Preoperative cervical traction with Gardner-Wells Tongs:
Who profits most?

Jan Rodemerk¹; Markus Pierscianek¹; Marvin Darkwah Oppong¹, M.D.; Daniela Pierscianek¹, M.D.; Philipp Dammann¹, M.D; Oliver Gembruch¹, M.D.; Neriman Özkan¹, M.D; Ulrich Sure¹, M.D.; Karsten H. Wrede¹, M.D.; Ramazan Jabbarli¹, M.D.

1. Department of Neurosurgery, University Hospital Essen, Germany

PMID: Accepted manuscript at Minervamedica – Neurosurgical sciences
DOI: Accepted manuscript at Minervamedica – Neurosurgical sciences

ABSTRACT

Background: Preoperative traction with the Gardner-Wells tongs (PTGWT) is a valuable option for cervical spine injuries with malalignment. The aim of this study was to analyze the factors related to the treatment success of PTGWT.

Methods: All consecutive cases with PTGWT due to cervical spine injury with malalignment treated between 01/2010 and 09/2020 were included. Patients’ records were reviewed for demographic and clinical characteristics. Treatment success was evaluated upon the angle correction in the sagittal plane using the computed tomography scans before and after the treatment.

Results: Of 20 patients in the final analysis (median age: 77.5 years; 12 females [60%]), 14 individuals were treated for the type-II odontoid fracture, and six cases presented with subluxation fractures between C3 and C7. After PTGWT and subsequent intraoperative reposition, there was an improvement of the median deviation angle from initial 32° to 5.5°. PTGWT resulted in a significant improvement of the median deviation angle for the odontoid (17°, p<0.0001), but not for the subluxation (4°, p=0.10) fractures. The time interval between trauma and PTGWT was associated with the treatment success of subluxation (p=0.051) but not of odontoid (p=0.87) fractures. Older individuals aged 51³ years showed better reposition results with PTGWT (17° vs. 7.5°, p=0.02). There were no PTGWT-related complications in the cohort.

Conclusion: PTGWT is an effective and safe treatment for cervical spine injuries with malalignment. The patients with odontoid fractures might particularly profit from the PTGWT. Treatment delay seems more relevant for PTGWT success in subluxation than in odontoid fractures.

INTRODUCTION

Traumatic injuries are a leading cause of death and disability, and approximately 3.5% of seriously injured traffic accident victims suffer a cervical spine injury. (1) In all trauma patients with spinal injuries, about every second patient has the cervical spine involved. (2) Moreover, the prevalence of cervical spine injuries in unconscious patients is twice as high as in awake patients. (3) With an incidence of 64/100,000 and an increased prevalence in the age groups 15-45 and 65-80, there is a risk of lifelong disabling neurological complications leading to a considerable economic burden on society. (4-8)

Odontoid fractures represent about 20% of all cervical fractures. (9-11) With a prevalence of over 60%, the Anderson and d’Alonzo type II fracture is the most common form of odontoid fractures. (12-14) When this fracture is unstable, it can cause spinal cord damage or even paraplegia. (15-17) In situations of spinal cord injuries, immediate treatment is of great importance. A precise treatment guideline or necessary evidence for different treatments’ benefits is lacking or very controversial discussed. (18-20)

In addition, over 70% of traumatic subaxial cervical spine injuries(C3-C7) can be realigned by traction. (21) Subaxial injuries with axial misalignment are classified by AO Spine as follows: B2, B3, C, F4. (22) Further, we refer to these injuries as “subluxation fractures”.

Cervical traction with Gardner-Wells tong (GWT) is a commonly used approach for treating cervical spine trauma and spinal deformity. As a temporary device, the spinal traction utilizes a tensile force to achieve improved alignment until either surgery is performed or strictly conservative treatment is targeted. Tongs most commonly are placed through the skull’s outer table at a point 1 cm above and in line with the pinna bilaterally. (23) Contraindications of the GWT application in cervical spine injuries include distractive injuries, associated skull fracture, local inflammation, and stable fractures, especially without neurological signs when only a collar or other bracing form may suffice. (24-26)

In the German guidelines for injury of the upper cervical spine (AWMF-Nr. 012-011), no reference is made to extension treatment in the surgical setting, but extension treatment is strictly discouraged in the conservative setting. (27)

This study aims to determine the factors related to the treatment success of preoperative traction with GWT (PTGWT) in cervical spine fractures.

