Avila University

Analysis of Spinal Decompression via Surgical Methods and Traction Therapy

Paige Barrett

BI 499

Dr. Fitch

December 9, 2014

Introduction

Americans have an 80 percent chance of encountering back pain in their lifetime

(Cutts and Clark, 2004). This literature review will look at and evaluate the methods for

spinal decompression in the treatment of back pain and injuries used in today’s United

States healthcare system. This project is worth conducting because back pain, especially

low back pain (LBP), is responsible for higher instances for anxiety, depression, and

somatization and not all back pain is being remedied (Bener et al., 2013). In fact, “about

1% of the U.S. population… is disabled as a result of LBP (Tekur et al., 2008).”

According to Hampton (2004), LBP is responsible for an annual health care spending of

$90 million. As a Pre-Health/Pre-Physical Therapy major, this subject is relevant to my

degree as well as to my future career field. This literature review will examine the current

methods for the treatment of back pain and injuries through both surgical and non-

surgical spinal decompression. Decompression methods were chosen because of the

support that compression of spinal structures directly effects neurologic function which

includes pain and disability (Reinhold et al., 2010). Both acute and chronic back pain will

be treated in these studies, with acute accounting for back pain lasting 6-16 weeks and

chronic lasting more than 1 year (Chanda et al., 2011). Surgical treatment in the cervical,

thoracic, and lumbar spine will be covered as well as traction therapy, a well-known non-

surgical decompression option. After summarizing these treatment options, I will then

attempt to point out the strengths and weaknesses of each. I will also analyze them for

areas of possible improvement.

Surgical Decompression

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Cervical Spine

The timing of the surgery can have an effect on the neurological outcome of

cervical spinal decompression surgery. Fehlings et al. (2012) conducted a study in which

early (>24 hrs) and delayed (<24 hrs) spinal cord injury surgeries were compared on their

ability to produce a good outcome. Two hundred twenty-two patients provided follow

ups after surgery at the 6 month mark, of whom 19.8% of early surgery patients had

improvement in impairment and 8.8% of delayed surgery patients had improvement in

impairment. Also, 45.9% of all of the patients had no improvement in impairment. It is

thus suggested that early decompression surgery on cervical spinal cord injury produces a

better outcome than delayed surgery. A study produced by Cadotte et al. (2010) supports

these findings and points out that it is the prevention of the destructive nature of

prolonged compression that is partly responsible for the better outcome in early surgery.

There is a debate on what the optimal timing of surgery for this specific injury is, but it is

generally agreed that the early timeframe is within twenty-four hours after injury.

A treatment strategy utilized for cervical myelopathy, or spinal cord disease, is

circumferential decompression and fusion. This approach uses cages, pedicle screws, and

rods for fusion. A study conducted by Aryan and colleagues (2007) attempted to

deemphasize high morbidity rates associated with this approach. They analyzed fifty-

three patients who underwent the procedure at the University of California, San

Francisco, and found that none of the patients died due to surgery. In fact, eighty-five

percent of patients had improvement in pain. This study’s outcomes could be different

from the prior morbidity rate because patient inclusion was stricter, the procedure was

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more efficiently carried out, and there was no use of post-surgery halos. It can be

concluded from this study that circumferential decompression with fusion is a very

effective strategy to combat cervical myelopathy.

A treatment option for cervical spinal cord compression currently being explored

is the extended anterior cervical foraminotomy (EACF) approach which was proposed by

Kim et al. (2014). The authors wanted to address the problem of complications related to

treating cervical decompression with fusion by creating an approach that does not use

fusion. Twenty-two patients were operated on to address radicular and myelopathic

symptoms and were evaluated using VAS scores preoperatively and at postoperative

follow up which averaged 30.36 months. The VAS score was significantly improved at

follow up and no procedure-related complications arose. This study was very small and

the patients were heterogeneous in age and duration of symptoms. To validate this

approach, larger, stricter studies need to be conducted and longer follow up periods need

to be implemented.

