Neurochirurgia 19 (1976), 122-125 © Georg Thieme Verlag Stuttgart

Complications of Skull Caliper Traction G. Graziussi, M.D.*, L. Pellettieri, M.D.**

Summary During a period of 20 years 88 patients with fracture dislocation of the cervical spine were treated by attaching Crutchfield tongs to the skull. Sixty-seven per cent of all patients had some complications. The different types of complications are reported and discussed in order of frequency. Key-words: skull traction - epileptic seizures fusion.

Zusammenfassung Während einer Periode von 20 Jahren wurden 88 Patienten mit Luxationsfraktur des zervikalen Spinalkanals durch Anbringen der Crutchfieldzangen auf dem Schädel behandelt. 67 % aller Patienten haben Komplikationen verschiedener Art erhalten. Die verschiedenen Typen der Komplikationen werden in Ordnung der Frequenz diskutiert.

Skull caliper traction with Crutchfield tongs is a well-known and established way of managing fracture dislocations of the cervical spine. Complications are known to occur in connexion with the use of such traction. The complications of the caliper traction method are usually not dramatic and therefore often overlooked. Furthermore, in a neurosurcigal unit, cases requiring such traction are rare (in our material 4 cases/year) and any one neurosurgeon is not particularly experienced. Our own collected series indicate that the incidence of complications is greater than the literature indicates. In fact, such complica-

tions are mostly reported only as "case reports". This work is a review of the different types of complications which occurred among our patients. The complications are reported in order of frequency.

Material During a period of 20 years 88 patients (73 male and 15 female, between 11 and 84 years of age, most of them 30 to 70 years of age) with fracture dislocation of the cervical spine were admitted to the neurosurgical clinic in Gothenburg (47 had neurological deficit on admission). They were all primarily treated by attaching Crutchfield tongs to the skull and sixty-seven per cent of them developed some kind of complication (fig. 1). Technical failure, such as "slipping out of the tongs" and "loss of correction", occurred in 39 patients (440 % ) and might be the cause of more serious complications. The technical failures occurred most often during the first and during the fourth to fifth week of treatment (first week 21 our of 39 = 54 % ; forth to fifth week 16 out of 39 = 41 % ) . The high incidence during the first week probably depends on more than one factor: the tongs were not accurately inserted from the beginning or adjusted during the first days of use. Furthermore, excessive weights were often used during the first week. - The high incidence of slipping during the fourth or fifth week could be explained by the increased frequency of local infections

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* Visiting doctor, Division of Neurosurgery, Ospedale S. Gennaro, Naples, Italy ** Department of Neurosurgery, University of Gothenburg, Sahlgrenska sjukhuset, Gothenburg, Sweden

Complications of Skull Caliper Traction

123

type of complication {2.2%i

epileptic seizures

infections

(3.4%]

(18.4X1

loss of correction

mental

changes

(19.3 %',

(20.4 % i

slipping out of the tongs

(44

HIP

Abb. 1

88 patients number of

10

20

during this period (10 out of 13). Frequent changing of the amount of weight may also increase the incidence of slipping. In our material we noted unacceptable results from the traction or loss of correction in 17 out of 88 cases (19.3 % ) . All of these had to have operations to fuse the spine. In 8 of these patients the failure to obtain a reduction was preceded by the tongs slipping out. Cloward (1954) claims that the use of excessive weight may stretch the ligaments and that the removal of the tongs after a suitable period of time leads to return of the deformity {Horwitz and Rizzoli 1967). Mental changes occurred in 18 out of 88 patients (20.4 % ) . To our knowledge psychic imbalance in connexion with skull caliper traction is not mentioned in the literature. Our patients have not been systematically followed from a psychiatric point of view and the aetiology of the mental changes (skull traction and its consequences, primary damage of the CNS) cannot be reliably discussed. However, 9 of these had psychomotor restlessness, 6 had delirium tremens (all of those post-traumatic neurosis and one developed a reactive depression. It is our opinion that the occurrence of delirium tremens may be facilitated during skull caliper traction.

