Development of best practices in the utilization and implementation of pediatric cervical spine traction: a modified Delphi study

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  • 1 Department of Neurological Surgery, Columbia University Medical Center, New York, New York;
  • | 2 Rutgers New Jersey Medical School, Newark, New Jersey;
  • | 3 Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas;
  • | 4 Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee;
  • | 5 Department of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah;
  • | 6 Department of Neurosurgery, University of Washington/Seattle Children's Hospital, Seattle, Washington;
  • | 7 Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut;
  • | 8 Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland;
  • | 9 Department of Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado;
  • | 10 Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana;
  • | 11 Department of Neurosurgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio;
  • | 12 Department of Pediatric Neurosurgery, Children's Wisconsin, Milwaukee, Wisconsin;
  • | 13 Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri;
  • | 14 Division of Pediatric Neurosurgery, Cincinnati Children's Hospital, Cincinnati, Ohio;
  • | 15 Division of Pediatric Neurosurgery, Connecticut Children's Hospital, Hartford, Connecticut;
  • | 16 Department of Pediatric Orthopedic Surgery, Shriners Hospital for Children, Philadelphia, Pennsylvania;
  • | 17 Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina;
  • | 18 Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts;
  • | 19 Department of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida;
  • | 20 Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Alabama, Birmingham; and
  • | 21 Department of Neurosurgery, University of Pennsylvania/Children's Hospital of Philadelphia, Pennsylvania
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OBJECTIVE

Cervical traction in pediatric patients is an uncommon but invaluable technique in the management of cervical trauma and deformity. Despite its utility, little empirical evidence exists to guide its implementation, with most practitioners employing custom or modified adult protocols. Expert-based best practices may improve the care of children undergoing cervical traction. In this study, the authors aimed to build consensus and establish best practices for the use of pediatric cervical traction in order to enhance its utilization, safety, and efficacy.

METHODS

A modified Delphi method was employed to try to identify areas of consensus regarding the utilization and implementation of pediatric cervical spine traction. A literature review of pediatric cervical traction was distributed electronically along with a survey of current practices to a group of 20 board-certified pediatric neurosurgeons and orthopedic surgeons with expertise in the pediatric cervical spine. Sixty statements were then formulated and distributed to the group. The results of the second survey were discussed during an in-person meeting leading to further consensus. Consensus was defined as ≥ 80% agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree).

RESULTS

After the initial round, consensus was achieved with 40 statements regarding the following topics: goals, indications, and contraindications of traction (12), pretraction imaging (6), practical application and initiation of various traction techniques (8), protocols in trauma and deformity patients (8), and management of traction-related complications (6). Following the second round, an additional 9 statements reached consensus related to goals/indications/contraindications of traction (4), related to initiation of traction (4), and related to complication management (1). All participants were willing to incorporate the consensus statements into their practice.

CONCLUSIONS

In an attempt to improve and standardize the use of cervical traction in pediatric patients, the authors have identified 49 best-practice recommendations, which were generated by reaching consensus among a multidisciplinary group of pediatric spine experts using a modified Delphi technique. Further study is required to determine if implementation of these practices can lead to reduced complications and improved outcomes for children.

ABBREVIATIONS

HGT = HGT.

Illustration showing the robotic equipment, with navigation and an electrode placed in the brain, used during robotic thermocoagulative hemispherotomy. The upper right image shows the electrode trajectory in the parasagittal section, and the lower right image shows the area of hemispheric disconnection. Artist: Sandeep Kandregula. See the article by Chandra et al. (pp 688–699).

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