Thoracic Spine

In the thoracic spine, the posterior longitudinal ligament can become ossified and

push on the spinal cord. This pressure can cause myelopathy and decompression surgery

has been shown to improve neurological function. Yamazaki et al. (2010) used posterior

decompression with instrumented fusion (PDF) to treat thoracic myelopathy due to

ossification of the posterior longitudinal ligament. In a study that included 24 patients,

this procedure was performed and Japanese Orthopaedic Association (JOA) improvement

scores were recorded before surgery and then at 3, 6, 9, and 12 months after surgery. The

final follow-up was at four years and five months, on average. The study lasted from

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1989 to 2004 and the procedure first involved the use of hooks, but later utilized pedicle

screws for fusion. The JOA scores showed improvement in all patients at a recovery rate

of 58.1%. These scores peaked at nine months after surgery. This study showed that PDF

improves neurological functioning and that recovery progresses slowly. Also, they

detected continuing pressure on the anterior side of the spinal cord, but neurological

recovery still progressed. This showed that the posterior fusion promoted neurological

recovery even with continuing anterior compression.

For patients with tuberculosis (TB) of the thoracic spine, the efficacy of video-

assisted thoracoscopic surgery (VATS) is being explored. Kapoor and colleagues (2012)

conducted a retrospective study on VATS in thirty patients with TB with a minimum

five-year follow up. The surgery was performed with or without fusion and the data

collected included: blood loss, operative time, postoperative incision pain, duration of

hospital stay, neurological recovery, and progression of deformity. At final follow up

(60-90 months), 95% of patients were assigned an excellent or good outcome. It can be

concluded that VATS is a suitable approach to decompression surgery in the thoracic

spine of TB patients.

Haufe et. al (2010) executed a prospective study utilizing ten patients for the

treatment of thoracic disc pain or herniation to test the efficacy of percutaneous laser disc

decompression (PLDD). The inclusion criteria for the study consisted of failed

conservative treatment and confirmed discogenic compression as the source of pain. The

PLDD procedure utilizes a laser inserted into the nucleus pulposus of the affected disc

that evaporates water within the disc. This reduces the pressure within the disc to

effectively reduce pressure placed on surrounding structures. Water is not reabsorbed due

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to protein denaturation. This is a minimally invasive surgery and patients are only mildly

sedated during the procedure. The patients reported VAS scores preoperatively and

postoperatively at six-month intervals. Final follow up (18-31 months) revealed that VAS

scores significantly improved for thoracic pain. The size of this study is very small and a

larger study with a control group is needed to further test the efficacy of this approach.

Also, the authors note that laser selection is not conclusive among surgeons and that no

consensus has been reached on which type is best. This study provides an initial step in

the direction of providing another minimally invasive option for treating thoracic disc

pain.

Lumbar Spine

Surgical intervention in the lumbar spine can be performed with or without

fusion, with interbody cages, and can treat herniated discs and degenerative diseases, to

name a few. In a controlled study carried out by Antonio E. Castellvi et. al. (2014), a

surgical approach to indirect decompression of the vertebral discs and spinal canal was

observed in the lumbar spine. The lateral transpsoas approach was utilized to place an

interbody cage at the site of a collapsed disc and fuse the vertebral bodies. The disc is

removed in this process and is replaced by this cage for maximum stability. The cage

then provides ligamentotaxis, or continual longitudinal distraction. By correcting the

spinal distortion, the disc(s) and spinal canal are effectively decompressed. In this study,

pedicle screws were also utilized for the stabilization of the lumbar spine. Thirty-six

patients were effectively evaluated using CT scans, visual analogue scale (VAS) scores,

and Oswestry Disability Index (ODI) scores. The average age of patients was sixty-six

years and they all suffered from degenerative lumbar stenosis and unsuccessful non-

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surgical treatment. Exclusion factors were previous lumbar surgery, a fused facet, or

drifted disc fragment. There was improvement of each factor measured and each was

maintained at the one year mark. These included: spinal canal area, disc height, foraminal

area, VAS score, and ODI score. There was no statistical difference between three

months and one year. A longer follow-up period would be useful in determining the long-

term efficacy of the lateral approach. From these findings, it can be concluded that this

approach is effective in achieving at least short term decompression and lessening back

pain due to degenerative lumbar stenosis.