Infections. Infection occures both extraand intracranially, during skull traction therapy. These include infections of the soft tissues, infections of the bone, extradural infections and brain abscess (in our material 18.4%). The soft tissues at the entrance of the tongs should be considered infected in almost all cases. More serious infections were noticed in 13 cases (14.7 %) and in all these cases the infection was combined with slipping of the tongs. The infection was bilateral in 6 out of 13 cases. The treatment of local infection of the soft tissueshas been topical, mostly with antibiotics. New burr holes were made and tongs inserted in all these cases. Osteomyelitis occurredin only two cases (2.2 % ) , with local infection of the soft tissues but we believe that the number of cases of undiagnosed osteomyelitis is greater. In these two cases, no pathological changes could be seen on x-ray examination of the skull, but infected detritus could be washed out of the burr holes. Even here we used tropical treatment with antibiotics. Osteomyelitis at the end of the traction tongs has been priviously reported (Crutcbfield 1936: 1 case, Andersson 1956: 2 cases, Tindall, Flanagan, Nasbold 1959: 3 cases, Drake 1962: 1 case, Johnsson 1965, Malowski 1965, Northfield 1965, Kerr 1965: altogether 6 cases totally).

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scalp necrosis

G. Graziussi, L. Pellettieri

Extradural abscess was not present in our material but has been reported by others Tindall, Flanagan and Nashold 1959; 1 case, Taylor, Gleave 1962: 1 case, Harris and Wu 1965: 1 case, Weisl 1972: 1 case). However, brain abscess occurred in one case afterinfectionof soft tissues and osteomyelitis. After two weeks of skull tracttion the patient had Jacksonian fits on the right side. Angiography revealed a brain abscess in the left frontoparietal region. At operation, continuity between the extracranial infection and the intracranial abscess could be observed. The patient improved after the operation and the seizures could be kept under control by anti-epileptic drugs. - This complication (brain abscess) has been previously reported in the literature (Tindall, Flanagan and Nashold 1959: 3 cases, Harris and Wu 1965: 1 case, Carey 1965; 1 case, Clarke 1965: 1 case, Jobnsson 1965: 1 case, Robertson 1965: 1 case, Jamieson and Yelland 1965: 1 case, Horwitz and Rizzoli 1967: 1 case, Weisl 1972: 2 cases). Intracranial bleeding such as extradural or intracerebral haematoma may rarely complicate skull traction. No such complication was revealed in our material. Extradural bleeding has been reported previously (Cooper and Drake 1962: 1 case, McCaul 1965: 1 case). Intracerebral haematoma is also mentioned in the literature (Drake 1962: 1 case). In these cases the intracranial bleeding was caused by penetration of the tongs into the intracranial space. Epileptic seizures. Epileptic seizures occurred in 3 cases in our material (3.4 % ) , in one of them as a symptom of brain abscess, in one as a symptom of penetration of the tongs and in one, the correlation between seizures and traction procedures was uncertain. In the second case x-ray examination showed that the end of the tongs was 1.5 mm inside the tabula interna on the right side. The patient had left-sided seizures with subsequent paresis in his left arm one month after the insertion of the Crutchfield tongs. The tongs were

immediately removed, the monoparesis disappeared one week later and on discharge the patient only complained of astereognosis of the left hand. One and a half years later, the patient still had Jacksonian fits starting in his left arm (and generalized epilepsy), approximately once every two to three months. Anti-epileptic medication was completely successful. Epilepsy alone does not seem to be mentioned in the literature as a complication of skull traction. Unusual complications. Rare complications have been reported such as local pressure necrosis of the scalp at the apex of the tongs (Amies and Andersson 1965: 1 case), deterioration of the spinal neurological conditions immediately after the application of skull traction, thrombosis of a cerebral artery, etc. In our material we have two cases of scalp necrosis, in the occipital region, because of too much pressure between the neck and the surface of the bed. - A well directed traction which does not permit friction between scalp and surface of the bed, will avoid such a complication. Impairment of the neurological conditions did notoccur in our material after insertion of Crutchfield tongs. Impairment of neurological symptoms after application of skull traction and even immediate death has however been reported in the literature (Amies and Andersson 1956: 1 case, Rogers 1957: 1 case, Cloward 1961: 1 case). Thrombosis of the midlle cerebral artery is described by Drake 1962 as a secondary complication of the infection in a case of extradural abscess. Among the more rare complications in our material we can mention a patient who had difficulty in swallowing because of the strained position and some patients who complained of headache, because of the tongs.

