a modified Delphi stu

CLINICAL ARTICLEJ Neurosurg Pediatr 27:649–660, 2021

ABBREVIATIONS HGT = halo-gravity traction.SUBMITTED September 21, 2020. ACCEPTED October 30, 2020.INCLUDE WHEN CITING Published online April 2, 2021; DOI: 10.3171/2020.10.PEDS20778.

Development of best practices in the utilization and implementation of pediatric cervical spine traction: a modified Delphi studyNikita G. Alexiades, MD,1 Belinda Shao, MD, MPH,1,2 Bruno P. Braga, MD,3 Christopher M. Bonfield, MD,4 Douglas L. Brockmeyer, MD,5 Samuel R. Browd, MD, PhD,6 Michael DiLuna, MD,7 Mari L. Groves, MD,8 Todd C. Hankinson, MD, MBA,9 Andrew Jea, MD, MHA,10 Jeffrey R. Leonard, MD,11 Sean M. Lew, MD,12 David D. Limbrick Jr., MD, PhD,13 Francesco T. Mangano, DO,14 Jonathan Martin, MD,15 Joshua Pahys, MD,16 Alexander Powers, MD,17 Mark R. Proctor, MD,18 Luis Rodriguez, MD,19 Curtis Rozzelle, MD,20 Phillip B. Storm, MD,21 and Richard C. E. Anderson, MD1

1Department of Neurological Surgery, Columbia University Medical Center, New York, New York; 2Rutgers New Jersey Medical School, Newark, New Jersey; 3Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas;

4Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; 5Department of Pediatric Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah; 6Department of Neurosurgery, University of Washington/Seattle Children’s Hospital, Seattle, Washington; 7Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut; 8Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland;

9Department of Pediatric Neurosurgery, Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado; 10Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana; 11Department of Neurosurgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, Ohio; 12Department of Pediatric Neurosurgery, Children’s Wisconsin, Milwaukee, Wisconsin; 13Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri; 14Division of Pediatric Neurosurgery, Cincinnati Children’s Hospital, Cincinnati, Ohio; 15Division of Pediatric Neurosurgery, Connecticut Children’s Hospital, Hartford, Connecticut; 16Department of Pediatric Orthopedic Surgery, Shriners Hospital for Children, Philadelphia, Pennsylvania; 17Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina; 18Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts; 19Department of Neurosurgery, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida;

20Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Alabama, Birmingham; and 21Department of Neurosurgery, University of Pennsylvania/Children’s Hospital of Philadelphia, Pennsylvania

OBJECTIVE Cervical traction in pediatric patients is an uncommon but invaluable technique in the management of cer-vical trauma and deformity. Despite its utility, little empirical evidence exists to guide its implementation, with most prac-titioners 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 elec-tronically along with a survey of current practices to a group of 20 board-certified pediatric neurosurgeons and orthope-dic 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. Con-sensus 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, indi-cations, and contraindications of traction (12), pretraction imaging (6), practical application and initiation of various trac-tion 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

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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 invagi-nation, irreducible atlantoaxial rotatory subluxation, cer-vical kyphosis, and os odontoideum.5–9 The overwhelming majority of existing literature that guides clinical practice is based on adult patients; pediatric studies consist primar-ily of small case series highlighting individual institution-al 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 general-ized.

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 investi-gating the use of HGT for preoperative correction of cervi-cal 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. Fur-thermore, 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 neurologi-cal 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 meth-od has been adopted by many medical subspecialties to enable the development of best-practice guidelines and statements in areas where systematic study is prohibi-tively challenging.15,23–27 The technique brings together a group of experts by first distributing an iterative series of structured anonymous questionnaires based on exist-ing literature and pertinent clinical questions. The anony-mous nature of initial rounds removes direct confrontation while still allowing for constructive criticism. The modi-fied technique often culminates in an in-person meeting in which areas near consensus on prior rounds of ques-

tioning 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 surgi-cal 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.