Surgical decompression without fusion was utilized by Mannion and colleagues

(2010) in patients suffering from degenerative lumbar spinal disorders. In this study, 143

patients underwent decompression surgery and had follow-ups at the five year mark. In

seventy-six percent of patients, leg pain and disability significantly decreased and this

outcome was maintained at the five year follow up. The other twenty-four percent of

patients were re-operated on and had significantly worse outcomes than the patients who

did not undergo additional surgery. For both groups, low back pain was not significantly

reduced. Having a five year follow up strengthens the current knowledge of how long

these procedures can maintain results and this study is valuable in this regard. It should

also be noted that while disability and leg pain improved, low back pain could not be

significantly alleviated. This is important because people should know going into these

surgeries that their low back pain may not decrease.

Another study that had five-year follow ups was performed by Anjarwalla and

colleagues (2007). They looked at leg and back pain, used the ODI, and SF-36 (general

health questionnaire) in a group presenting with lumbar spinal stenosis who underwent

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decompression surgery. Fifty-one patients completed follow ups at 6 weeks, 1, and 5

years, revealing initial significant improvement in leg and back pain, physical function,

and social function. The greatest improvement is found at the one-year mark, while a

slight decline is seen at the five-year mark. All categories remained significantly

improved at the five-year mark, except for social functioning which did not remain

significantly improved from the baseline score. This could be due to psychological and

psychosocial factors as well as an uncertainty about their surgery success. Since the other

physical categories all improved, it is clear that decompression surgery is successful in

treating spinal stenosis.

When treating lumbar herniated discs, the goal of surgery is to decrease the

subsequent leg pain, as reported by Kleinstueck et al. (2011), and not necessarily treat

back pain. Also, the more back pain being reported pre-surgery is a good indicator that

there is a significantly less chance of a good outcome. Three-hundred eight patients were

utilized in this study on the correlation of pre-surgery back pain and post-surgery

outcome. The findings were that of the patients with high back pain, 69% had a good

outcome, whereas, patients with more leg pain had 84% good outcome. This is another

indicator that decompression surgery may not alleviate low back pain.

Lumbar nerve root compression can cause severe radiculopathy, which involves

muscle weakness and pain. Doi et al. (2011) performed a retrospective study on

seventeen patients who underwent intraforaminal and extraforaminal endoscopic

decompression, a minimally invasive surgery, to determine the efficacy of this approach.

A protruding disc was found using CT at the affected level in thirteen of the patients.

While JOA scores improved from preoperative to final follow up, 29% of patients had a

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reoccurrence of symptoms and underwent subsequent surgery. The authors discuss the

difficulty of correctly diagnosing the location of stenosis (which was present in all

patients) and that this difficulty might have caused the reoccurrence of symptoms. They

speculated that fusion might be a better option for posterior approaches. This study was

limited by size and a short follow up period which averaged 10.8 months. More

investigation is needed to determine the efficacy of this approach.

In a cadaver study conducted by Lauryssen et al. (2012), hemilaminotomy with

foraminotomy (HL) was compared to the use of a minimally invasive MicroBlade

Shaver® iO-Flex® system in decompression of lumbar stenosis. Bone, ligament, and soft

tissue were assessed using radiographic imaging. HL is a recognized decompression

surgery technique that is invasive, removing a lot of bone from the vertebra and leading

to post-surgery instability. The iO-Flex® is utilized for being minimally invasive and

producing as good or better results than HL. The study confirmed that HL required

significantly more laminar area removal (83%) than the iO-Flex® while the iO-Flex®

produced a greater foraminal width than did HL. Overall, the iO-Flex® system both

produced more decompression and maintained structures better than HL. Using this

MicroBlade Shaver® would produce decompression more efficiently as well as reduce

instability after surgery. Further research on live patients needs to be conducted to

confirm these findings.

Another cadaver study focusing on minimally invasive decompression surgery

was accomplished by Smith and colleagues (2014). Smith looked at the biomechanical

effects produced by minimally invasive unilateral approach, traditional with facet-sparing

approach, and traditional with non-facet sparing approach on the lumbar spine. Range of

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motion (ROM) was evaluated initially and then after each procedure was completed.

