1. Avila University
Analysis of Spinal Decompression via Surgical Methods and Traction Therapy
Paige Barrett
BI 499
Dr. Fitch
December 9, 2014

2. 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.
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3. Surgical Decompression
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
3

4. from the prior morbidity rate because patient inclusion was stricter, the procedure was
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
4

5. final follow-up was at four years and five months, on average. The study lasted from
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
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6. effectively reduce pressure placed on surrounding structures. Water is not reabsorbed due
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
6

7. years and they all suffered from degenerative lumbar stenosis and unsuccessful non-
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
7

8. health questionnaire) in a group presenting with lumbar spinal stenosis who underwent
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.
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9. While JOA scores improved from preoperative to final follow up, 29% of patients had a
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
9

10. approach, and traditional with non-facet sparing approach on the lumbar spine. Range of
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
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11. NIC due to DLSS that were treated at either one or two levels with the HeliFix IPD
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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12. 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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13. 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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14. 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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15. 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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16. 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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17. 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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18. 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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19. 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.
19

20. Table 1. Analysis of Articles
Contents 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
up
Follow Up Time Most 1-5 years Most immediate-14 weeks
20

21. Conclusion
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
21

22. used to collect data after the study. For surgical treatment, however, epidemiological
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
22

23. traction therapy, a patient should probably ask the physician for references to studies in
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
23

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

25. 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

26. Bibliography
Ahn, Yong, Hyun-Kyong Oh, Ho Kim, Sang-Ho Lee, and Haeng-Nam Lee. 2014.
Percutaneous endoscopic llumbar foraminotomy: an advanced surgical technique
and clinical outcomes. Neurosurgery. 75: 124-133.
Alexandre, Alberto, Andrea M. Alexandre, Mario De Pretto, Luca Coro, and Raul
Saggini. 2014. One-year follow-up of a series of 100 patients treated for lumbar
spinal canal stenosis by means of HeliFix interspinous process decompression
device. BioMed Research International. Doi: 10.1155/2014/176936.
Anjarwalla, N. K., L. C. Brown, A. H. McGregor. 2007. The outcome of spinal
decompression surgery 5 years on. European Spine Journal. 6:1842-1847.
Apfel, Christian C, Ozlem S Cakmakkaya, William Martin, Charlotte Richmond, Alex
Macario, Elizabeth George, Maximilian Schaefer, and Joseph V. Pergolizzi. 2010.
Restoration of disk height through non-surgical spinal decompression is
associated with decreased discogenic low back pain: a retrospective cohort study.
BMC Musculoskeletal Disorders. 11:155
Aryan, Henry E., Rene O. Sanchez-Mejia, Sharona Ben-Haim, Christopher P. Ames.
2007. Successful treatment of cervical myelopathy with minimal morbidity by
circumferential decompression and fusion. European Spine Journal. 16:1401-
1409.
Bener, Abdulbari, Mohamud Verjee, Elnour E. Dafeeah, Omar Falah, Taha Al-Juhaishi,
Josia Schlogl, Alhasan Sedeeq, and Shehryar Khan. 2013. Psychological factors:
anxiety, depression, and somatization symptoms in low back pain patients.
Journal of Pain Research. 6: 95-101.
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3569050/>
Cadotte, David, Anoushka Singh, and Michael Fehlings. 2010. The timing of surgical
decompression for spinal cord injury. Medicine Reports. 2: 67.
Castellvi, Antonio E., Thomas W. Nienke, German A. Marulanda, Ryan D. Murtagh,
Brandon G. Santoni. 2014. Indirect decompression of lumbar stenosis with
transpsoas interbody cages and percutaneous posterior instrumentation. Clinical
Orthopaedics and Related Research. Doi: 10.1007/s11999-014-3464-6.
Cevik, Remzi, Aslan Bilici, