Continuing Education Activity

Cervical traction is a non-invasive procedure used to provide symptomatic relief for a variety of cervical pathologies. Though it can lead to temporary symptomatic relief, there is limited data on its long-term safety and therapeutic efficacy. This activity reviews the indications, contraindications, and techniques involved in performing cervical traction and highlights the role of the interprofessional team in caring for patients who utilize cervical traction.

Objectives:

• Describe the conditions that cervical traction is used for.
• Outline the contraindications to cervical traction.
• Explain how to monitor a patient undergoing cervical traction.
• Explain the importance of a well-coordinated interprofessional team in the care of patients that are considering cervical traction.

Introduction

The practice of spinal traction goes back to the fourth century BC, where Hippocrates first described it as a treatment for kyphosis. It was subsequently implemented in other spinal pathologies including cervical pain and myelopathy. In the 1600s, the Germans employed cervical traction in their medical practice, as an adjunct to open reduction of cervical dislocations, and fractures. In 1929, the Halter device was introduced for the reduction of cervical injuries; then several other devices followed to ensure more efficient traction. To date, there is no accurate description of the mechanism of relief provided by cervical traction. The theory behind its efficiency emphasizes the widening of the intervertebral foramen upon traction, with separation of the facet joint. This will relieve the sustained pressure on the nerve roots, and hence alleviate symptoms of radiculopathy. Other theories suggest that traction allows for cervical muscle relaxation, and is not involved in intervertebral separation.[1][2]

Indications

Cervical traction has been used in a variety of cervical pathologies:

• Cervical disc disease
• Cervical spine fracture
• Facet joint dislocation
• Atlantoaxial subluxation
• Occipitocervical synopsis
• Spondylosis
• Radiculopathy
• Foraminal Stenosis
• Myofascial tightness

Overall, most published studies on cervical traction for spondylosis and myelopathy are of low quality and include a small number of participants. Among the few studies with adequate statistical power, there is no evidence on the long-term benefits of cervical traction, although many articles suggest a definitive temporary relief. Likewise, intermittent traction was not able to achieve a more favorable outcome than its sustained counterpart, despite its theory of increasing blood flow to the spine parenchyma and nerve roots. However, the practice of cervical traction in fractures and facet joint dislocations is important when used along with closed reduction and fixation. In cases of facet joint dislocation, failure of traction suggests the need for surgical intervention. [3][4][5][6]

[7]Moreover, the use of cervical traction for atlantoaxial subluxation is well established in the pediatric population as a second-line treatment. Failure to improve after a trial of soft collar and pain management for two weeks necessitates cervical traction. In cases of no improvement after the third week, surgical management is required. Cervical traction is also a standard of practice in occipitocervical synopsis where symptoms are limited to pain, along with a trial of a cervical collar. If neurological deficits are suspected, surgical evaluation is warranted.

Contraindications

There are no scientific reports that accurately describe the contraindications and relative contraindications for cervical traction. Probable contraindications and/or relative contraindications to cervical or lumbar traction include the following:

• Acute torticollis
• Aortic Aneurysm
• Active peptic ulcer disease
• Diskitis
• Old age
• Osteomyelitis
• Osteoporosis
• Ligamentous instability
• Primary or metastatic tumor
• Spinal cord tumor
• Myelopathy
• Pregnancy
• Severe anxiety
• Untreated hypertension
• Vertebral-basilar artery insufficiency
• Midline herniated nucleus pulposus
• Restrictive lung disease
• Hernia

Preparation

The patient's vital signs should be monitored before and immediately following the application of cervical traction in all high-risk patients, especially in those with high blood pressure or cardiac problems. It is important to obtain a detailed history and perform a systematic physical exam, before cervical traction, to rule out any contraindications.

Technique or Treatment

There are different ways to apply cervical traction to the cervical neck. [8][9][10][11][9]

Manual Cervical Traction

Manual traction is mainly for diagnostic purposes, with the ability to confirm a suspected diagnosis after successful relief of symptoms.

• The head and neck are held in the hands of the practitioner, and then gentle traction of a pulling force is applied.
• Intermittent periods of traction can be applied, holding each position for about 10 seconds.