They found that the minimally invasive approach created less ROM in flexion-extension,

axial rotation, and lateral bending toward the approach side when compared to the

traditional approaches. These findings are consistent with the study conducted by

Lauryssen et al. (2012), but improve them by also comparing traditional approach with

facet-sparing surgery to the minimally invasive approach. As these are both cadaver

studies, more studies on live patients need to be carried out.

Percutaneous decompression surgery was performed on forty patients with

neurogenic claudication as a result of lumbar spinal stenosis in a study conducted by

Mekhail and colleagues (2012). Pain and function-related results were evaluated by the

Pain Disability Index (PDI), Roland-Morris Disability Questionnaire, standing time,

walking distance, and Visual Analog Score (VAS). Follow ups occurred at 3, 6, 9, and 12

months after surgery. Compared to baseline scores, all pain and function-related

measures were significantly improved. This study showed the efficacy for percutaneous

decompression surgery to treat neurogenic claudication which results from lumbar spinal

stenosis. This is a less invasive procedure and its positive results are consistent with the

findings of other minimally invasive surgeries.

Another option for treating the neurogenic intermittent claudication (NIC) that

results from degenerative lumbar spinal stenosis (DLSS) is the implantation of

interspinous process decompression devices (IPDs). These devices are implanted between

spinal processes at the affected level and provide a continual flexion in the spine.

Alexandre et al. (2014) completed a study of one hundred patients who presented with

NIC due to DLSS that were treated at either one or two levels with the HeliFix IPD

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device. At the 12-month follow up, baseline scores for VAS, Roland-Morris, LBP, leg

pain, NIC, walking distance, and medication intake were all significantly improved. No

adverse effects were observed, although two patients had their IPD device removed due

to its not being effective. It can be concluded that the use of the HeliFix IPD is both safe

and effective, and should be considered for DLSS patients with failed conservative

treatment.

Weiner and colleagues (2007) questioned whether or not the preoperative

radiographic severity of lumbar spinal stenosis would determine the outcomes of surgical

decompression. In their prospective study, they included twenty-seven patients who had

degenerative spinal canal stenosis at the L4-L5 level. Each patient was given a survey,

both before and after surgery, to determine Neurogenic Claudication Outcome Score

(NCOS), a measure of pain and disability. Each patient’s MRI was evaluated to

determine cross-sectional area of the spinal canal which was used to determine severity

of the canal stenosis. The patients then underwent a minimally invasive decompression

surgery. It was found that when preoperative cross-sectional area of the spinal stenosis

was surgically reduced by more than fifty percent, all patients had satisfactory outcomes.

Also, for a reduction of 50% or less, 46% of patients reported an unsatisfactory outcome.

They concluded that patients presenting with more severe spinal canal stenosis would

have better surgical outcomes. They also hypothesized that a possible reason for this was

that their affected nerve root was stronger and allowed them to live pain-free long after

the onset of compression and also allowed them to recover more fully than those with

lesser degrees of compression. This, when investigated further, could be a very useful

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tool in predicting patient outcomes as well as informing patients of what to expect from

their decompression surgery.

In a more recent cohort study that was carried out by Ahn et al. (2014), an

endoscopic technique for treating lumbar foraminal stenosis was evaluated for its

effectiveness. The percutaneous endoscopic lumbar foraminotomy (ELF) is a minimally-

invasive technique that was performed on thirty-three patients. MacNab criteria, VAS

score, and ODI score were collected prior to surgery and then at 6 weeks, 1 year, and 2

years after. The modified MacNab criteria are used to assess clinical outcomes and, at the

final follow up, indicated that 81.8% of patients reported a good or excellent rating. Both

VAS and ODI scores were significantly improved at final follow up, with the greatest

improvement occurring at 6 weeks and slightly dropping at the 2 year follow up. This

approach has been shown to be effective at decompression and reducing pain and

disability. The most valuable aspect of this approach is that it is effective in targeting the

bony structures whereas, in past trials, other techniques had only targeted soft tissue.

These findings are consistent with results of other minimally invasive approaches.

Most patients presenting with back pain have comorbidities and Tsutsui et al.