Discussion Complications of skull caliper traction (Crutchfield's tongs) seem to occur more of-

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ten than previously reported. To our knowledge there is no conclusive report on the frequency of complications due to the skull traction. Sixty-seven per cent of our patients treated by skull traction had complications. The tongs should be tightened daily to minimize the risk of slipping: it should be done carefully in order to avoid penetration of the intracranial cavity. Sterility in inserting the tongs and daily dressing of the wounds is, of course, necessary. In case of infection, new burr holes should be made in incisions located elsewhere and new tongs inserted. Too much traction can compromise a good reduction. In our opinion a proper aim is to obtain reduction of the dislocation progressively, with increasing weights within the first 12 hours. The load should be decreased as soon as the dislocation is corrected, under repeated x-ray control. The direction of the tractionis also important and the possibility of scalp necrosis

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between occiput and bed surface, because of abnormal pressure, should be kept in mind. Sedatives and neuroleptics should be used when necessary and particularly during the first week of skull traction.p Even although skull caliper traction is still a valualbe form of therapy in fracture dislocation of the cervical spine, the risk of the listed complications must be considered in evaluating other types of tongs and of treatment such as open fusion. Fusion may be a primary alternative when the patient is admitted to the hospital and not only as a remedy to unsuccessful skull traction. This applies particularly in elderly patients in order to mobilize them as quickly as possible and also in young patients with low cervical lesions(C V, C VI, C VII), if they are completely paraplegic, because of the risk of instability.

References 1 Amies, E. W., F. M. Andersson: Fracture of the odontoid process. Report of sexty-three cases. A.M.A. Arch. Surg. 72 (1956) 377-393 2 Cloward, R. B.: Treatment of acute fractures and fractures-dislocations of the cervical spine by vertebral-body fusion. A report of eleven cases. J. Neurosurg. 18 (1961) 201-209 3 Crutchfield, W. G.: Further observations on the treatment of fracture dislocations of the cervical spine with skeletal traction. Surg. Gynecol. Obst. 63 (1936) 513-517 4 Crutchfield, W. G.: Skeletal traction in treatment of injuries to the cervical spine. J.A.M.A. 155 (1954) 29-32 5 Drake, C: Cervical spinal-cord injury. J. Neurosurg. 19 (1962) 487-494 6 Harris, P., P. H. T. Wu: The management of patients with injury of the cervical spine using Blackburn skull calipers and the stryker turning frame. Paraplegia 2 (1965) 278 7 Hooper, R.: Observations on extradural haemorrhage. Brit. J. Surg. 47 (1959) 71

8 Horwiiz, N. H., H. V. Rizzoli: Postoperative complications in neurosurgical practice. The William and "Wilkins Company, Baltimore 1967 9 Jamieson, K. G., 1. D. N. Yelland: Cerebral abscess due to skull traction. Austral 6c New Zeeland J. Surg. 34 (1965) 301 10 Norton, W. L.: Fractures and dislocations of the cervical spine. J. Bone Joint Surg. 44A (1962) 115-139 11 Rogers, W. A.: Fractures and dislocations of the cervical spine. And end-result study. J. Bone Joint Surg. 39A ¡1957) 341-376 12 Taylor, R. G., J. R. W. Gleave: Injuries to the cervical spine. Proc. Roy. Soc. Med. 55 (1962) 1053-58 13 Tindall, G. T., J. F. Flanagan, B. S. Nashold Jr.: Brain abscess and osteomyelitis following skull traction. A report of three cases. A.M.A. Arch. Surg. 79 (1959) 638641 14 Weisl, H.: Unusual complications of skull caliper traction. J. Bene Joint Surg. 54B (1972) 143-145

Dr. G. Graziussi, Visiting doctor, Division of Neurosurgery, Ospedaie S. Gennaro, Naples, Italy

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Complications of Skull Caliper Traction

Complications of skull caliper traction.

Neurochirurgia 19 (1976), 122-125 © Georg Thieme Verlag Stuttgart Complications of Skull Caliper Traction G. Graziussi, M.D.*, L. Pellettieri, M.D.**...
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