MethodsFocus 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) in-dications 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 par-ticipants to assess general practice patterns (described below). Primary survey responses were collected and analyzed, and potential consensus statements were for-mulated based on initial responses. A second survey was distributed to participants that included these statements. Results of the second survey were collected and state-ments were modified and revised. A face-to-face meeting was then convened to foster discussion and provide an op-portunity to revise statements that reached near consensus (60%–79%). A final document presenting consensus state-ments was generated.

ParticipantsNineteen pediatric neurosurgeons and one pediatric

orthopedic surgeon from children’s hospitals in North America with experience in managing children with cer-vical 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 col-laboration, clinical experience and volume, prior research into pediatric cervical pathologies, and membership in academic pediatric neurosurgical and spine organizations.

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 multidisciplin-ary group of pediatric spine experts using a modified Delphi technique. Further study is required to determine if imple-mentation of these practices can lead to reduced complications and improved outcomes for children.https://thejns.org/doi/abs/10.3171/2020.10.PEDS20778KEYWORDS cervical spine traction; cervical spine deformity; modified Delphi method; cervical spine trauma


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Initial SurveyUsing SurveyMonkey (SVMK Inc.), we distributed a

54-item online survey to participating surgeons in Octo-ber 2018. The survey was segmented into 5 sections with initial questions acquiring background information on the participants, followed by sections detailing goals, indica-tions, and contraindications of traction; pretraction imag-ing; placement and management of traction; and compli-cation 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. Par-ticipants 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.

Delphi Round 1Responses from the initial survey were used to gener-

ate 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 state-ment 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 elec-tronically 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.

Delphi Round 2A face-to-face meeting was held in December 2018

with 12 participants in attendance. An anonymous au-dience 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 state-ments 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.

ResultsParticipant Characteristics

Of the 20 participants invited to participate in the study, 100% completed the initial survey of current prac-

tices. 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 MethodThe 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 ante-rior or posterior approaches to the craniovertebral junction or subaxial spine” (79%). 2) “In the absence of neurolog-ic 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 deformi-ties” (73.7%). 5) “Halter traction may be used in patients of any age” (79%). 6) “Cervical traction should be con-sidered for the reduction of coronal deformity” (73.7%). 7) “Cervical traction should be considered for coronal de-formities 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%).

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 re-quired for children < 6 years of age prior to placement of halo” (57.9%). 4) “If first line management of pin site in-fections fails, pin removal should be performed” (63.2%). An additional 8 statements listed in Table 4 did not reach consensus.

Ultimately, the group elected to revisit the above 4 in-determinant statements in addition to the 12 statements near consensus. Using the Delphi method, 5 statements near consensus and 4 indeterminate statements were sub-sequently 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 disagree-ment (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 par-


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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 termina-

tion of traction?CONTINUED ON PAGE 653 »



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ticipants present at the face-to-face session agreed to sup-port the publication of the resulting consensus statements.

DiscussionIn this study, we demonstrate that by using a modi-

fied Delphi method, a multidisciplinary group of pedi-atric cervical spine experts was able to reach consensus on 49 statements regarding utilization and implementa-tion 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 nu-ances of cervical traction in the pediatric population. Fur-thermore, they establish a foundation of consensus state-ments on which future research can be built.

Unquestionably, cervical spine traction provides sig-nificant benefit when employed in appropriate clinical scenarios. While nearly all neurosurgeons have some ex-perience 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 indi-cations and contraindications, types of traction appropri-ate for different age groups, protocols for implementation, and management of complications associated with trac-tion. 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 clini-cians, 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 sys-tematizing consensus building by employing repeated ad-ministration 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 Del-phi method in this study led to 49 consensus statements

regarding multiple aspects of the utilization and imple-mentation of pediatric cervical spine traction, including goals, indications, contraindications, imaging, manage-ment protocols, and complications.

