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

Nikita G. AlexiadesDepartment of Neurological Surgery, Columbia University Medical Center, New York, New York;

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Belinda ShaoDepartment of Neurological Surgery, Columbia University Medical Center, New York, New York;
Rutgers New Jersey Medical School, Newark, New Jersey;

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Bruno P. BragaDepartment of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas;

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Christopher M. BonfieldDepartment of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee;

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Douglas L. BrockmeyerDepartment of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah;

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Samuel R. BrowdDepartment of Neurosurgery, University of Washington/Seattle Children's Hospital, Seattle, Washington;

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Michael DiLunaDepartment of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut;

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Mari L. GrovesDepartment of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland;

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Todd C. HankinsonDepartment of Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado;

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Andrew JeaDepartment of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana;

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Jeffrey R. LeonardDepartment of Neurosurgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio;

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Sean M. LewDepartment of Pediatric Neurosurgery, Children's Wisconsin, Milwaukee, Wisconsin;

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David D. Limbrick Jr.Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri;

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Francesco T. ManganoDivision of Pediatric Neurosurgery, Cincinnati Children's Hospital, Cincinnati, Ohio;

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Jonathan MartinDivision of Pediatric Neurosurgery, Connecticut Children's Hospital, Hartford, Connecticut;

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Joshua PahysDepartment of Pediatric Orthopedic Surgery, Shriners Hospital for Children, Philadelphia, Pennsylvania;

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Alexander PowersDepartment of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina;

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Mark R. ProctorDepartment of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts;

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Luis RodriguezDepartment of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida;

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Curtis RozzelleDepartment of Neurosurgery, Division of Pediatric Neurosurgery, University of Alabama, Birmingham; and

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Phillip B. StormDepartment of Neurosurgery, University of Pennsylvania/Children's Hospital of Philadelphia, Pennsylvania

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Richard C. E. AndersonDepartment of Neurological Surgery, Columbia University Medical Center, New York, New York;

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Free access

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 .

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.

In Brief

A group of experts conducted a modified Delphi study to identify best practices in pediatric cervical spine traction given the lack of evidence-based guidance in the literature. Consensus was reached on 49 best-practice recommendations spanning the utilization and implementation of traction for pediatric cervical trauma and deformity. These recommendations provide a foundation for clinicians to better incorporate cervical traction into their practices.

Traction is an invaluable tool for the management of both cervical spine trauma and cervical spine deformity. The use of traction to achieve closed reduction, for example, is widely used in traumatic facet dislocations and odontoid fractures.1–4 Furthermore, halo-gravity traction (HGT) has demonstrated benefit in the management of spinal deformity including basilar invagination, irreducible atlantoaxial rotatory subluxation, cervical kyphosis, and os odontoideum.5–9 The overwhelming majority of existing literature that guides clinical practice is based on adult patients; pediatric studies consist primarily of small case series highlighting individual institutional practices.10–13 In addition, there is little to no guidance in the literature regarding the use of traction in very young children to whom standard techniques cannot be generalized.

HGT is frequently employed preoperatively in the management of pediatric spinal deformity to gradually improve spinal alignment prior to definitive fixation.5,14,15 However, there is very little literature specifically investigating the use of HGT for preoperative correction of cervical deformity in a pediatric population.13 Although clinical evidence and anecdotal evidence exist for the use of HGT in a variety of pathologies, there is very little guidance regarding specific indications or contraindications. Furthermore, the age at which HGT is recommended or even technically feasible is not well defined.15–17 Alternative methods of traction, such as a halter device and Gardner-Wells tongs, are even less well studied.18–19 Management of specific traction-related complications, including pin loosening and infection, skull fracture, and intracranial abscess formation, along with focal and general neurological worsening while in traction, have all been addressed in the adult literature, but few recommendations exist to guide practice.5,14,20–22

The paucity of empirical evidence surrounding many of these topics prompted use of the Delphi method to try to build consensus among a multidisciplinary group of experienced pediatric spine surgeons. The Delphi method has been adopted by many medical subspecialties to enable the development of best-practice guidelines and statements in areas where systematic study is prohibitively challenging.15,23–27 The technique brings together a group of experts by first distributing an iterative series of structured anonymous questionnaires based on existing literature and pertinent clinical questions. The anonymous nature of initial rounds removes direct confrontation while still allowing for constructive criticism. The modified technique often culminates in an in-person meeting in which areas near consensus on prior rounds of questioning can be discussed, debated, and modified to achieve consensus. This method has been previously applied to develop best practices to minimize wound complications following complex tethered cord surgery, minimize surgical site infections after pediatric deformity surgery, and optimize responses to intraoperative neuromonitoring changes during spinal surgery.15,23,27 The goal of this study was to use this technique to build consensus and establish best practices for the use of pediatric cervical traction in order to enhance its utilization, safety, and efficacy.

Methods

Focus and Design of the Modified Delphi Study

The focus of this study was to investigate best practices surrounding the use of pediatric cervical traction for both traumatic injuries and the broad spectrum of acquired and congenital cervical spine deformities. A systematic literature review was initially performed to examine the existing evidence supporting the following topics: 1) indications and contraindications of traction; 2) pretraction imaging practices; 3) acceptable age and force ranges for halter, halo, and Gardner-Wells devices; 4) specific traction protocols; 5) management of pin complications; and 6) management of neurological complications. An electronic survey was generated and distributed to participants to assess general practice patterns (described below). Primary survey responses were collected and analyzed, and potential consensus statements were formulated based on initial responses. A second survey was distributed to participants that included these statements. Results of the second survey were collected and statements were modified and revised. A face-to-face meeting was then convened to foster discussion and provide an opportunity to revise statements that reached near consensus (60%–79%). A final document presenting consensus statements was generated.