(2013) conducted a study on lumbar spinal stenosis that was comorbid with degenerative

lumbar scoliosis (DLS). Their retrospective study was done to see whether or not

decompression surgery could improve low back pain (LBP) in this specific comorbid

instance. Forty-nine patients with lumbar spinal stenosis, DLS, and preoperative LBP had

decompression surgery and were evaluated using JOA score. Their radiologic data were

also evaluated for coronal and sagittal Cobb angles, apical vertebral rotation and

anteroposterior and lateral spondylolisthesis to determine whether or not a relationship

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existed between one or more of these and lingering postoperative LBP. After analysis, it

was found that 59.1% of the patients were alleviated of their LBP and that preoperative

apical vertebral rotation had a significant correspondence to postoperative lingering LBP.

The authors hypothesized that it was the DLS that had this effect on decompression

surgery for lumbar spinal stenosis and that, without this comorbidity, patients would have

better pain outcomes. They did not find that the amount of preoperative LBP

corresponded to either better or worse outcomes as Kleinstueck et al. (2011) did. They

suggested that fusion be added to the decompression in this instance to address the spinal

rotation due to DLS. It was shown by Aryan et al. (2007), Yamazaki et al. (2010), and

Castellvi et al. (2014) that decompression surgery with fusion produced an improvement

in LBP in the cervical, thoracic, and lumbar spine which gives credit to the hypothesis

presented by Tsutsui et al. (2013). Furthermore, Mannion et al. (2010) found that without

fusion, LBP was not significantly reduced in degenerative spinal disorders. It would seem

as though fusion would indeed have a beneficial effect for LBP.

A study was conducted by Reindl and colleagues (2003) for an elderly patient

population to determine the risks of spinal decompression surgery compared to total hip

arthroplasty. They included sixty-eight patients in the decompression group and sixty-

eight patients in the hip surgery group and evaluated their medical histories

retrospectively. The data collected included: age, gender, American Society of

Anesthesologists (ASA) score, early postoperative complication rate, operative time,

length of hospital stay, life-threatening complications, major complications, and minor

complications. The study found that only operative time was significantly longer in the

decompression group. The result that complication rate did not significantly differ

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between groups suggests that the decision to undergo decompression surgery in an

elderly patient is much like deciding to go through a total hip arthroplasty which is a

well-accepted plan of action.

Another study done on lumbar spinal stenosis was completed by Son et al. (2013).

They retrospectively compared decompression and decompression with fusion in

patients over sixty-five who had at least two affected levels of spinal stenosis. Sixty

patients were separated into either the decompression group or the fusion group and

underwent their respective surgeries. Leg pain and LBP were assessed before surgery and

again at 6 weeks, 6 months, 1 year, and 3 years after surgery using VAS and ODI scores.

The lumbar lordotic angle was assessed before surgery and at final follow up and Odom’s

criteria were given at the last follow up to determine overall satisfaction of the patients.

At final follow up, VAS leg pain, VAS LBP, and ODI scores were significantly improved

in both groups, but were not significantly different between groups. Although, at the six-

week mark, VAS LBP was significantly better in the decompression group compared to

the fusion group. The lumbar lordotic angle significantly improved in the fusion group at

final follow up, but not in the decompression group. There was no significant difference

in Odom’s criteria between groups. It can be concluded that in an elderly population with

multilevel lumbar spinal stenosis, both decompression alone and decompression with

fusion produce similar results. According to the authors, though, fusion may cause

instability in surrounding spinal structures, and a limitation to this study was that it was

conducted retrospectively, leaving room for different techniques to have been performed

and meaning that several different factors may have dictated which surgery was

undergone by each patient. It can also be noted that there is no difference in recovery

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with or without physiotherapy following surgery and up to two years afterwards

(Mannion et al., 2007).

Sang-Mi Yang and colleagues (2013) conducted a study that included at least 3-

year follow ups for lumbar spinal stenosis. The twenty-one patients underwent bilateral

microdecompression by unilateral or bilateral laminotomy (BML), a minimally invasive

surgery. The patients were evaluated pre- and postoperatively using JOA scores, leg pain,

LBP, and neurogenic claudication. All of these measures significantly improved at final

follow up except LBP. Sixty-two percent of patients had an excellent, good, or fair

outcome. The authors concluded that BML is effective at producing a good result in

treating lumbar spinal stenosis, but decompression with fusion could have been a better

choice for some of the older patients due to instability. Another method using a

microscope and tubular retractor system operates under the same hypothesis that

minimally invasive surgeries produce better results due to less tissue damage (Popov and

Anderson, 2012). This study was limited due to its retrospective nature and small patient

number.