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

The broad category of goals, indications, and contrain-dications 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 pop-ulations. Following the initial Delphi round, 12 statements reached consensus with an additional 7 statements reach-ing consensus after the second, in-person Delphi session.

Four statements regarding overarching goals of cervi-cal traction reached consensus, including 1) reduction of sagittal deformity (94.75% strongly agree or agree); 2) re-duction 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 main-tain 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 cervi-cal 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, expe-rience and clinical judgment are imperative. These state-ments 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 invagi-nation” (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 uni-

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TABLE 1. Round 1: Electronic survey of current practices

47. Second line management of pin site infections should include: topical antibiotics, intravenous antibiotics, pin removal, pin exchange and/or termi-nation 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.


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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. CONTINUED ON PAGE 655 »



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lateral 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 in-dicated for unilateral or bilateral jumped facets” (100%).

Two statements regarding pathologies in which traction is contraindicated reached consensus: “traction is contra-indicated in atlantooccipital dislocations” (100% strongly agree or agree) and “in traumatic distraction injuries” (94.74%). The group acknowledged the role of rigid im-mobilization 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 Del-phi round: Gardner-Wells traction is contraindicated in patients with 1) osteogenesis imperfecta (94.73%), 2) open fontanelles (94.73%), and 3) “halo traction is contraindicat-ed 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 consen-sus 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 em-ploying 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 appropri-ate 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 im-aging in various clinical scenarios. A total of 6 statements regarding pretraction imaging reached consensus follow-ing 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 ra-diographs should be obtained prior to initiation of trac-tion to evaluate for reducibility. With regard to MRI, the group agreed that deformity patients should obtain cervi-cal spine MRI prior to the initiation of traction (89.47%), and that when available, cervical spine MRI should be ob-tained 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 empha-sized 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’ prefer-ences for operative planning and minimization of radia-tion exposure. Contrary to some pediatric orthopedic lit-erature,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 ob-tained if there is any suggestion of skull abnormality or hydrocephalus (94.74%). These 2 statements emphasize


TABLE 2. Round 2: Building consensus for best practices

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 im-

provement, 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.


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TABLE 3. Final consensus for best practices to guide the use of cervical spine traction

Consensus (%)

TotalStrongly Agree Agree

Goals, indications, & contraindications 1. Goals of cervical traction include reduction of sagittal deformity. 94.75 63.16 31.58 2. Goals of cervical traction include reduction of reducible deformities. 100 84.21 15.79 3. Goals of cervical traction include reduction of dislocations. 100 57.89 42.11 4. Goals of cervical traction include simplification of surgery to anterior or posterior approach to the craniovertebral junction or subaxial spine.

100 100 0

5. Cervical traction should be considered for kyphotic deformities greater than 31 degrees or based on reducibility on flexion-extension radiographs.

94.74 26.32 68.42

6. In the absence of neurologic symptoms traction should be considered for nonreducible atlantoaxial rotary subluxation. 100 100 0 7. In the absence of neurologic symptoms traction is indicated for unilateral or bilateral jumped facets. 100.0 42.11 57.89 8. In the presence of neurologic symptoms traction should be considered for unilateral or bilateral jumped facets. 100 100 0 9. Preoperative cervical traction should be considered for reduction of basilar invagination. 89.48 26.32 63.16 10. Preoperative cervical traction should be considered for reduction of kyphotic deformities. 89.48 42.11 47.37 11. Preoperative cervical traction should be considered for reduction of swan neck deformities. 100 100 0 12. Cervical traction is contraindicated in atlantooccipital dislocations. 100 89.47 10.53 13. Cervical traction is contraindicated in traumatic distraction injuries. 94.74 47.37 47.37 14. Gardner-Wells traction is contraindicated in patients with osteogenesis imperfecta. 94.73 21.05 73.68 15. Halo traction is contraindicated in patients with open fontanelles. 89.48 10.53 78.95 16. Gardner-Wells traction is contraindicated in patients with open fontanelles. 94.73 21.05 73.68 17. Halter traction may be used in patients of any age. 100 100 0 18. Placement of a halo should not be used in patients less than 1 year of age. 100 100 0 19. Gardner-Wells tongs should not be used in children less than 3 years of age. 100 100 0Pretraction imaging 20. Cervical spine radiographs should be obtained prior to the initiation of traction. 100 63.16 36.84 21. If not clinically contraindicated, flexion-extension or lateral bending radiographs should be obtained prior to initiation of traction to evaluate for reducibility.