Participants

Nineteen pediatric neurosurgeons and one pediatric orthopedic surgeon from children's hospitals in North America with experience in managing children with cervical spine disorders (defined as fellowship trained, with a subspecialty interest in the pediatric spine, and a national reputation) were identified and recruited as participants for the study. Individuals were selected based on prior collaboration, clinical experience and volume, prior research into pediatric cervical pathologies, and membership in academic pediatric neurosurgical and spine organizations.

Initial Survey

Using SurveyMonkey (SVMK Inc.), we distributed a 54-item online survey to participating surgeons in October 2018. The survey was segmented into 5 sections with initial questions acquiring background information on the participants, followed by sections detailing goals, indications, and contraindications of traction; pretraction imaging; placement and management of traction; and complication management (Table 1). Participants were initially asked how many years they had been in practice and to estimate how many patients they had placed in cervical traction each year and over the course of their career. Participants were also queried using a 3-point Likert scale (very willing, somewhat willing, not willing) regarding how willing they would be to change their practices based on the results of the current study.

TABLE 1.

Round 1: Electronic survey of current practices

1. Goals of cervical traction include correction of sagittal balance, correction of coronal balance, avoidance or minimization of anterior approaches to the CVJ or subaxial spine, reduction of reducible deformities and/or reduction of traumatic or other dislocations?
2. Traction should be considered for what degree of kyphotic deformity?
3. Traction should be considered for what degree of coronal deformity?
4. In the absence of neurologic symptoms and radiographic malalignment in which traumatic pathologies is traction indicated?
5. In the presence of neurologic symptoms and radiographic malalignment in which traumatic pathologies is traction indicated?
6. Preoperative traction should be considered for what cervical deformities?
7. Any form of traction should be contraindicated in the following scenarios: atlantooccipital dislocation, spinal cord compression requiring immediate decompression, traumatic dislocation injuries.
8. Halo/Gardner-Wells traction should be contraindicated in the following scenarios/pathologies: osteogenesis imperfecta, skeletal dysplasia, skull fractures, open fontanelles.
9. Upright cervical X-rays should be obtained prior to the initiation of traction.
10. If not clinically contraindicated flexion-extension or bending X-rays should be obtained to evaluate for reducibility prior to initiation of traction.
11. MRI should be obtained prior to initiation of traction in deformity patients.
12. MRI should be obtained prior to initiation of traction in neurologically intact trauma patients.
13. MRI should be obtained prior to initiation of traction in trauma patients with neurologic deficits.
14. If there is reason to suspect skull abnormality or hydrocephalus, dedicated skull or cranial imaging should be obtained prior to initiation of traction.
15. A head CT is recommended for children <6 years of age to locate the best pin sites for halo fixation.
16. What is the minimum age for a patient to be placed in halter traction?
17. What is the minimum age for a patient to be placed in halo traction?
18. What is the minimum age for a patient to be placed in Gardner-Wells traction?
19. If placing a halo how many pins do you place for patients between 1–2 years of age?
20. If placing a halo how many pins do you place for patients between 3–5 years of age?
21. If placing a halo how many pins do you place for patients between 6–12 years of age?
22. If placing a halo how many pins do you place for patients greater than 12 years of age?
23. How much torque do you use to tighten pins in children 1–2 years of age?
24. How much torque do you use to tighten pins in children 3–5 years of age?
25. How much torque do you use to tighten pins in children greater than 6 years of age?
26. How frequently do you tighten pins?
27. Do you routinely place a thoracic bump or bolster in very young patients undergoing traction due to head size?
28. Do you routinely give muscle relaxants to patients undergoing traction?
29. What weight do you use when starting initial traction in trauma patients?
30. How do you determine goal traction weight in trauma patients?
31. Is there a maximum goal weight that you routinely employ in traction for traumatic indications?
32. What time interval do you use between addition of weight in traumatic dislocation injuries?
33. How frequently do you obtain imaging during traction for traumatic indications?
34. Once at goal weight in patients undergoing traction for traumatic etiologies do you obtain further cervical imaging?
35. What weight do you use when starting initial traction in deformity patients?
36. How do you determine goal traction weight in deformity patients?
37. Is there a maximum goal weight that you routinely employ in traction for deformity patients?
38. What time interval do you use between addition of weight in deformity patients?
39. How frequently do you obtain imaging during traction for deformity correction?
40. Once at goal weight in patients undergoing traction for deformity correction do you obtain further cervical imaging?
41. What is the maximum amount of time you would leave a deformity patient in traction?
42. Do you leave deformity patients in traction overnight?
43. How frequently do you conduct formal neurologic exams by a physician during traction?
44. Pin site care should consist of the following: cleaning with alcohol, warm saline, betadine, chlorhexidine, hydrogen peroxide and/or application of antibiotic ointment?
45. Pin site care should be performed at what frequency during traction?
46. First line management of pin site infections should include: topical antibiotics, intravenous antibiotics, pin removal, pin exchange and/or termination of traction?
47. Second line management of pin site infections should include: topical antibiotics, intravenous antibiotics, pin removal, pin exchange and/or termination of traction?
48. Neurologic changes should be managed by: removal of most recently added weight, removal of 50% of weight or removal of all weight?
49. Cervical spine X-rays should be obtained in the event of any neurologic change.
50. Cervical spine MRI should be obtained in the event of any neurologic changes.
51. Would you be willing to alter any aspect of your standard practices regarding cervical spine traction as a result of evidence based or consensus driven findings?

