Spine Traction in Scoliosis            9-23-2020

Question:

My child’s spine doctor says they want to use “traction” on my child’s spine.  This sounds scary.  What is it?  Is this something new?  I have never heard of it.

Answer:

Spine traction to correct spinal deformity is not a new concept; in fact, the first applications were reported in ancient Hindu mythological epics (3500-1800 BC)(Kumar K.:  Spinal deformity and axial traction.  Spine 21:653-656, 1996). Hippocrates (c. 460 BC – 380 BC) could be considered the first to study the spine and spinal deformity, and introduced the terms “scoliosis” and “kyphosis”. He invented the Hippocrates Bench or Board through which the patient’s spine was stretched, while awake, to help with their spinal deformity.  The traction was applied by pulling on the head and neck on one end, and pulling down through the legs on the other end.  A winch would gradually increase the stretch on the spine, then a practitioner could then push on the spine to induce a corrective force to the chest and spine.

 

 In addition, he developed the Hippocrates Ladder which hung the patient upside down or head up.  This traction method used gravity to improve the spine deformity.  Almost 5 centuries later Galen of Pergamon (c. 130-200 AD) furthered the concepts introduced by Hippocrates and advanced the entire field medicine in many ways.

 

Traction for spinal deformity correction fell into disfavor due to the production of spinal cord injury and paraplegia created by the application of excessive distraction to the spine. 

However, over the last three decades, with refinement in the knowledge of spinal anatomy and biomechanics, the concept of controlled axial traction has regained attention with the use of the Harrington outrigger, Cotrel traction, and halo traction. 

In the next three posts I will outline the 3 most commonly-applied techniques of spinal traction currently in use:

1. Preoperative halo-gravity traction
2. Intraoperative halo-femoral traction
3. Internal “dis-traction” technique (Table 1).

The purpose of spine traction in 2020 is to improve spinal deformity safely and then apply a spine cast or spinal implants to further correct the spine deformity and to maintain the improved spine position.  Traction has been shown by multiple authors and centers to be a safe procedure which improves the outcomes of casting or surgery.  We use all three of the above-mentioned traction strategies at Washington University School of Medicine, at our Shriners Hospital for Children and St. Louis Children's Hospital. 

The below table highlights the strengths and weaknesses of each type of traction we will discuss in the upcoming blog posts……..

	Strengths	Weaknesses
Preoperative Halo-gravity	1. Permits gradual application of traction 2. Correction while patient is awake 3. Low risk of neurologic problems	1. Requires weeks or months of continuous, daily treatment 2. Pin site issues 3. Contraindicated for cervical and occipito-cervical instability
Intraoperative Halo-femoral	1. Preoperative hospitalization unnecessary 2. Can easily adjust traction force to achieve desired correction 3. Improves pelvic obliquity 4. Decreases operative time	1. Additional operative time for halo application and traction pin insertion with scarring 2. Contraindicated for cervical or occipito-cervical instability 3. Relative contraindication with kyphotic deformity
Internal Dis-traction	1. No external force application	1. Shorter-term application of traction; less stress relaxation and creep