100 42.11 57.89

22. A head CT is not required for children prior to placement of halo. 100 100 0 23. Cervical spine MRI should be obtained prior to initiation of traction in deformity patients. 89.47 52.63 36.84 24. When available, cervical spine MRI should be obtained prior to initiation of traction in trauma patients without neurologic deficits.

89.48 42.11 47.37

25. When available, cervical spine MRI should be obtained prior to initiation of traction in trauma patients with neurologic deficits.

84.22 42.11 42.11

26. If there is reason to suspect skull abnormality or hydrocephalus, dedicated skull or cranial imaging should be obtained prior to initiation of traction.

94.74 42.11 52.63

Traction initiation guidance 27. When placing a halo in children 1–2 years of age at least 8 pins should be used. 94.74 31.58 63.16 28. When placing a halo in children 3–5 years of age at least 6 pins should be used. 94.73 36.84 57.89 29. When placing a halo in children greater than 12 years of age at least 4 pins should be used. 94.74 42.11 52.63 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.

100 15.79 84.21

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.

94.74 31.58 63.16

32. When placing a halo in children greater than 8 years of age pins should be tightened to between 6 and 8 inch- pounds.

84.21 10.53 73.68

33. When placing a halo, pins should be tightened at placement and at least one additional time. 94.73 36.84 57.89 34. A thoracic bump or bolster should be used as needed in very young patients undergoing traction due to head size. 100 31.58 68.42Traction protocol guidance 35. Muscle relaxants should be routinely given to patients undergoing traction unless medically contraindicated. 94.74 15.79 78.95

CONTINUED ON PAGE 657 »



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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 pe-diatric patients.31,32 It is unclear how these data general-ize 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 tight-ness 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 tight-ened based on age, skull thickness, and number of pins placed (94.74%). In patients greater than 8 years, consen-sus 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 consen-sus that a thoracic bump or bolster should be used as need-ed in very young patients (100%).

Best-Practice Statements Surrounding Traction ProtocolsThe diverse array of cervical pathologies that may re-

quire cervical traction presents a challenge in standardiz-ing any traction protocols. Appropriate initial weight, total


TABLE 3. Final consensus for best practices to guide the use of cervical spine traction

Consensus (%)

TotalStrongly Agree Agree

Traction protocol guidance (continued) 36. Starting traction weight in trauma and deformity patients should be based on age, level of injury or region of deformity.

100 42.11 57.89

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.

100 47.37 52.63

38. Repeat cervical spine radiographs should be obtained upon each addition of weight in patients undergoing traction for traumatic indications.

94.74 31.58 63.16

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.

89.48 26.32 63.16

40. Once at goal weight, cervical spine radiographs should be obtained, with additional imaging as clinically indicated, in patients undergoing traction for traumatic indications.

100 26.32 73.68

41. Once at goal weight, cervical spine radiographs should be obtained, with additional imaging as clinically indicated, in patients undergoing traction for deformity correction.

100 26.32 73.68

42. Neurologic exams by a physician or equivalent provider should be performed after each addition of weight and at least once daily.

100 57.89 42.11

Traction complication management 43. Pin site care should consist of cleaning with alcohol, betadine, hydrogen peroxide, saline, or chlorhexidine. 94.74 31.58 63.16 44. Pin site care should be performed at least once a day. 94.74 31.58 63.16 45. Oral or topical antibiotics should be considered for first line therapy of pin site infections. 100 100 0 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.