CVJ = craniovertebral junction.

Delphi Round 1

Responses from the initial survey were used to generate 60 potential consensus statements (Table 2). Questions covering multiple pathologies or practices were divided into isolated statements. Open-ended questions from the initial survey were adapted and modified into a statement with a response in the form of a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). While the language and structure of statements were altered, the topics covered were unchanged. The survey was electronically distributed in November 2018, and responses were anonymously collected. Responses achieving ≥ 80% agreement (strongly agree and agree) or disagreement (disagree and strongly disagree) were considered to have reached consensus. Responses achieving near consensus (≥ 70%–79%) were the primary focus of discussion at the face-to-face meeting.

TABLE 2.

Round 2: Building consensus for best practices

1. Goals of cervical traction include reduction of sagittal deformity.
2. Goals of cervical traction include avoidance of anterior or posterior approaches to the craniovertebral junction or subaxial spine.
3. Goals of cervical traction include reduction of reducible deformities.
4. Goals of cervical traction include reduction of dislocations.
5. Cervical traction should be considered for the reduction of coronal deformity.
6. Cervical traction should be considered for kyphotic deformities greater than 31 degrees or based on reducibility on flexion-extension radiographs.
7. Cervical traction should be considered for coronal deformities greater than 31 degrees or based on reducibility on lateral bending radiographs.
8. In the absence of neurologic symptoms traction is indicated for atlantoaxial rotary subluxation.
9. In the presence of neurologic symptoms traction is indicated for atlantoaxial rotary subluxation.
10. In the absence of neurologic symptoms traction is indicated for unilateral or bilateral jumped facets.
11. In the presence of neurologic symptoms traction is indicated for unilateral or bilateral jumped facets.
12. Preoperative cervical traction should be considered for reduction of basilar invagination.
13. Preoperative cervical traction should be considered for reduction of kyphotic deformities.
14. Preoperative cervical traction should be considered for reduction of swan neck deformities.
15. Preoperative cervical traction should be considered for reduction of coronal deformities.
16. Cervical traction is contraindicated in atlantooccipital dislocations.
17. Cervical traction is contraindicated in traumatic distraction injuries.
18. Halo traction is contraindicated in patients with osteogenesis imperfecta.
19. Gardner-Wells traction is contraindicated in patients with osteogenesis imperfecta.
20. Halo traction is contraindicated in patients with open fontanelles.
21. Gardner-Wells traction is contraindicated in patients with open fontanelles.
22. Cervical spine radiographs should be obtained prior to the initiation of traction.
23. If not clinically contraindicated, flexion-extension or lateral bending radiographs should be obtained prior to initiation of traction to evaluate for reducibility.
24. Cervical spine MRI should be obtained prior to initiation of traction in deformity patients.
25. When available, cervical spine MRI should be obtained prior to initiation of traction in trauma patients without neurologic deficits.
26. When available, cervical spine MRI should be obtained prior to initiation of traction in trauma patients with neurologic deficits.
27. If there is reason to suspect skull abnormality or hydrocephalus, dedicated skull or cranial imaging should be obtained prior to initiation of traction.
28. A head CT is not required for children <6 years of age prior to placement of halo.
29. Halter traction may be used in patients of any age.
30. Halo traction should not be used in patients less than 1–2 years of age.
31. Gardner-Wells tongs should not be used in children less than 5 years of age.
32. When placing a halo in children 1–2 years of age at least 8 pins should be used.
33. When placing a halo in children 3–5 years of age at least 6 pins should be used.
34. When placing a halo in children 6–12 years of age at least 6 pins should be used.
35. When placing a halo in children greater than 12 years of age at least 4 pins should be used.
36. When placing a halo in children 1–2 years of age pins should be tightened to patient's age in inch-pounds or until finger tight.
37. When placing a halo in children 3–7 years of age pins should be tightened based on age, skull thickness and number of pins placed.
38. When placing a halo in children greater than 8 years of age pins should be tightened to between 6 and 8 inch-pounds.
39. When placing a halo, pins should be tightened at placement and at least one additional time.
40. A thoracic bump or bolster should be used as needed in very young patients undergoing traction due to head size.
41. Muscle relaxants should be routinely given to patients undergoing traction unless medically contraindicated.
42. Starting traction weight in trauma and deformity patients should be based on age, level of injury or region of deformity.
43. Goal traction weight in trauma and deformity patients should be determined based on level of injury, region of deformity in the cervical spine or radiographically based on serial images.
44. Repeat cervical spine radiographs should be obtained upon each addition of weight in patients undergoing traction for traumatic indications.
45. Repeat cervical spine radiographs should be obtained upon each addition of weight or at least once daily in patients undergoing traction for deformity correction.
46. Once at goal weight, cervical spine radiographs should be obtained, with additional imaging as clinically indicated, in patients undergoing traction for traumatic indications.
47. Once at goal weight, cervical spine radiographs should be obtained, with additional imaging as clinically indicated, in patients undergoing traction for deformity correction.
48. Patients with cervical spine deformity should be maintained in traction for no longer than 2 weeks.
49. Neurologic exams by a physician or equivalent provider should be performed after each addition of weight and at least once daily.
50. Pin site care should consist of cleaning with alcohol, betadine, hydrogen peroxide, saline or chlorhexidine.
51. Pin site care should include application of antibiotic ointment.
52. Pin site care should be performed at least once a day.
53. Antibiotic ointment should be used as first line therapy for pin site infections.
54. If first line management of pin site infections fails, pin removal should be performed.
55. If first line management of pin site infections fails, intravenous antibiotics should be initiated.
56. If first line management of pin site infections fails, traction should be terminated.
57. Neurologic changes in deformity patients undergoing traction should prompt removal of the most recently added weight and if no immediate improvement, removal of all weight.
58. Neurologic changes in trauma patients undergoing traction should prompt removal of the most recently added weight and if no immediate improvement, removal of all weight.
59. Cervical spine radiographs should be obtained in the event of any neurologic changes.
60. Cervical spine MRI should be obtained in the event of any persistent neurologic changes after the removal of weight.

