Traction and Bracing

The pins are first tightened by hand, then with a torque wrench to 6 to 8 lb to engage the outer table of the skull. The torque should be rechecked within the next 48 hours.

Few problems have been associated with acute halo use, the most significant being pin loosening and pin infection, occurring in up to 25% of instances. This is generally manifested by local pain and discomfort and is helped by careful daily cleaning of the pin sites.

After the halo has been applied, the amount of traction to be used must be determined. A very general guideline is no more than 5 lb of traction per injury level so that 30 to 35 lb may be used for an injury at C6-7. On a practical level, however, for injuries such as bilateral locked facets, up to 80 to 90 lb may be necessary to achieve reduction.

Once traction is instituted, it is important to monitor response by clinical findings and radiographic studies. It is a generally accepted procedure to add cervical traction in increments of 5 to 10 lb every 20 to 30 minutes until reduction is achieved, there is clinical or radiographic evidence of overdistraction, or a maximum weight has been reached. Because there is often significant cervical muscle spasm, it is may be necessary to administer muscle relaxants to aid in realignment.

For certain injuries, especially those with a significant ligamentous disruption, such as atlantoaxial dislocation, any traction may be contraindicated. A specific concern over bilateral facet dislocation is the possibility of an associated traumatic disk herniation, estimated by some to be as high as 25%. Realignment of the spine in such a setting could cause significantly increased spinal cord compression. Although not universally agreed, obtaining an MRI before the application of traction is advisable.

Traction is not used for thoracolumbar spine injuries. Those injuries not requiring internal stabilization are generally successfully treated with a thoracolumbosacral orthosis. For injuries involving the lumbosacral junction, a hip extension added to the orthosis provides increased stability.

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