Non-surgical Decompression

A clinical trial evaluating the correlation between disc height and low back pain

in patients with either lumbar disc degeneration or herniation who were treated with

motorized traction was carried out by Apfel and colleagues (2010). The trial included

thirty participants, all of whom underwent decompression therapy for six weeks. Pain

was measured on a 0-10 scale as voiced by the participants and disc height was measured

using CT. These measures were taken before and after the 6-week treatment and pain

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significantly decreased and disc height significantly increased. The results suggest a

correlation between disc height and low back pain, but since it was a cohort study and not

blinded, only correlation can be confirmed and not causation. Further studies have been

blinded and randomized to produce more sound results than this study. Also, pain was

reported verbally in the Apfel study and, as such, is subjective. A more objective rating of

pain is needed to create a more reliable scale with which to compare outcomes.

Another study that was conducted in a cohort fashion was performed by Yang and

Yoo (2014). They evaluated the effect of stretching the hamstring muscles in conjunction

with motorized traction. Twenty patients with L4-L5 herniated discs underwent a 4-week

treatment of traction and stretching and reported pain and function scores via VAS and

Oswestry scales. Both VAS and Oswestry scores were significantly reduced following

the treatment, but with no control group, this study is limited.

A study on traction as a means to alleviate discogenic low back pain using the

Intervertebral Differential Dynamics Therapy (IDD Therapy) was done by Schimmel et

al. (2009). This study was a blind and randomized control trial consisting of sixty

participants with low back pain lasting over a year who had previously tried other

therapeutic programs. The two groups were the IDD group and the SHAM group. The

IDD protocol includes 20 25-minute sessions over a span of 6 weeks that utilize

alternating decompression and rest periods per session using 50 percent of a person’s

body weight. The device used is the Accu-SPINA device in which the patient is in a

supine position with belts around the hips and chest and is intended to increase disc

vitality. The SHAM program followed the same treatment times, but did not use an

effective weight. Both therapies were added to an activity program. Fifty-six participants

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finished the program with follow-up analysis. For the VAS low back pain score, a

decrease was found in both groups, but no difference was detected between groups.

Similarly, the results for the ODI, Short-Form 36 (SF-36), and VAS leg pain improved in

both groups, but there was no difference between groups. Also, there was a decrease in

pain medication use in each group. Overall, time was an important factor in improvement

and there was no statistical difference between the IDD group and the SHAM group.

Possible error could be in the amount of weight being used in the treatment. With this

traction therapy being an added treatment to an activity program, it can be concluded that

IDD therapy does not improve results already being generated by an activity program. A

strength of this study is that it limited inclusion criteria to having a bulging disc or disc

disease, so in the case of these two maladies, IDD therapy is not an effective treatment.

Sari and colleagues (2005) conducted a study on horizontal traction using CT to

look at the effects of traction therapy on lumbar herniated discs in thirty-two patients.

They looked at “herniated area, spinal canal area, intervertebral disc heights, neural

foraminal diameter, and m. psoas diameter.” They found that herniated area and m. psoas

diameter were reduced and that spinal canal area and neural foraminal diameter

increased. Disc height increased on the posterior side, but was static on the anterior side.

These findings, while useful in concluding that traction therapy has a physical effect,

could have been more valuable had they been compared with pain and disability

outcomes.

Onel et al. (1989) compares outcomes in disability and pain with physical changes

occurring with traction. This was accomplished using CT, physical measurements, and

the Global Clinical Evaluation. They found that 93.3% of the 30 patients that underwent

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the traction therapy improved in function and pain. Overall, they found that traction

treatment of median and posterolateral herniations resulted in better outcomes than did

treatment of lateral herniations.