Delphi Round 2

A face-to-face meeting was held in December 2018 with 12 participants in attendance. An anonymous audience response system (Poll Everywhere) was used in which participants entered their responses to statements using their personal smartphone or computer. Responses were tallied and projected in real time to participants. Statements near consensus were discussed in detail, and modifications to the statements were made in order to achieve consensus. Finalized statements achieving ≥ 80% consensus were then incorporated into consensus statements of proposed best practices. At the conclusion of the discussion, participants were asked whether they would 1) agree to the publication of these consensus statements, and 2) implement the consensus statements into their practice. All initial participants, including those unable to attend the face-to-face meeting, reviewed and approved the final consensus statements and manuscript prior to publication.

Results

Participant Characteristics

Of the 20 participants invited to participate in the study, 100% completed the initial survey of current practices. Of these participants, 57.9% have been in practice for 11–15 years, 21.1% have been in practice for 6–10 years, 10.5% for greater than 20 years, and 5.3% for both 0–5 years and 16–20 years in practice. Per year, 73.7% of participants estimated placing between 0 and 5 patients in cervical traction, and 26.3% estimated placing between 6 and 10 patients in traction. Over their careers, 42.1% of participants estimated that they have placed 0–25 patients in cervical traction, 42.1% estimated between 26 and 50 patients, 10.5% had placed 51–75 patients in traction, and 5.3% had placed 76–100 patients in traction. The figures in this highly experienced cohort highlight the rarity with which cervical traction is employed in pediatric patients.

Delphi Method

The initial round of 60 proposed consensus statements resulted in agreement ≥ 80% for the 40 statements listed in Table 3. Eight statements reached near consensus in agreement (70%–79% strongly agreed or agreed). The statements near consensus in agreement were as follows: 1) “Goals of cervical traction include avoidance of anterior or posterior approaches to the craniovertebral junction or subaxial spine” (79%). 2) “In the absence of neurologic symptoms traction is indicated for atlantoaxial rotary subluxation” (73.7%). 3) “In the presence of neurologic symptoms traction is indicated for unilateral or bilateral jumped facets” (79%). 4) “Preoperative cervical traction should be considered for reduction of swan neck deformities” (73.7%). 5) “Halter traction may be used in patients of any age” (79%). 6) “Cervical traction should be considered for the reduction of coronal deformity” (73.7%). 7) “Cervical traction should be considered for coronal deformities greater than 31 degrees or based on reducibility on lateral bending radiographs” (79%). 8) “Preoperative cervical traction should be considered for reduction of coronal deformities” (73.7%).

TABLE 3.