MATERIALS AND METHODS

Patient population

This retrospective study included all consecutive cases with PTGWT due to cervical spine trauma at our institution between 01/2010 and 09/2020. The ethics approval for this study was provided by the institutional review board (18-8049-BO). The exclusion criteria were: a) PTGWT due to and/or presence of additional not trauma-related cervical spine lesions with/without associated fractures like neoplasia or inflammatory processes; b) short-term PTGWT (<24h) not related to patients’ incompliance, and c) the cases with only intraoperative traction with GWT.

PTGWT management

If there were no contraindications related to patients’ comorbidities or missing consent, all cases with an unstable cervical spine injury and concomitant dislocation were the matter of surgical treatment with the spine stabilization and intraoperative open reposition. The patients with unstable odontoid (Anderson and D’Alonzo Type II) and subluxation fractures (AO-Spine: B2, B3, C or F4) were also considered for preoperative closed reduction of dislocation using the PTGWT, unless there were contraindications for PTGWT like local skin/bone lesions at the site of intended pins insertion, expected incompliance due to known psychic disorders, and cardiorespiratory instability. There were no strict restrictions for PTGWT concerning the time interval since trauma; however, the patients were usually not the matter of PTGWT for the traumas older than two weeks.

According to the institutional standard operating procedures, PTGWT was performed under strict surveillance of neurologic and vital parameters at our intensive or intermediate care units. The maximal applied weight load was 10% of the body weight, beginning with 4.5 kg and further gradual increase under x-ray control during the traction time. Commonly, PTGWT was performed for 2 – 3 days from admission until surgery with intraoperative removal of GWT and patients’ positioning under C-arm control. Computed tomography (CT) scans were performed routinely at the end of PTGWT and after the surgery. According to the WHO pain management guidelines (28), the adequate pain relief was achieved using the non-steroidal anti-inflammatory drugs, alone or combined with opioids.

Data management

The patients’ records and imaging data were retrospectively analyzed using the clinical information system and picture archiving and communication system. Recorded data included patients’ age, sex, height, weight, variety of comorbidities, neurological status at admission, prior to surgery and at discharge, date of trauma and admission, GWT application, and operation, as well as the occurrence of any PTGWT-related complications and PTGWT abortion due to patients’ incompliance. Muscle strength was evaluated at admission and discharge after the Medical Research Council Manual Muscle Testing scale. Type of cervical fracture, angular deviation at admission, before and after surgery, and structural cord injuries were registered from the perioperative imaging and patients’ records. The radiographic measurements were performed using the Centricity Enterprise Web V3.0 (GE Healthcare, Barrington, IL, USA).

Angular deviation measurement

To quantify the angular deviations before and after each treatment step, the midline slices in the sagittal planes of the CT or, if not available, of the magnetic resonance imaging scans were analyzed. For odontoid fractures, a line was drawn along the posterior vertebral line of the dens base. Then, a second line was drawn between the lowest points on the posterior vertebral lines of the fractured dens fragment and the dens base (Figure 1). For luxation fractures, the first line was drawn along the posterior vertebral line of the lower vertebra. The second line was drawn between the highest points on the posterior vertebral lines of the lower and higher vertebrae (Figure 2).  Finally, the angle resulting from the crossing of these two lines was calculated as the deviation angle.

Study endpoints and statistical analysis

The primary study endpoint was the evaluation of the factors related to the treatment success, defined as the correction of the angular deviation on the CT scans, or, if not available, using the magnetic resonance imaging, between the condition at admission, after PTGWT and after surgery. The secondary endpoint was the occurrence of PTGWT-related complications (deterioration of the angular deviation under the PTGWT, perforation and/or loss of attachment of the pins, local infections at the side of the pins, neurological deterioration during the PTGWT). The diagnosis-related groups were regarded as major categories, whereat the associations of the study endpoints with other parameters were analyzed in the whole cohort and within the major categories.