100 42.11 57.89

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.

94.74 42.11 52.63

48. Cervical spine radiographs should be obtained in the event of any neurologic changes. 100 68.42 31.58 49. Cervical spine MRI should be obtained in the event of any persistent neurologic changes after the removal of weight. 100 63.16 36.84


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and goal weight, traction duration, and timing of imag-ing 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 con-tinued 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

TABLE 4. Cervical traction practices that did not reach consensus

Intervention

Response (%)

SummaryStrongly Agree Agree Disagree

Strongly Disagree

1. Cervical traction should be considered for the reduction of coronal deformity. 26.32% disagree 10.53 63.16 26.32 0.002. Cervical traction should be considered for coronal deformities greater than 31

degrees or based on reducibility on lateral bending radiographs. 21.05% disagree 10.53 68.42 21.05 0.00

3. In the presence of neurologic symptoms traction is indicated for atlantoaxial rotary subluxation.

47.37% disagree 21.05 31.58 42.11 5.26

4. Preoperative cervical traction should be considered for reduction of coronal deformities.

26.32% disagree 5.26 68.42 26.32 0.00

5. Halo traction is contraindicated in patients with osteogenesis imperfecta. 47.37% disagree 15.79 36.84 42.11 5.266. When placing a halo in children 6–12 years of age at least 6 pins should be used. 31.58% disagree 21.05 47.37 31.58 0.007. Patients with cervical spine deformity should be maintained in traction for no

longer than 2 weeks.42.11% disagree 15.79 42.11 42.11 0.00

8. Pin site care should include application of antibiotic ointment. 31.58% disagree 21.05 47.37 21.05 10.539. Antibiotic ointment should be used as first line therapy for pin site infections. 36.84% disagree 5.26 57.89 36.84 0.0010. If first line management of pin site infections fails, intravenous antibiotics should

be initiated. 36.84% disagree 5.26 57.89 36.84 0.00

11. If first line management of pin site infections fails, traction should be terminated. 89.48% disagree 0.00 10.53 78.95 10.53

TABLE 5. Round 3: Revisions to selected statements at in-person meeting to achieve consensus

Initial Statement Final 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 indi-cated 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%)



Alexiades et al.

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. Con-sensus 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 de-formity (100%) patients, consensus was reached that “re-peat cervical X-rays should be obtained once at goal weight with additional imaging as clinically indicated.” Two addi-tional 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 relax-ants should be routinely given to patients undergoing trac-tion 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, intracra-nial pin migration, and pin site infection, are commonly reported in the literature and most often managed con-servatively.20,22 At their most extreme, pin site complica-tions 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 con-sist of cleaning with alcohol, betadine, hydrogen peroxide, saline or chlorhexidine” (94.74%). Variation in individual practices, and the general lack of evidence, limited consen-sus 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 ap-propriate 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 improve-ment 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 StudiesConsensus-driven studies such as this have limitations

inherent to their design. The need for such a study high-lights 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. Fur-thermore, 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 com-munity settings is not clear. Additionally, while our par-ticipant 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.

ConclusionsIn an attempt to improve and standardize the use of

cervical traction in pediatric patients, we present 49 best-practice recommendations generated by reaching consen-sus among a multidisciplinary group of pediatric spine ex-perts using a modified Delphi technique. These statements aim to provide a broad clinical framework for clinicians employing pediatric cervical traction. Further study is re-quired to determine if implementation of these practices can lead to reduced complications and improved outcomes for children.

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

Author ContributionsConception and design: all authors. Acquisition of data: all authors. Analysis and interpretation of data: all authors. Draft-ing 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.

CorrespondenceNikita G. Alexiades: The Neurological Institute of New York, Columbia University Medical Center, New York, NY. [email protected].


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