Final consensus for best practices to guide the use of cervical spine traction

Consensus (%)
TotalStrongly AgreeAgree
Goals, indications, & contraindications
 1. Goals of cervical traction include reduction of sagittal deformity.94.7563.1631.58
 2. Goals of cervical traction include reduction of reducible deformities.10084.2115.79
 3. Goals of cervical traction include reduction of dislocations.10057.8942.11
 4. Goals of cervical traction include simplification of surgery to anterior or posterior approach to the craniovertebral junction or subaxial spine.1001000
 5. Cervical traction should be considered for kyphotic deformities greater than 31 degrees or based on reducibility on flexion-extension radiographs.94.7426.3268.42
 6. In the absence of neurologic symptoms traction should be considered for nonreducible atlantoaxial rotary subluxation.1001000
 7. In the absence of neurologic symptoms traction is indicated for unilateral or bilateral jumped facets.100.042.1157.89
 8. In the presence of neurologic symptoms traction should be considered for unilateral or bilateral jumped facets.1001000
 9. Preoperative cervical traction should be considered for reduction of basilar invagination.89.4826.3263.16
 10. Preoperative cervical traction should be considered for reduction of kyphotic deformities.89.4842.1147.37
 11. Preoperative cervical traction should be considered for reduction of swan neck deformities.1001000
 12. Cervical traction is contraindicated in atlantooccipital dislocations.10089.4710.53
 13. Cervical traction is contraindicated in traumatic distraction injuries.94.7447.3747.37
 14. Gardner-Wells traction is contraindicated in patients with osteogenesis imperfecta.94.7321.0573.68
 15. Halo traction is contraindicated in patients with open fontanelles.89.4810.5378.95
 16. Gardner-Wells traction is contraindicated in patients with open fontanelles.94.7321.0573.68
 17. Halter traction may be used in patients of any age.1001000
 18. Placement of a halo should not be used in patients less than 1 year of age.1001000
 19. Gardner-Wells tongs should not be used in children less than 3 years of age.1001000
Pretraction imaging
 20. Cervical spine radiographs should be obtained prior to the initiation of traction.10063.1636.84
 21. If not clinically contraindicated, flexion-extension or lateral bending radiographs should be obtained prior to initiation of traction to evaluate for reducibility.10042.1157.89
 22. A head CT is not required for children prior to placement of halo.1001000
 23. Cervical spine MRI should be obtained prior to initiation of traction in deformity patients.89.4752.6336.84
 24. When available, cervical spine MRI should be obtained prior to initiation of traction in trauma patients without neurologic deficits.89.4842.1147.37
 25. When available, cervical spine MRI should be obtained prior to initiation of traction in trauma patients with neurologic deficits.84.2242.1142.11
 26. If there is reason to suspect skull abnormality or hydrocephalus, dedicated skull or cranial imaging should be obtained prior to initiation of traction.94.7442.1152.63
Traction initiation guidance
 27. When placing a halo in children 1–2 years of age at least 8 pins should be used.94.7431.5863.16
 28. When placing a halo in children 3–5 years of age at least 6 pins should be used.94.7336.8457.89
 29. When placing a halo in children greater than 12 years of age at least 4 pins should be used.94.7442.1152.63
 30. When placing a halo in children 1–2 years of age pins should be tightened to patient's age in inch-pounds or until finger tight.10015.7984.21
 31. When placing a halo in children 3–7 years of age pins should be tightened based on age, skull thickness and number of pins placed.94.7431.5863.16
 32. When placing a halo in children greater than 8 years of age pins should be tightened to between 6 and 8 inch-pounds.84.2110.5373.68
 33. When placing a halo, pins should be tightened at placement and at least one additional time.94.7336.8457.89
 34. A thoracic bump or bolster should be used as needed in very young patients undergoing traction due to head size.10031.5868.42
Traction protocol guidance
 35. Muscle relaxants should be routinely given to patients undergoing traction unless medically contraindicated.94.7415.7978.95
 36. Starting traction weight in trauma and deformity patients should be based on age, level of injury or region of deformity.10042.1157.89
 37. Goal traction weight in trauma and deformity patients should be determined based on level of injury, region of deformity in the cervical spine or radiographically based on serial images.10047.3752.63
 38. Repeat cervical spine radiographs should be obtained upon each addition of weight in patients undergoing traction for traumatic indications.94.7431.5863.16
 39. Repeat cervical spine radiographs should be obtained upon each addition of weight or at least once daily in patients undergoing traction for deformity correction.89.4826.3263.16
 40. Once at goal weight, cervical spine radiographs should be obtained, with additional imaging as clinically indicated, in patients undergoing traction for traumatic indications.10026.3273.68
 41. Once at goal weight, cervical spine radiographs should be obtained, with additional imaging as clinically indicated, in patients undergoing traction for deformity correction.10026.3273.68
 42. Neurologic exams by a physician or equivalent provider should be performed after each addition of weight and at least once daily.10057.8942.11
Traction complication management
 43. Pin site care should consist of cleaning with alcohol, betadine, hydrogen peroxide, saline, or chlorhexidine.94.7431.5863.16
 44. Pin site care should be performed at least once a day.94.7431.5863.16
 45. Oral or topical antibiotics should be considered for first line therapy of pin site infections.1001000
 46. Neurologic changes in deformity patients undergoing traction should prompt removal of the most recently added weight and if no immediate improvement, removal of all weight.10042.1157.89
 47. Neurologic changes in trauma patients undergoing traction should prompt removal of the most recently added weight and if no immediate improvement, removal of all weight.94.7442.1152.63
 48. Cervical spine radiographs should be obtained in the event of any neurologic changes.10068.4231.58
 49. Cervical spine MRI should be obtained in the event of any persistent neurologic changes after the removal of weight.10063.1636.84

Four statements that were indeterminant were also agreed on for further discussion. 1) “Halo traction should not be used in patients less than 1–2 years of age” (68.4%). 2) “Gardner-Wells tongs should not be used in children less than 5 years of age” (42.1%). 3) “Head CT is not required for children < 6 years of age prior to placement of halo” (57.9%). 4) “If first line management of pin site infections fails, pin removal should be performed” (63.2%). An additional 8 statements listed in Table 4 did not reach consensus.

TABLE 4.

Cervical traction practices that did not reach consensus

InterventionResponse (%)
SummaryStrongly AgreeAgreeDisagreeStrongly Disagree
1. Cervical traction should be considered for the reduction of coronal deformity.26.32% disagree10.5363.1626.320.00
2. Cervical traction should be considered for coronal deformities greater than 31 degrees or based on reducibility on lateral bending radiographs.21.05% disagree10.5368.4221.050.00
3. In the presence of neurologic symptoms traction is indicated for atlantoaxial rotary subluxation.47.37% disagree21.0531.5842.115.26
4. Preoperative cervical traction should be considered for reduction of coronal deformities.26.32% disagree5.2668.4226.320.00
5. Halo traction is contraindicated in patients with osteogenesis imperfecta.47.37% disagree15.7936.8442.115.26
6. When placing a halo in children 6–12 years of age at least 6 pins should be used.31.58% disagree21.0547.3731.580.00
7. Patients with cervical spine deformity should be maintained in traction for no longer than 2 weeks.42.11% disagree15.7942.1142.110.00
8. Pin site care should include application of antibiotic ointment.31.58% disagree21.0547.3721.0510.53
9. Antibiotic ointment should be used as first line therapy for pin site infections.36.84% disagree5.2657.8936.840.00
10. If first line management of pin site infections fails, intravenous antibiotics should be initiated.36.84% disagree5.2657.8936.840.00
11. If first line management of pin site infections fails, traction should be terminated.89.48% disagree0.0010.5378.9510.53

Ultimately, the group elected to revisit the above 4 indeterminant statements in addition to the 12 statements near consensus. Using the Delphi method, 5 statements near consensus and 4 indeterminate statements were subsequently modified and consensus was achieved, as shown in Table 5. At the conclusion of the process, 49 statements reached consensus resulting in the current best-practice statements (Table 3), with exclusion of 11 statements that did not reach consensus (Table 4). One statement, “If first line management of pin site infection fails, traction should be terminated,” reached consensus in disagreement (89.5%), but the group declined to discuss it further. All respondents stated that they were willing or somewhat willing to alter aspects of their current practices based on best-practice consensus statements. Furthermore, all participants present at the face-to-face session agreed to support the publication of the resulting consensus statements.