It also allows the performer to apply controlled pressure on pressure points, which helps alleviate the patient's pain. Ideally, it is done at a 20-degree angle of flexion, but the examiner must explore all angles, including the extension of the neck and chin rotation, with a thorough assessment of each position.

Mechanical Cervical Traction

Mechanical traction includes pinning, with the placement of a Halo device around the head; where anterior pins are placed 1 cm above each of the eyebrows, and two posterior pins are placed on the opposite end of the skull. The addition of pins can be essential if further stabilization is required.

• A harness attaches to the head and neck of the patient while he is laying down on his/her back.
• The harness is itself attached to a machine that applies a traction force, which can be regulated through a control panel.

Other shorter-term traction devices comprise the Gardner-Wells tongs, which constitute two pins, pointing upward (towards the vertex of the head), to be placed below the temporal ridge, bilaterally. In both cases, careful pinning is to be applied with a torque pressure of 2 lb (0.9 kg) to 4 lb (1.8 kg) in the pediatric population, and up to 8 lb (3.6 kg) in adults.

Mechanical traction requires a 0-degree angle pull for C1 and C2 pathologies, and a 20-degree angle flexion for below C2 cases. Moreover, the force applied during pull tension must not exceed 10 lb (4.5 kg) in cases of C1-C2 subluxation, but can otherwise increase up to 45 lb (20.4 kg). Some practices require a gradual increase of the pull tension, while others prefer choosing the lowest weight inciting an effective response.

Over-the-Door Traction

This is a more practical way of applying cervical traction, that is more accessible to outpatient practices.

• Over-the-door traction entails strapping a harness to the head and neck of the patient that is in a seated position.
• The harness is connected to a rope in a pulley system over a door. The force is applied using weights (a sandbar or a waterbag) attached to the other end of the rope.

Furthermore, intermittent traction is another modality where a repeated sequence of rest and traction is applied. It is believed to increase blood flow to the nerve roots and spine parenchyma. One must understand that during the rest phase, tension is not entirely released. As a general rule, intermittent traction is the method of choice for degenerative disc disease and/or joint hypomobility. On the other hand, sustained traction is most often used for neck pain of muscle or soft tissue etiology, and/or disc herniations. Cervical traction can be applied while the patient is supine or seated. The supine position is preferred, allowing for more posterior pressure loading. This will ensure cervical muscle relaxation and transmit less pressure on the temporomandibular joint (TMJ). The sitting position is favored only for patients who cannot lay supine for a prolonged period of time, as in cases of patients suffering from reflux esophagitis.

Complications

Complications are rare, providing that patients are adequately screened for conditions that are contraindicated. Postprocedural increase in peripheral nerve pain and a decrease in central pain, increase in neurological symptoms, or sudden disappearance of central pain are alarming signs of traction-induced spinal cord compromise.

Clinical Significance

Cervical traction is a simple procedure, performed by physical therapists and physicians.  It constitutes several modalities of practice depending on the pathology being treated. The established efficiency of this technique in cervical fractures, facet joint dislocations, and other orthopedic diseases makes it a useful tool for medical practitioners. However, its role in chronic cervical spondylosis is uncertain. For this purpose, the design of randomized controlled trials on adequate population samples, comparing cervical traction to sham traction, would provide the scientific community with information of great importance about the use of cervical traction in spinal cord spondylosis.

Enhancing Healthcare Team Outcomes

The application and education of the patient in regards to cervical traction may be done by EMS, physical therapists, physicians, and orthopedic nurses. While the procedure is simple, it is important that the patient be monitored by the nurse and physical therapist for complications and improvement. The nurse and therapist should coordinate reporting with the treating clinician.

Complications are rare, providing that patients are adequately screened for conditions that are contraindicated. Postprocedural increase in peripheral nerve pain and a decrease in central pain, increase in neurological symptoms, or sudden disappearance of central pain are alarming signs of traction-induced spinal cord compromise.[11] An interprofessional team approach to evaluation and education of patients requiring cervical traction will provide the best outcomes. [Level 5]