History

Hippocrates described the use of traction for the reduction of vertebral dislocation more than 2000 years ago,² but the modern era of traction started with the use of a halter device by Taylor in 1929 to reduce a cervical dislocation.³ In 1933, Crutchfield introduced the use of tongs inserted into the skull, and this method forms the basis for the current practice of skeletal traction.⁴ Crutchfield’s tongs were placed near the vertex of the skull and thus were prone to dislodgement if greater than 30 pounds of weight was applied. In 1973 the Gardner-Wells tongs were introduced, which are designed so that pins are placed below the equator of the skull and thus have greater resistance to pull-out.⁵ The halo device, which uses four pins for skull fixation, was described for use in skeletal traction by Nickel et al.⁶

Head Halter Traction

Head halter systems usually consist of two pads, one placed under the chin and one placed under the occiput. The pads should be fitted so that pressure is applied evenly to both pads and a metal spreader connects the pads to a rope to which weight is applied.

Head halter traction is often used as a component of nonsurgical treatment of painful manifestations of cervical spondylosis, including neck pain and radiculopathy. This is usually done on an outpatient basis and often as part of a home program. The patient typically uses up to 10 pounds of weight attached for several sessions per day. The effectiveness of this treatment is uncertain: a systematic review of published series found some evidence to suggest a benefit, but the methodological quality of the studies was felt to be poor.⁷

Head halter traction has been used for the reduction of atlantoaxial rotatory subluxation in pediatric patients. Subach et al. used halter traction to reduce atlantoaxial subluxation in a series of patients ranging in age from 3 to 11 years. They were able to achieve reduction in over 90% of patients; the mean amount of weight used was 4 pounds and the mean length of time necessary to achieve reduction was 4 days.⁸

Skeletal Traction

Skeletal traction involves the attachment of a “clamp” to the bony calvarium, which allows a greater amount of weight to be used to generate the distraction force. The most common use of this type of traction is to stabilize or reduce traumatic deformities such as cervical fractures and dislocations. This type of traction can also be used to correct deformities that have a degenerative, neoplastic, or infectious etiology. Skeletal cervical traction has the benefit of allowing the gradual and regulated realignment of the spinal column while the neurologic status of the patient is closely monitored.

Before traction is applied to the cervical spine, it is important that the patient’s hemodynamic and pulmonary status be stabilized, including the placement of intravascular catheters and intubation if necessary. A baseline neurologic examination should be documented, and a lateral cervical spine radiograph should be obtained.

Gardner-Wells Tongs

The Gardner-Wells tongs consist of a C-shaped rectangular rod with an S-shaped link in the center to which the application rope is applied. At each end of the C that arches over the head are threaded bolts with sharp, pointed tips. The pins should be placed through the outer table of the calvarium but should not penetrate the inner table. On one pin is a spring device that protrudes 1 mm when the appropriate amount of tension is applied to penetrate the outer table of the calvarium (Fig. 186-1).

FIGURE 186-1 Gardner-Wells tongs may be applied without shaving the head. The regions over the ears are thoroughly prepared with a sterilizing solution, and a local anesthetic is instilled into the skin, subcutaneous tissue, and periosteum. Once the device is properly aligned, the screws are tightened until the pressure indicator (inset) appears.

The pins of the tongs are placed below the equator of the calvarium and 2 to 3 cm above the ears. The location of the pins varies, depending on whether traction is desired with the cervical spine in the neutral, flexed, or extended position. A fixation point that is on a line from the tip of the mastoid process to the tip of the pinna results in traction in the neutral orientation. If a site is selected ventral to this point, traction will be applied in extension; conversely, if the site selected is dorsal, the result will be traction with the spine in flexion. Alternatively, the amount of extension or flexion can be changed by altering the height of the pulley, which will alter the angle of the traction line: if the pulley is raised, flexion is usually achieved, and if the pulley is lowered, extension usually results.

Once the site of pin placement has been selected, the area is shaved and skin cleansed with povidone-iodine solution. It is important to anesthetize the skin, subcutaneous tissue, and periosteum by infiltrating with 1% lidocaine since inadequate anesthesia may cause the patient to move, resulting in movement of an unstable cervical spine. The pins are twisted into place at the selected entry point by hand simultaneously by tightening the curled knobs until the spring device pushes out 1 mm. This indicates that 25 pounds of force is applied; tightening beyond this point could lead to penetration of the inner table. At this point the tongs are tilted back and forth to set the pins. Nuts on the threaded pins allow the depth of position to be precisely fixed. Traction can now be applied. Within 12 to 24 hours a slight tightening should be attempted; after this the pins should not be disturbed.

Cranial Halo

Cranial halo traction provides four-point skeletal fixation via a circumferential metal ring. This ring can be attached to a rope and weights much like Gardner-Wells tongs or may be attached through metal uprights to a rigid vest that can be used for stabilization during mobilization. The halo vest has been used for stabilization of fractures or other unstable conditions of the cervical spine. If it is planned that a halo vest or jacket is to be subsequently used for ambulatory stabilization, the use of the halo ring for the initial traction may obviate the need to switch from tongs to a halo ring once the desired degree of reduction has been achieved and the patient is to be mobilized.