Low back pain patients with various maladies were analyzed for changes in disc

space in a traction study by Cevik et al. (2007). This study utilized a traction table which

put the patients in a prone position as apposed to the widely used supine position. Three

groups were assigned: traction with heating therapy, sham traction with heating therapy,

and traction with heating therapy occurring prior to traction. The sham group only

produced one significant widening of disk space (L5-S1), while the other two groups

produced significant widening in L1-L2, L3-L4, and L5-S1 disc spaces. The traction with

heating therapy group also produced significant widening in L2-L3 and L4-L5 disc

spaces. The study concluded that significant decompression occurred in more disc spaces

in the traction with heating therapy group than in the sham traction with heating therapy

and traction with heating therapy occurring prior to traction groups. Also, the prone-

positioning traction table used produced results consistent with supine-positioning tables.

Heating therapy used during traction produced the best results, suggesting that it

promotes decompression. This could be achieved because the heat relaxed the muscles

involved.

Chronic neck pain was treated using either traction or infrared irradiation (control

group) in a study produced by Chiu and colleagues (2011). Computerized randomization

placed 40 people into the traction group and 39 people into the control group.

Measurements included the Chinese version of Northwick Park Neck Pain (a disability

score), verbal numerical pain scale, and cervical active range of motion. No significant

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difference was found between groups at the final follow up of twelve weeks. From this

study, it can be concluded that traction therapy for chronic neck pain is not a viable

treatment.

In a study done by Guvenol et al. (2000), traction therapy to treat lumbar disc

herniation was compared to inverted spinal traction, a traction technique that effectively

hangs the patient from his or her ankles in order to use gravity to produce a pull in the

spine. Eleven patients in the traction group and twelve patients in the inversion group

completed final follow up. Measurements were taken before the first treatment, after the

last treatment, and three months after the last treatment and included: straight leg test,

finger-to-floor distance, deep tendon reflexes, sensory impairment, motor strength, verbal

pain score, and CT. Significant improvement was seen in both groups for verbal pain

score and straight leg test at final follow up, but there was no difference between groups.

Before treatment, the traction group had a significantly greater disc protrusion than the

inversion group and at final follow up, the investigators found that disc protrusion

significantly decreased in the traction group. At final follow up, there was no difference

between groups regarding amount of disc protrusion. The limitations of this study

include: size, lack of randomization, and lack of a control group. This study seems to be

preliminary and does not proclaim efficacy for either traction or inverted traction.

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Table 1. Analysis of ArticlesContents Surgical Treatment (n=18) Traction Therapy (n=8)

No Control Group 90% 66%Study Size (<20) 15% 16%Study Size (21-50) 45% 50%Study Size (>51) 40% 33%Date of Publication (<2000)

0% 16%

Date of Publication (2001-2010)

30% 66%

Date of Publication (>2011)

70% 0%

Treatment Success 93% 25%Reductions Pain Only Deformity Only Both Neither

0% 6% 93% 0%

12% 25% 25% 37%

Reductions Recorded Immediately Long Term (>12mo) Early & Maintained

(>12mo)

6% 0% 93%

100% 0% 0%

Strengths Strict inclusion/exclusion criteria

Long-term follow up

Weaknesses No control group No control group Weak proof of

causation Short-term follow

upFollow Up Time Most 1-5 years Most immediate-14 weeks

Conclusion

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Surgical decompression is often successful in lessening back pain and disability

by a significant amount, and the improvement is often maintained at twelve months. In

the lumbar spine, surgery may only improve the subsequent leg pain and functional

movement, but not necessarily improve low back pain (Mannion et al., 2010; Kleinstueck

et al., 2011). This is important for a patient to know before electing surgery: a reduction

in leg, but not back pain may be a more realistic expected outcome than a reduction of leg

and back pain. It is difficult to produce an overall rating for the efficacy of treatments in a

review paper such as this one, because problems at different levels of the spine can lead

to different outcomes after a given treatment, and because different diagnoses can lead to

different outcomes after a given treatment. So far, it can be concluded that minimally-

invasive surgical approaches are more effective than more invasive techniques at

producing decompression and at reducing the risk for multiple adverse effects (Haufe et

al., 2010; Mekhail et al., 2012; Ahn et al., 2014; Yang et al., 2013; Popov and Anderson,

2012). A better understanding of these outcomes might emerge if more studies were

conducted and if more existing studies were reviewed for an analysis such as the one

being attempted here. Regarding clinical trials involved in both surgical and traction

studies, the number of participants used is usually small. If these numbers could be

increased in future investigations, a greater amount of data could be produced for each

trial, leading to more confidence in the conclusions that are drawn. Surgical studies

usually include large numbers of participants, but are often conducted epidemiologically.