Statistical analysis was performed using the R and R-Studio software packages (R version 3.6.2, https://cran.r-project.org/ bin/windows/base/; R-Studio version 1.2.5033, https://rstu-dio.com/products/rstudio/download/) with the following additional packages: GGPlot2, GGExtra, Wesanderson, RODBC, Readxl, AICcmodavg, psych, and fBasic. For categorical variables, we calculated proportions and used a 2-sided t-test. For continuous variables, median values with interquartile ranges (IQR, between the 25. and 75. percentile) or mean values with standard deviation (SD) were reported for non-normally and normally distributed continuous data respectively. The Mann-Whitney U test, Kruskal-Wallis multiple comparison tests, and the Spearman correlation was applied for the complete cohort. We used the ANOVA test for multivariate analysis with three variables. The significance level α was set to 0.05, and the CI was set to 0.95%.

Data availability

The data that support the findings of this study are available from the senior author (Ramazan.Jabbarli@uk-essen.de) upon reasonable request.

RESULTS

Patient cohort

The final cohort comprised 20 patients (Figure 3) – median age: 77.5 years (range 25 – 85 years), 12 were females (60%). According to the fracture type, 14 individuals were treated for the type II odontoid fracture, the remaining six cases presented with subluxation fractures between C3 and C7. Radiologically, facet dislocation was observed in all subluxation fractures. In 90% of the cases, low-energy trauma was the cause of the fracture, while the rest sustained the injury in a traffic accident. A spinal cord injury occurred in 30% of the cases (14% of the odontoid and 66% of subluxation fractures), and 15% of the cohort had a lethal outcome, of which two had a subluxation (33%) and one an odontoid (7%) fracture. The median time between the accident and the application of PTGWT was 12 h (IQR: 7.5-47.5 h), but most trauma patients (n=15; 75%) were treated with GWT in under 24h after the trauma. The median duration of PTGWT was two days (IQR: 1–3d).

Median angular deviation at admission was 32° (IQR: 26.3°-36.8°), whereas there was no significant difference between the type II odontoid (median: 30°, IQR: 23°-36°) and subluxation (median: 36°, IQR: 35°-37°, p=0.23, see Table 1) fractures. The median angle deviation went to 5.5° (IQR: 1°-14.3°) in the final postoperative CT imaging. In total, the treatment concept of PTGWT and subsequent surgery lead in 50% of the cases to an almost physiological restoration of the angular deviation (≤ 5°).

PTGWT timing

There were no substantial differences between the PTGWT management of odontoid and subluxation fractures. In particular, the comparison of the interval between accident and start of PTGWT (p=0.35: median 13.5h [IQR: 7.0–95.8h] vs. 12h [IQR: 9–12h] for odontoid and subluxation fractures, hereinafter) and the duration of PTGWT (p=0.96: 2d [IQR: 1.0-2.8d] vs. 2d [IQR: 1.3-2.8d]) showed similar results.

Treatment success after PTGWT

PTGWT resulted in an angle improvement of up to 37° (median: 14°, IQR: 7°-19.5°), which were mostly independent of the patients’ demographic characteristics and comorbidities (Table 2). Younger patients <51 years old) showed poorer results regarding the angle correction after PTGWT in the whole cohort (p=0.02: 7.5° [IQR: 7.3°-7.8°] vs. 17° [IQR: 7°-20°]). Individuals with diabetes mellitus showed a trend to better treatment success with PTGWT (p=0.06: 20° [IQR: 19.5°-22°] vs. 9° [IQR: 6.8°-17.5°]).

In the odontoid type II fractures (Figure 2), PTGWT resulted in significant angle reduction compared to the initial values: median 17° (IQR: 9°-19.5°), p=0.00007. In contrast, subluxation fractures (Figure 3) showed minor improvement with the PTGWT: median 4° (IQR: 1.5-10.5°), p=0.10.

Treatment delay showed no impact on the treatment success with the PTGWT on odontoid fractures (p=0.87), but a borderline significance for the subluxation fractures (p=0.051). In particular, the subluxation fractures with the immediate beginning (<6h after trauma) of the GWT traction resulted in the median reduction of the angular deviation after PTGWT by 24°. Even a short delay in treatment (³12 hours) resulted in the angular reduction of a maximum of 6°.

Finally, the duration of the PTGWT was not associated with the angle reduction of the odontoid (≤2d: median: 15.5° [IQR: 9.5°–19.3°] vs. ≥3d: median: 19° [IQR: 13°-28°], p=0.63) and subluxation (≤2d: median: 13° [IQR: 7.5°-18.5°] vs. ≥3d: median: 3° [IQR: 1.5-4.5°], p=0.53) fractures.

