, or in conjunction with surgery, it promotes normal spinal cord alignment, decompression of the nerves and spinal cord, protection of soft tissues, and bone healing. The initial use of skeletal traction for the treatment of spinal fractures has been attributed to Hippocrates and the Greeks in the 4th century B.C., though the use was limited to thoracic dislocations at that time. ¹ In the mid-17th century, toward the end of the Renaissance Period, Fabricius Hildanus developed the first device specifically designed to reduce cervical spine fracture-dislocations, though it was not widely adopted. The device consisted of forceps which were spread apart and affixed to the back of the neck. A needle was threaded in between its ends and inserted below the spinous process. Traction was then placed using the forceps. ¹^,²

It was not until the early 20th century, however, that the importance of treating cervical spinal cord injuries (SCIs) became apparent. Citing the increasing number of automobile accidents and hyperflexion injuries, Alfred Taylor outlined a method by which skin traction could be used to stabilize the cervical spine. This became known as halter traction. It utilized the mandible and inion for support and was used successfully in the management of pediatric atlantoaxial rotatory subluxations and cervical radiculopathy in adult patients. ³^,⁴^,⁵ However, only limited force could be applied using this technique and several complications could result from its use including temporomandibular dysfunction and pressure ulcers. Its use was also contraindicated in patients with mandibular fractures. As a result, its role in the long-term reduction of cervical spine injuries has since been limited. ⁶

The largest increase in the number of cervical skeletal traction devices occurred during the period immediately preceding World War II. ¹ In 1933, W.G. Crutchfield reported the use of modified Edmonton extension tongs (later termed Crutchfield tongs), which could be inserted into the skull above both ears, for the reduction of a cervical fracture dislocation. ¹^,⁶ Today, Gardner–Wells tongs, which were first described in the medical literature in 1973, are the most frequently used iteration of the cranial tong design (▶ Fig. 5.1a). These allow for application of greater traction forces compared to previous designs and contain a C-shaped bow that is affixed to the skull through two pins. ⁷^,⁸ The typical fixation point is 2 cm above the superior aspect of the pinna of the ear in line with the external auditory meatus. Traction can be gradually maintained through the addition of weights attached to a rope and pulley system which is attached to the bow.

Fig. 5.1 A 33-year-old woman fell down stairs on her birthday and was brought emergently to the emergency room. She had neck pain, an inability to move her lower extremities, and weakness and numbness in her hands. A detailed neurological assessment confirmed an American Spinal Injury Association A spinal cord injury at the C7 level. Plain films were normal to the C6 level and C7 was not able to be visualized. A STAT computed tomography (CT) scan was obtained. (a) CT scan sagittal reconstructions—Bilateral jumped facets with the subluxation just short of completely burying the facets (partially perched). (b) Patient was taken immediately to Radiology suite and placed in traction. No reduction was achieved at 70 lb. At 90 lb, reduction occurred with a palpable “clunk.” Immediately, the weights were reduced to 20 lb and alignment was maintained. (c) Patient was taken from Radiology suite directly to the operating room for an anterior cervical discectomy and fusion (ACDF) at C6–C7. This surgery was performed in less than 1 hour from when the fall occurred. Six-month postoperative images show solid fusion with bridging trabecular bone and no motion between the spinous processes on flexion/extension views. The patient regained motor and sensory functions in the initial 48 hours following surgery. At her 6-month evaluation, she had only numbness in the left C7 dermatome. The rationale for going immediately to traction was the complete injury and the perceived need to reduce the subluxation as soon as possible. In this setting, our opinion was that magnetic resonance imaging would delay the treatment and could lessen the chance of a neurological recovery.

Similarly, Perry and Nickel, in 1959, reported using a “halo skeletal apparatus” for the management of poliomyelitis-induced cervical spine instability. ⁹ The cranial halo consists of a metal ring that is anchored to the skull using a four-pin fixation system, utilizing two anterior and two posterior pins secured in the outer table of the cortical bone. For pediatric patients with thinner skulls, six or eight points of fixation at lower insertion torques are utilized to secure the halo to the skull to decrease the risk of penetrating the skull proper. As is the case with Gardner–Wells tongs, weights can also be hung from a rope and pulley system to maintain traction. Alternatively, the halo ring can be attached to adjustable rods and a fleece-lined vest to allow for rigid fixation/immobilization of the cervical spine and maintenance of cervical spine stability following successful closed reduction. The device is indicated in the outpatient setting where patient mobility is necessary.