The problems with this approach are that data prior to treatment may not be available,

and/or the methods used to collect data before the study may be different from methods

used to collect data after the study. For surgical treatment, however, epidemiological

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studies may be the best way to conduct research because large populations are available

and treatment details are usually provided.

In regards to traction therapy, there are mixed outcomes regarding the

effectiveness of traction versus sham traction. Using CT, it can be seen that traction

produces physical changes in spinal structures, but, overall, whether these changes

produce pain lessening is unclear (Sari et al., 2005; Cevik et al., 2007). A study discussed

in this paper that included a control group and was blinded revealed that there is no

difference in pain reduction between traction therapy and physical activity programs

(Schimmel et al., 2009). Similar findings were produced in a literature review conducted

by Gay et al. (2005), in which the authors concluded that there was not as yet sufficient

evidence to support the safety and success of traction therapy. Heterogeneous patient

inclusion as well as small sample size and lack of randomization are to blame for the low

quality of many studies regarding traction therapy (Macario and Pergolizzi, 2006). Also,

many studies, both surgical and traction, are conducted with only a cohort group, or are

conducted without a control group. Additional studies that are randomized, double-

blinded, and large need to be conducted to evaluate the efficacy of traction therapy for

treating back pain. Moreover, traction therapy is a very expensive treatment, and its cost

is contributing to the healthcare spending on back pain patients (Daniel, 2007).

In conclusion, as things now stand, there appears to be no easy way for a

particular patient with back pain to make a decision regarding the type of treatment to

choose. In general, this review finds that traction therapy is often not more effective than

control treatments, especially regarding long-term effectiveness. Thus, before electing

traction therapy, a patient should probably ask the physician for references to studies in

22

which the diagnosis, exact type of traction therapy, and affected spinal region (cervical,

thoracic, or lumbar) in the study matches his or her own situation. If studies can be found

in which these three criteria match the situation of the patient, and if these studies show

that traction therapy produced long-term improvement relative to control therapy, then

electing traction therapy may be a reasonable choice.

In general, surgical approaches to treating back pain appear to be more effective

than traction therapy. This statement, however, absolutely cannot be viewed as blanket

advice advocating surgery for back pain. Instead, it appears that the only way for a

patient to make a truly informed choice will be to carefully read the available literature, a

task that is very difficult for the lay person. In reading the literature, the patient needs to

be aware of several issues. One issue is that the efficacy of surgical intervention (like

that of traction therapy) may be different if the problem is at the cervical, the thoracic, or

the lumbar level. A second issue is that the efficacy of surgical intervention (like that of

traction therapy) may be different shortly after the surgery than it is much later. A third

issue is that different surgical approaches to the same problem may produce different

expected outcomes. A general rule regarding this third issue appears to be that minimally

invasive surgical approaches are often superior to surgical approaches that are more

invasive, but even this advice cannot be viewed as applying to every situation (i.e. when

fusion is necessary).

It is possible that, in the future, additional studies will help clear the muddy

waters regarding the choice of treatment for back pain. Until then, however, a patient

must expect to spend considerable time and effort, perhaps in consultation with an

advocate such as a primary care physician with experience in interpreting primary

23

literature, if he or she is to make the most informed choice possible regarding the

treatment of his or her back pain.

A final complication for an individual patient is the following. This review

considers only two broad treatment options for back pain: surgery and traction therapy.

Other treatment options, however, such as steroid injections, exist for some types of back

problems. Thus, when making a final decision regarding back pain treatment, many

patients should consider these alternative treatment options in addition to considering

surgery and traction therapy.

24

Acknowledgments

The Avila science faculty for helpful comments throughout the course of this project

The Avila librarians for help with tracking down articles

Dr. Fitch for not only his guidance, but also support and encouragement, without whom, this project would not have been possible

25

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