Treatment success after surgery

Surgery resulted in a significant misalignment correction in the subluxation fractures (median: 20.5° [IQR: 9.8°-29.0°], p=0.01). The degree of intraoperative success was less prominent in the odontoid fractures (median: 1° [IQR: -3°-10°], p=0.23, Figure 4).

PTGWT complications

There was no case of perforation, loss of attachment of the pins, or other GWT-related complications in the cohort. However, PTGWT had to be discontinued after one day in one incompliant patient with progredient organic psycho-syndrome.

Clinical course Muscle strength reduction at admission was documented in 5 subluxation and 4 odontoid fractures. After PTGWT and subsequent surgery, a neurological improvement at discharge was documented in three subluxation and one odontoid malalignment. However, one patient with odontoid fracture experienced a mild neurological deterioration (reduction by one strength level) after surgery. The remaining cases showed no changes in the neurological status throughout the hospital treatment.

DISCUSSION

Cervical spine injuries with concomitant dislocation present challenging findings, which frequently require a complex treatment approach. In our series of 20 patients with odontoid and subluxation fractures, PTGWT with subsequent intraoperative reposition and stabilization resulted in the improvement of the median deviation angle from 32° at admission to 5.5° at discharge. Different patient- and treatment-related factors should be considered during perioperative management with GWT, and some of them might impact the treatment success.

Due to its simplicity in use and effectiveness in reducing dislocation, GWT has become popular in treating traumatic cervical fractures. The advantages of GWT over previous traction devices include the lack of drill holes and skin incisions. (29, 30) Early closed reduction is mostly a safe and effective procedure that supports neurological rehabilitation after cervical fractures. (31) We observed only one case with treatment discontinuation due to incompliance in our series but no other cases with GWT-related complications. This rate is comparable to the meager complication rates already described for the use of GWT. (32) Nevertheless, a few long-term complications during the application should be mentioned. The most severe described complication is the perforation of the skull, which so far has only occurred after an application time of ≥35 days. (32) Another rare complication of GWT is the brain abscess. The abscess occurs due to skin infection, which tracts through the pin site. The complication rate is described with ~0.5% of any cervical traction. (32) Because these severe complications occur merely after a long period and the short-term complications, such as pin loosening, asymmetrical positioning, and superficial infection, can be easily managed, a temporarily limited PTGWT installation appears as relatively safe.

Treatment success: what really counts

Of all baseline demographic and clinical characteristics of the patients selected for the PTGWT, patients’ age was significantly associated with treatment success. Higher grade of angular correction with GWT in elderly patients might be related to increasing muscular atrophy in these individuals and therefore lower resistance to external traction forces with GWT. The observed trend to better results after PTGWT in patients with diabetes mellitus is somewhat related to the confounding effect of patients’ age since diabetes is more common in older individuals.

The correct timing of traction is very controversially discussed. Most authors recommend an “as soon as possible” policy, even a limit of 5 days is reported, after which a closed reduction might no longer be possible. (31, 33, 34) However, we successfully treated the patients with odontoid fractures with PTGWT regardless of the treatment delay. Therefore, we recommend the PTGWT for the dislocated odontoid fractures even in the cases with a longer time interval, provided there are no contraindications for GWT use. Of note, significant angle reduction has rarely been achieved with surgical treatment of odontoid fractures at our center. This circumstance might be related to the fact that the PTGWT already achieved the significant amount of possible correction capacity in these cases. Therefore, rather the odontoid’s stabilization was in focus of these surgeries than the intention of further correction of the malalignment.

In subluxation fractures, we could not achieve a significant reduction in angle deviation with PTGWT, and a more extended treatment duration did not show any correlation with improved angular reduction before surgery. However, the association between treatment timing and PTGWT success in subluxation fractures may indicate the relevance of treatment delay for the prognosis of success with GWT treatment in this type of cervical spine trauma. Our results indicate that the chances for a significant angle correction under PTGWT substantially reduce after a short period after subluxation fractures. Nevertheless, 4 out of 6 patients with motoric deficits at admission had increased muscle strength at discharge. Even in a patient with a subluxation fracture older than ten days, a benefit regarding muscle strength could be reported.