5.2 Indications for Use

Cervical traction is indicated in the context of facet dislocations (▶ Fig. 5.2a–c), certain types of occipital condyle and C1 fractures, C2 hangman and odontoid fractures (particularly type II), rotatory atlantoaxial subluxations, lateral mass fractures, subaxial compression fractures, burst fractures, and in patients with kyphotic/scoliotic deformities. ¹⁰^,¹¹^,¹²^,¹³ However, cranioskeletal traction is contraindicated in patients with skull fractures and bone density disorders such as Paget disease. Relative contraindications may include occipitocervical dislocations and subluxations, intracranial pathologies requiring open surgical management (i.e., hemorrhage, neoplasms, etc.), cervical distraction-extension injuries, in cases where there is evidence of disc or bone displaced within the spinal canal (▶ Fig. 5.3), ¹⁰ and in young patients without fused cranial plates (less than 3 years of age). Caution must be exercised when applying traction in patients with decreased consciousness and in patients who are not stable and/or alert, as obtaining neurological assessments both prior to and following the application of weighted traction, may not be possible.

Fig. 5.2 (a) Gardner–Wells tongs in place with traction. (b) Procedural steps:

(1) Gardner–Wells tongs: Place pins through the tongs into scalp and pericranium. Tighten both pins simultaneously until torque indicator on one pin protrudes approximately 1 to 2 mm, indicating adequately tightened screws.

(2) Halo ring: Tighten two diametrically opposed screws simultaneously until “finger tight.” Then tighten the other two screws simultaneously until “finger tight.” At this point, use torque wrench to adequately and safely secure pin tightness to preset maximal torque (8 inch-lb for adults).

Pearls:

• Pay attention to eyes and eyebrows to avoid pinning eyes open or closed.

For children: Use lower final torque for tightening (4–8 inch-lb for children aged 3–10 years, 2–4 inch-lb for children under age 3 years). Use multiple (6–10) pins in order to distribute pressure evenly circumferentially and avoid fracture or excessive skull penetration. Also, use specially supplied pediatric pins with short tips and wide flange, if available. (c) Procedural steps: Select correct vest size for the patient. Connect posterior ring to posterior vest with upright post. Connect anterior ring to anterior vest with upright posts. Connect anterior/posterior halves of vest to each other. Once in place, secure the ring to the posts at each point with torque wrench, maintaining head in correct alignment. Check post-placement X-rays immediately after placement and when upright day 1 and day 3.

Pearls:

• Important note: Every brand and style of halo vest and head ring comes with a detailed set of instructions for application. It is recommended to review these instructions carefully prior to applying the apparatus.

• Incorrect sizing of vest can lead to loss of alignment.

• If posterior vest has not been “preplaced,” patient can be logrolled, or elevated 30 degrees while head held in gentle manual traction.

• Tape wrench to anterior vest for easy access in emergency.

• Watch for pressure ulcers at sites of excess pressure on shoulders, back, and chest.

(Fig. 5.2a reproduced from An HS, Singh K. Synopsis of Spine Surgery. New York, NY: Thieme; 2016. Fig. 5.2b, c reproduced from Ullman JS, Raskin PB. Atlas of Emergency Neurosurgery. New York, NY: Thieme; 2015.)