TABLE 5.

Round 3: Revisions to selected statements at in-person meeting to achieve consensus

Initial StatementFinal Statement (% agree or strongly agree)
Goals of cervical traction include avoidance of anterior or posterior approaches to the craniovertebral junction or subaxial spine.Goals of cervical traction include simplification of surgery to anterior or posterior approach to the craniovertebral junction or subaxial spine. (100%)
In the absence of neurologic symptoms traction is indicated for atlantoaxial rotary subluxation.In the absence of neurologic symptoms traction should be considered for nonreducible atlantoaxial rotary subluxation. (100%)
In the presence of neurologic symptoms traction is indicated for unilateral or bilateral jumped facets.In the presence of neurologic symptoms traction should be considered for unilateral or bilateral jumped facets. (100%)
Preoperative cervical traction should be considered for reduction of swan neck deformities.Preoperative cervical traction should be considered for reduction of swan neck deformities. (100%)
Halter traction may be used in patients of any age.Halter traction may be used in patients of any age. (100%)
Halo traction should not be used in patients less than 1–2 years of age.Placement of a halo should not be used in patients less than 1 year of age. (100%)
Gardner-Wells tongs should not be used in children less than 5 years of age.Gardner-Wells tongs should not be used in children less than 3 years of age. (100%)
A head CT is not required for children <6 years of age prior to placement of halo.A head CT is not required for children prior to placement of halo. (100%)
If first line management of pin site infections fails, pin removal should be performed.Oral or topical antibiotics should be considered for first line therapy of pin site infections.(100%)

Discussion

In this study, we demonstrate that by using a modified Delphi method, a multidisciplinary group of pediatric cervical spine experts was able to reach consensus on 49 statements regarding utilization and implementation among children undergoing cervical spine traction for trauma or deformity. Our hope is that these consensus statements will be thought of as best practices and provide guidance for practitioners who are unfamiliar with the nuances of cervical traction in the pediatric population. Furthermore, they establish a foundation of consensus statements on which future research can be built.

Unquestionably, cervical spine traction provides significant benefit when employed in appropriate clinical scenarios. While nearly all neurosurgeons have some experience with cervical spine traction in adults, experience in children is rare.13,28 It is not surprising, therefore, that very little evidence-based guidance exists for even the most basic questions regarding traction, such as the indications and contraindications, types of traction appropriate for different age groups, protocols for implementation, and management of complications associated with traction. Fortunately, a recent small clinical study started to address some of these issues by demonstrating safety and efficacy of HGT for pediatric cervical spine disorders.13 However, the general infrequency of pediatric cervical traction makes generating robust clinical evidence very challenging. Even among our group of experienced clinicians, a majority (73%) placed between 0 and 5 children in traction for any cervical pathology in the past year, and 84.2% had placed fewer than 50 children in traction in their entire career.

Additional methods of research are critical to provide clinical guidance and focus future research. Harnessing the power of clinical experience and expertise through consensus building among experts is one way to advance the field, by potentially decreasing variance and guiding clinical practices. The Delphi method is a means of systematizing consensus building by employing repeated administration of surveys to a group of experts followed by focused discussion and consensus-based modification of statements after each session.23–26 Application of the Delphi method in this study led to 49 consensus statements regarding multiple aspects of the utilization and implementation of pediatric cervical spine traction, including goals, indications, contraindications, imaging, management protocols, and complications.

Best-Practice Statements Surrounding Goals, Indications, and Contraindications of Pediatric Cervical Traction

The broad category of goals, indications, and contraindications of cervical traction explored specific pathologies that may be addressed with traction, in addition to the use of various traction devices in specific age groups and populations. Following the initial Delphi round, 12 statements reached consensus with an additional 7 statements reaching consensus after the second, in-person Delphi session.

Four statements regarding overarching goals of cervical traction reached consensus, including 1) reduction of sagittal deformity (94.75% strongly agree or agree); 2) reduction of reducible deformities (100%); 3) reduction of dislocations (100%); and 4) simplification of surgery to an anterior or posterior approach to the craniovertebral junction or subaxial spine (100%). The first 3 statements regarding goals required no further discussion and maintain broad support in the literature among both pediatric and adult populations.1–3,13 The group elected to modify an initial statement, “goals include avoidance of anterior or posterior approaches to the CVJ [craniovertebral junction] or subaxial spine,” in order to clarify that preoperative traction may allow a simplification of surgical approaches, thus not necessitating 360° fusion procedures.6,9

A total of 7 statements regarding indications for cervical traction reached consensus: 4 after the initial Delphi round and 3 following in-person discussion to soften the strength of the statements. Each modified statement was altered from “is indicated” to “should be considered” to reflect the fact that given the lack of robust evidence, experience and clinical judgment are imperative. These statements included cervical traction should be considered for 1) “kyphotic deformities greater than 31 degrees or based on reducibility on flexion-extension radiographs” (94.74% agree or strongly agree); 2) “reduction of basilar invagination” (89.48%); 3) “reduction of kyphotic deformities” (89.48%); and 4) “reduction of swan neck deformities” (100%). Consensus was also reached that traction should be considered 5) “in the absence of neurologic symptoms for nonreducible atlantoaxial rotary subluxation” (100%); and 6) “in the presence of neurologic symptoms for unilateral or bilateral jumped facets” (100%). Given the broad experience in the literature, the group determined that only 1 statement merited inclusion of the term “indication": 7) “in the absence of neurological symptoms traction is indicated for unilateral or bilateral jumped facets” (100%).