Limitations

The present study is limited by the considerable selection and information bias related to the study’s retrospective design. This cohort’s sample size is too small to adjust the study results for the effects of potentially relevant outcome confounders, like patients’ age and treatment delay. Additionally, this study does not present long-term results, so patients’ outcome is only reported until discharge. Further studies with a larger sample size and long-term observations are needed to obtain a unified and proven treatment regimen for cervical fractures and GWT use.

CONCLUSIONS

PTGWT is an effective, safe, and well-tolerated treatment for cervical spine injuries with angular malalignment. Patients with odontoid fracture may especially benefit from PTGWT. Treatment delay seems relevant for PTGWT success in subluxation fractures of the cervical spine. In contrast, PTGWT might be useful for odontoid fractures even at longer time intervals after trauma.

SOURCES OF FUNDING

None.

DISCLOSURE

Dr. Wrede received personal fees from Biogen for expert opinion on aneurysms and vestibular schwannomas outside the submitted work. The other authors report no conflicts.

CONFLICT OF INTEREST

None.

REFERENCES

1.            Hasler RM, Exadaktylos AK, Bouamra O, Benneker LM, Clancy M, Sieber R, et al. Epidemiology and predictors of cervical spine injury in adult major trauma patients: a multicenter cohort study. J Trauma Acute Care Surg. 2012 Apr;72(4):975-81.

2.            Kumar R, Lim J, Mekary RA, Rattani A, Dewan MC, Sharif SY, et al. Traumatic Spinal Injury: Global Epidemiology and Worldwide Volume. World Neurosurg. 2018 May;113:e345-e63.

3.            Milby AH, Halpern CH, Guo W, Stein SC. Prevalence of cervical spinal injury in trauma. Neurosurg Focus. 2008;25(5):E10.

4.            Furlan JC, Noonan V, Cadotte DW, Fehlings MG. Timing of decompressive surgery of spinal cord after traumatic spinal cord injury: an evidence-based examination of pre-clinical and clinical studies. J Neurotrauma. 2011 Aug;28(8):1371-99.

5.            Stephan K, Huber S, Haberle S, Kanz KG, Buhren V, van Griensven M, et al. Spinal cord injury–incidence, prognosis, and outcome: an analysis of the TraumaRegister DGU. Spine J. 2015 Sep 1;15(9):1994-2001.

6.            Ter Wengel PV, De Witt Hamer PC, Pauptit JC, van der Gaag NA, Oner FC, Vandertop WP. Early Surgical Decompression Improves Neurological Outcome after Complete Traumatic Cervical Spinal Cord Injury: A Meta-Analysis. J Neurotrauma. 2019 Mar 19;36(6):835-44.

7.            Yadollahi M, Paydar S, Ghaem H, Ghorbani M, Mousavi SM, Taheri Akerdi A, et al. Epidemiology of Cervical Spine Fractures. Trauma Mon. 2016 Jul;21(3):e33608.

8.            Hu R, Mustard CA, Burns C. Epidemiology of incident spinal fracture in a complete population. Spine (Phila Pa 1976). 1996 Feb 15;21(4):492-9.

9.            Dunn ME, Seljeskog EL. Experience in the management of odontoid process injuries: an analysis of 128 cases. Neurosurgery. 1986 Mar;18(3):306-10.

10.          Scheyerer MJ, Zimmermann SM, Simmen HP, Wanner GA, Werner CM. Treatment modality in type II odontoid fractures defines the outcome in elderly patients. BMC Surg. 2013 Nov 9;13:54.

11.          Vasudevan K, Grossberg JA, Spader HS, Torabi R, Oyelese AA. Age increases the risk of immediate postoperative dysphagia and pneumonia after odontoid screw fixation. Clin Neurol Neurosurg. 2014 Nov;126:185-9.

12.          Muller EJ, Schwinnen I, Fischer K, Wick M, Muhr G. Non-rigid immobilisation of odontoid fractures. Eur Spine J. 2003 Oct;12(5):522-5.

13.          Anderson LD, D’Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am. 1974 Dec;56(8):1663-74.

14.          Clark CR, White AA, 3rd. Fractures of the dens. A multicenter study. J Bone Joint Surg Am. 1985 Dec;67(9):1340-8.

