Constantoyannis C, Konstantinou D, Kourtopoulos H, Papadakis N.
Department of Neurosurgery,
University of Umea, Umea, Sweden.
OBJECTIVE: To describe the use of intermittent cervical traction in managing 4 patients with cervical radiculopathy and large-volume herniated disks.
CLINICAL FEATURES: Four patients had neck pain radiating to the arm. The clinical examination was typical in all cases for radiculopathy of cervical origin. Magnetic resonance imaging (MRI) of the cervical spine revealed large-volume herniated disks in all patients.
INTERVENTIONS AND OUTCOME: The treatment consisted of intermittent on-the-door cervical traction under the supervision of our physiotherapists. Complete symptom resolution for each patient occurred within 3 weeks. One patient who had an episode of recurrence 16 months after the first treatment was successfully managed again with cervical traction and physiotherapy.
CONCLUSION: Cervical spine traction could be considered as a therapy of choice for radiculopathy caused by herniated disks, even in cases of large-volume herniated disks or recurrent episodes.
From the FULL TEXT Article
Conservative treatment is generally believed to alleviate symptoms of cervical radiculopathy, at least for the short term. The long-term prognosis remains unknown, with studies reporting both positive and negative results. [10, 11] It is probable that different inclusion and evaluation criteria for the symptoms resulted in wide variances in reported outcomes.
Neck pain is usually mechanical and not neurogenic; treatment, therefore, ranges from immobilization with a collar and medications to physiotherapy, manipulation, and traction. In our department, more than 150 patients had radiculopathy of cervical origin and were treated by traction and physiotherapy during the last 6 years with positive results. During that same period, 85 patients with cervical spondylotic myelopathy or intractable pain from herniated disks underwent surgery. We use on-the-door traction of the cervical spine with a commercially available home cervical traction system. The correction of posture and orientation of the patient during the treatment are organized and assisted by our physiotherapists. The treatment involves intermittent traction, that is, traction applied for 45 minutes followed by 15-minute intervals without traction. We initiate the treatment in the morning with a pull of 2 to 3 pounds; after the second hour, we increase it to 5 pounds for the remainder of the day.
Patients receive treatment for 6 to 8 hours a day, while they watch television or read a magazine. We recommend that patients use a cervical collar (Philadelphia type) the remainder of the day. The usual treatment duration is 3 weeks. Muscle relaxants and anti-inflammatory medication are also prescribed.
Saal  described a study of 26 patients with disk protrusions less than 4 mm and radiculopathy, in which neurologic deterioration did not occur in any of the patients, all of whom were managed with traction, physical therapy, and anti-inflammatory medications. In another study, Moeti  used cervical traction to treat patients with radiculopathy and found that patients whose symptoms lasted more than 12 weeks showed less favorable improvement.
These 4 cases described here illustrate the potential for successful treatment with cervical traction in patients with large-volume herniated cervical disks or with recurrent episodes of radiculopathy. All patients received treatment soon after the initiation of symptoms (7 days to 2 weeks). This might be very important for the outcome, because early intervention is believed to be more successful.  Some authors have studied the mechanisms affecting herniated disk regression and resorption,  and their results suggest that once the herniated disk material is exposed to the vascular environment of the epidural space, cellular mechanisms contribute to regression. Because large and extruded disks have wider exposure to these resorption mechanisms, they tend to regress more rapidly and the response to early therapeutic intervention is better.
Neurosurgeons, orthopedics, chiropractors, and physiotherapists grapple in their daily practice with the decision to use surgical or conservative treatment for herniated cervical disks. We do not advocate conservative treatment in cases of herniated disks with myelopathy or with progressive neurologic deficits, but we believe that nonsurgical treatment should be always considered when radiculopathy is present, even cases with large-sized disk herniations or recurrences of pain.