Two statements regarding pathologies in which traction is contraindicated reached consensus: “traction is contraindicated in atlantooccipital dislocations” (100% strongly agree or agree) and “in traumatic distraction injuries” (94.74%). The group acknowledged the role of rigid immobilization in a halo vest in these pathologies yet agreed that the direct application of traction led to undue risk of neurological worsening in these scenarios.29,30

Three statements related to contraindications to the use of particular traction mechanisms in specific patient populations reached consensus following the initial Delphi round: Gardner-Wells traction is contraindicated in patients with 1) osteogenesis imperfecta (94.73%), 2) open fontanelles (94.73%), and 3) “halo traction is contraindicated in patients with open fontanelles” (89.48%). Although little empirical evidence exists to support these statements, the high level of concern regarding placing pins in very thin and malleable bone led to a consensus. An additional 3 statements related to the minimum safe age at which various traction devices may be used reached consensus after in-person discussion. The statement indicating that “halter traction may be used in patients of any age” (100%) required no further modification after members of the group elaborated on their experience in effectively employing halter traction in newborn infants. The statement “halo traction should not be used in patients less than 1–2 years of age” was modified to “halo traction should not be used in patients less than 1 year of age” (100%). Based on the group's experience, consensus was reached that in an intraoperative setting, “Gardner-Wells tongs could be used in patients as young as 3 years of age” (100%).

Best-Practice Statements Surrounding Pretraction Imaging

Given the rarity of pediatric cervical traction, no clear guidelines exist on what types of imaging are appropriate or required and when they should be performed. We sought to provide some clarity for clinicians in this area by generating consensus on the minimum appropriate imaging in various clinical scenarios. A total of 6 statements regarding pretraction imaging reached consensus following the initial Delphi round, and one additional statement was modified to reach consensus during the in-person session.

All members of the group agreed that cervical spine radiographs should be obtained prior to the initiation of traction for any reason (100% strongly agree or agree). The group also unanimously agreed that if not clinically contraindicated, flexion-extension or lateral bending radiographs should be obtained prior to initiation of traction to evaluate for reducibility. With regard to MRI, the group agreed that deformity patients should obtain cervical spine MRI prior to the initiation of traction (89.47%), and that when available, cervical spine MRI should be obtained prior to traction in both the presence (84.22%) and the absence (89.48%) of neurological symptoms in trauma patients. During in-person discussion, the group emphasized that MRI was not required if it would significantly delay the initiation of traction. No statements specifically discussed the use of cervical spine CT as this is largely dependent on each case and individual clinicians’ preferences for operative planning and minimization of radiation exposure. Contrary to some pediatric orthopedic literature,15 the group reached consensus that cranial CT is not required for any child prior to halo application (100%), but that dedicated skull or cranial imaging should be obtained if there is any suggestion of skull abnormality or hydrocephalus (94.74%). These 2 statements emphasize the importance of clinician judgment when weighing the risk-benefit of cranial irradiation and determination of safe pin site placement.17

Best-Practice Statements Surrounding Initiation of Traction

Determining the safest and most effective method to place a child in traction is among the unique challenges surrounding pediatric cervical traction. Experimental data in saw bone skulls demonstrate that the pullout strength of 6 and 10 pin halo configurations tightened to between 2 and 8 inch-pounds exceeds the average weight of pediatric patients.31,32 It is unclear how these data generalize to clinical practice, and it does not consider the safety of force application on an immature skull. Therefore, we sought to provide guidance through expert consensus on the minimum number of pins and appropriate pin tightness for halo application in various pediatric age groups. Consensus was reached that “at least 8 pins should be used in children 1–2 years of age” (94.74% strongly agree or agree); “at least 6 pins should be used in children 3–5 years of age” (94.73%); and “at least 4 pins should be used in children greater than 12 years of age” (94.74%). Due to the high variability of skull growth and thickness among children between 6–12 years of age, consensus could not be reached for this age group.

With regard to pin tightness, all participants agreed that in children 1–2 years of age pins should be tightened to finger tightness or the patient's age in inch-pounds (100%). In patients 3–7 years of age, where skeletal immaturity persists, consensus was reached that pins should be tightened based on age, skull thickness, and number of pins placed (94.74%). In patients greater than 8 years, consensus was reached that pins should be tightened to between 6 and 8 inch-pounds, as is standard practice in adult patients (84.21%). Additionally, consensus was reached that when placing a halo, pins should be tightened at placement and at least one additional time (94.73%). Very young children and infants present an additional challenge in that their head size is large relative to their body, which results in neck flexion when supine.33,34 The group reached consensus that a thoracic bump or bolster should be used as needed in very young patients (100%).

Best-Practice Statements Surrounding Traction Protocols

The diverse array of cervical pathologies that may require cervical traction presents a challenge in standardizing any traction protocols. Appropriate initial weight, total and goal weight, traction duration, and timing of imaging and neurological examinations are all influenced by the patient's age and pathology. Other published traction protocols for thoracolumbar spinal deformity and cervical deformity patients recommend starting with small weights and advancing to a goal weight between 30%–50% of the total body weight reached over about 2 weeks, and continued for a duration of 3–8 weeks.13,15 Our group reached consensus on 2 general statements regarding starting weight and goal weight of traction in both deformity and trauma patients: “starting weight should be based on age, level of injury or region of deformity” (100% strongly agree or agree), and “goal weight should be based on level of injury, region of deformity or radiographically based on serial imaging” (100%).