5.3 Gardner–Wells Tongs

5.3.1 Tong Placement

As had been previously discussed, the Gardner–Wells tongs consist of a stainless steel or graphite-based C-shaped rod attached via two-point pin fixation to the skull (▶ Fig. 5.2a). Once a thorough history has been taken and a detailed neurological assessment (including analysis of sensation and motor responses) of the patient has been performed, he or she is placed in the supine position on a hard surface. The sites where the two pins are to be inserted should be cleaned with an antiseptic solution. A local anesthetic can then be applied to these regions. The pins are positioned 2 cm superior to the pinna in line with the external auditory meatus while being inferior to the equator of the calvarium to prevent slippage. They can be placed anterior to, in line with, or posterior to the external auditory meatus depending on the degree of neck flexion or extension required to achieve spinal cord decompression and cervical alignment. This may be done with the aid of imaging. Once the pins are secured to the outer table of the skull (at which point the unmarked indicator stems protrude approximately 1 mm and indicate that 25 pounds of force have been applied), nuts should be secured lateral to the tong proper to prevent pin detachment (▶ Fig. 5.2b). ¹⁴ The pins should be retightened only once within the first 24 hours. A rope-and-pulley system can be then attached to the center of the rod for the application of weighted traction that is in line with the axial skeleton. Manipulation of the height of the rope-and-pulley system allows for control of the degree of flexion or extension of the cervical spine. Traction is typically applied in 5 to 10 lb increments (over 15- to 20-minute time intervals), between which serial neurological and radiological examinations are performed in order to identify changes in neurological status, and/or any evidence of overdistraction injury. ¹⁵ Much variability exists regarding the ideal weight to use for traction. Some surgeons have used 5 lb per level as the maximum amount of weight applied, while other prior studies have recommended traction weights of 45 to 80 pounds be applied. ¹⁶^,¹⁷^,¹⁸^,¹⁹ Adjuvant muscle relaxants can also be administered to prevent muscle spasm. ²⁰ Once closed reduction is achieved, traction weights can be reduced and the patient can be placed. Typically, upon reduction of a subluxation, a traction weight between 15 and 20 lb is adequate to maintain the reduction.

5.3.2 Clinical Outcomes Following Closed Reduction of the Cervical Spine with Gardner–Wells Tongs

Gardner–Wells tongs are utilized to provide temporary (rather than long-term) craniocervical traction for the restoration of anatomic alignment of the spine and, thereby, achieve spinal cord decompression. ¹⁹ The most common indications for their use include unilateral or bilateral cervical facet joint dislocations (▶ Fig. 5.2 and ▶ Fig. 5.3). ¹⁴ Star et al reported on their use of the Gardner–Wells tongs in 1990 for the closed reduction of cervical facet dislocations in a series of 53 patients. They found that 68% of patients in their cohort had an improvement in neurological status following the application of traction. Based upon a cadaveric analysis, they advised that the tongs could support traction weights of up to 100 lb. ⁸ In 1993, Cotler et al reported on a series of 24 patients with C4–C7 facet joint dislocations who underwent successful reduction via weighted traction of up to 140 lb and subsequent posterior fusion procedures. Of note, these “high-weight” reductions were performed under continuous direct observation by the treatment team who immediately decreased the weight upon achieving reduction. The authors did not note any instances of deterioration in neurological status. ²¹ Gardner–Wells tongs have been used for the application of cranioskeletal traction following isolated cervical facet fractures as well. In a systematic review performed by Kepler et al, the authors documented that 63.8% of patients with cervical facet fractures underwent successful closed reduction with tongs. ²² Successful closed reduction has also been reported in a series of 121 patients with cervical compressive burst fractures, extension injuries, or fractures with subluxations. The average time taken to achieve reduction in these patients was 2.1 hours. ²⁰ Subsequent open surgical reduction was required in two (2.4%) patients.

Fig. 5.3 A 45-year-old woman was assaulted by her boyfriend and she sustained a cervical spine injury. She was brought to the emergency room, awake and coherent, and a neurological examination demonstrated only a right sided C5 nerve deficit. Spinal cord function was preserved. (a) Plain radiograph demonstrated perched facets at the C4–C5 level. (b) A CT scan with sagittal reconstructions showed that the perched facets were actually partially jumped (high-riding facets). (c) A magnetic resonance imaging (MRI) study showed a large herniated disc located behind the C4 vertebral body with a significant C4–C5 subluxation and cord compression but no abnormal cord signal in the spinal cord proper. Abnormal signal traversed the C4–C5 disc space and there was splaying of the spinous processes of C4–C5 with abnormal signal in the interspinous ligaments. (d) One-year postoperative plain film demonstrating successful fusion (C4–C6) following an AP treatment including a C5 corpectomy followed by posterior lateral mass fusions from C4–C6. The patient was taken to an MRI study because her neurological examination demonstrated only minor nerve root symptomatology, and she was wide awake and able to cooperate with serial neurological examinations. Upon noting the large disc herniation at C4–C5, the decision was made to not utilize traction (out of concern for inducing a cord deficit); rather, an immediate operation was performed which decompressed the cord anteriorly and then stabilized posteriorly. At 1 year postoperatively, she was neurologically intact.

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