Overdistraction: a hazard of skull traction in the management of acute injuries of the cervical spine

Abstract

In acute cervical spine trauma, skull traction is used to reduce a dislocation or fracture dislocation, to immobilize an unstable lesion until definitive treatment (operative or conservative) is possible or, more rarely, as a definitive treatment until healing occurs. This method may be dangerous when an unstable lesion is accidentally overdistracted. A few cases have been reported in the literature, some with neurological complications. We report five cases in which overdistraction was seen. Two hangman's fractures were overdistracted. One of the two patients developed a Cheyne-Stokes breathing pattern during traction which resolved after the weight was reduced. Furthermore, two hyperextension/distraction injuries (C4/5 and C6/7) and one bilateral C5/6 fracture dislocation were overdistracted without neurological deterioration. Occipitocervical dislocations, fractures of the odontoid process, hangman's fractures, hyperextension/distraction injuries and bilateral dislocations or fracture dislocations may present disruption of both the anterior and posterior elements. Therefore, these injuries are specially vulnerable to overdistraction when skull traction is used. To prevent accidental overdistraction during skull traction, we recommend the use of less weight than is generally proposed in the literature. To reduce a dislocation, we start traction weight at 2 kg and slowly increase it under continuous neurological and radiological monitoring until reduction is completed. Traction of 5-7 kg is usually sufficient; however, heavier traction may occasionally be necessary. After reduction is completed, traction is reduced to 2 kg. This weight is sufficient to immobilize a lesion until definitive treatment is possible. Inadvertent rotation may be prevented by placing sandbags on both sides of the head.