15.          Dailey AT, Hart D, Finn MA, Schmidt MH, Apfelbaum RI. Anterior fixation of odontoid fractures in an elderly population. J Neurosurg Spine. 2010 Jan;12(1):1-8.

16.          Di Paolo A, Piccirilli M, Pescatori L, Santoro A, D’Elia A. Single institute experience on 108 consecutive cases of type II odontoid fractures: surgery versus conservative treatment. Turk Neurosurg. 2014;24(6):891-6.

17.          Joaquim AF, Ghizoni E, Tedeschi H, Yacoub AR, Brodke DS, Vaccaro AR, et al. Upper cervical injuries: Clinical results using a new treatment algorithm. J Craniovertebr Junction Spine. 2015 Jan-Mar;6(1):16-20.

18.          Gelb DE, Aarabi B, Dhall SS, Hurlbert RJ, Rozzelle CJ, Ryken TC, et al. Treatment of subaxial cervical spinal injuries. Neurosurgery. 2013 Mar;72 Suppl 2:187-94.

19.          Fiumara E, Tumbiolo S, Lombardo MC, Maugeri R, Porcaro S, Gioia F, et al. Type II Odontoid Fracture: a case series highlighting the treatment strategies. Acta Neurochir Suppl. 2019;125:317-24.

20.          Denaro V, Papalia R, Di Martino A, Denaro L, Maffulli N. The best surgical treatment for type II fractures of the dens is still controversial. Clin Orthop Relat Res. 2011 Mar;469(3):742-50.

21.          Aebi M. Surgical treatment of upper, middle and lower cervical injuries and non-unions by anterior procedures. Eur Spine J. 2010 Mar;19 Suppl 1:S33-9.

22.          Vaccaro AR, Koerner JD, Radcliff KE, Oner FC, Reinhold M, Schnake KJ, et al. AOSpine subaxial cervical spine injury classification system. Eur Spine J. 2016 Jul;25(7):2173-84.

23.          Gardner WJ. The principle of spring-loaded points for cervical traction. Technical note. J Neurosurg. 1973 Oct;39(4):543-4.

24.          Lauweryns P. Role of conservative treatment of cervical spine injuries. Eur Spine J. 2010 Mar;19 Suppl 1:S23-6.

25.          Wang JH, Daniels AH, Palumbo MA, Eberson CP. Cervical Traction for the Treatment of Spinal Injury and Deformity. JBJS Rev. 2014 May 27;2(5).

26.          Jeanneret B, Magerl F, Ward JC. Overdistraction: a hazard of skull traction in the management of acute injuries of the cervical spine. Arch Orthop Trauma Surg. 1991;110(5):242-5.

27.          Scholz MO, G. Verletzungen der oberen Halswirbelsäule. AWMF; 2018 [20.02.2021]; S 1:[Available from: https://www.awmf.org/leitlinien/detail/ll/012-011.html.

28.          WHO Guidelines for the Pharmacological and Radiotherapeutic Management of Cancer Pain in Adults and Adolescents. Geneva2018.

29.          Grundy DJ. Skull traction and its complications. Injury. 1983 Nov;15(3):173-7.

30.          Choo JH, Liu WY, Kumar VP. Complications from the Gardner-Wells tongs. Injury. 1996 Sep;27(7):512-3.

31.          Grant GA, Mirza SK, Chapman JR, Winn HR, Newell DW, Jones DT, et al. Risk of early closed reduction in cervical spine subluxation injuries. J Neurosurg. 1999 Jan;90(1 Suppl):13-8.

32.          Saleh H, Yohe N, Razi A, Saleh A. Efficacy and complications of the use of Gardner-Wells Tongs: a systematic review. J Spine Surg. 2018 Mar;4(1):123-9.

33.          O’Connor PA, McCormack O, Noel J, McCormack D, O’Byrne J. Anterior displacement correlates with neurological impairment in cervical facet dislocations. Int Orthop. 2003;27(3):190-3.

34.          Donnarumma P, Bozzini V, Rizzi G, Berardi A, Merlicco G. Surgical management of C-type subaxial cervical fractures using cervical traction followed by anterior cervical discectomy and fusion within 12 h after the trauma. J Craniovertebr Junction Spine. 2017 Oct-Dec;8(4):338-41.