No evidence exists to guide the timing and frequency of imaging during the course of cervical traction. Consensus among our group was reached that “repeat cervical spine radiographs should be obtained upon each addition of weight in traction for traumatic indications” (94.74%). In “deformity patients, repeat cervical spine radiographs were recommended upon each addition of weight or at least once a day” (89.48%). In both trauma (100%) and deformity (100%) patients, consensus was reached that “repeat cervical X-rays should be obtained once at goal weight with additional imaging as clinically indicated.” Two additional statements related to the protocol specifics reached consensus: “neurological exams should be performed by a physician or equivalent provider after each addition of weight or at least once a day” (100%), and “muscle relaxants should be routinely given to patients undergoing traction unless medically contraindicated” (94.74%).

Best-Practice Statements Surrounding Traction Complication Management

Patients undergoing cervical traction are at risk for a variety of complications due to the invasive nature of pin placement and changes in spinal alignment. Hardware-related complications, such as pin loosening, intracranial pin migration, and pin site infection, are commonly reported in the literature and most often managed conservatively.20,22 At their most extreme, pin site complications can lead to skull fracture, epidural hematoma, and intracranial abscess formation.21,35 As such, strategies to minimize halo- and traction-related complications were an important focus of our group's attention. Consensus was reached that “pin site care should occur at least once a day” (94.74% strongly agree or agree) and “should consist of cleaning with alcohol, betadine, hydrogen peroxide, saline or chlorhexidine” (94.74%). Variation in individual practices, and the general lack of evidence, limited consensus surrounding the management of pin site complications, but after in-person discussion consensus was reached that “oral or topical antibiotics should be considered for first line therapy of pin site infections” (100%).

Neurological complications may also occur in patients undergoing cervical traction ranging from an isolated cranial nerve palsy to quadriplegia. While most of these complications are transient or resolve with management,20 little guidance exists in the literature regarding what appropriate management entails. Consensus was reached in both trauma (94.74%) and deformity (100%) cases that “in the event of neurological change the most recently added weight should be removed and if no immediate improvement occurs all weight should be removed.” Consensus was also reached that “cervical spine radiographs should be obtained in the event of any neurological change” (100%) and “cervical spine MRI should be obtained in the event of any persistent neurological change after removal of weight” (100%).

Limitations and Future Studies

Consensus-driven studies such as this have limitations inherent to their design. The need for such a study highlights the lack of quality empirical evidence available and a reliance on expert opinion. While this study was able to generate consensus statements regarding pediatric cervical traction, it cannot provide evidence-based firm guidelines for management of these complex cases. Furthermore, the group of experts in this study all practice in North America at large academic children's hospitals; thus, the generalizability of these statements to more community settings is not clear. Additionally, while our participant selection process sought to provide the broadest and most experienced group possible, prior collaboration played a significant role. Future studies can employ a more systematic approach to selection in order to ensure more diversity of opinions. Nevertheless, the goal of this study was to provide a framework of clinical recommendations for clinicians to build upon and guide future multicenter studies to standardize the practice of cervical traction in children.

Conclusions

In an attempt to improve and standardize the use of cervical traction in pediatric patients, we present 49 best-practice recommendations generated by reaching consensus among a multidisciplinary group of pediatric spine experts using a modified Delphi technique. These statements aim to provide a broad clinical framework for clinicians employing pediatric cervical traction. Further study is required to determine if implementation of these practices can lead to reduced complications and improved outcomes for children.

Disclosures

Dr. Limbrick: support of non–study-related clinical or research effort from Medtronic and Microbot Medical. Dr. Pahys: consultant for DePuy Synthes, NuVasive, and Zimmer Biomet.

Author Contributions

Conception and design: all authors. Acquisition of data: all authors. Analysis and interpretation of data: all authors. Drafting the article: Alexiades, Shao, Anderson. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Alexiades. Study supervision: Anderson.

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  • Collapse
  • Expand

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).

  • 1

    Sellin JN, Shaikh K, Ryan SL, et al.. Clinical outcomes of the surgical treatment of isolated unilateral facet fractures, subluxations, and dislocations in the pediatric cervical spine: report of eight cases and review of the literature. Childs Nerv Syst. 2014;30(7):12331242.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Parada SA, Arrington ED, Kowalski KL, Molinari RW. Unilateral cervical facet dislocation in a 9-year-old boy. Orthopedics. 2010;33(12):929.

  • 3

    Özbek Z, Özkara E, Vural M, Arslantaş A. Treatment of cervical subaxial injury in the very young child. Eur Spine J. 2018;27(6):11931198.

  • 4

    Kim W, O’Malley M, Kieser DC. Noninvasive management of an odontoid process fracture in a toddler: case report. Global Spine J. 2015;5(1):5962.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Rinella A, Lenke L, Whitaker C, et al.. Perioperative halo-gravity traction in the treatment of severe scoliosis and kyphosis. Spine (Phila Pa 1976). 2005;30(4):475482.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Abd-El-Barr MM, Snyder BD, Emans JB, et al.. Combined preoperative traction with instrumented posterior occipitocervical fusion for severe ventral brainstem compression secondary to displaced os odontoideum: technical report of 2 cases. J Neurosurg Pediatr. 2016;25(6):724729.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Peng X, Chen L, Wan Y, Zou X. Treatment of primary basilar invagination by cervical traction and posterior instrumented reduction together with occipitocervical fusion. Spine (Phila Pa 1976).2011;36(19):15281531.

    • Crossref
    • PubMed
    • Search Google Scholar
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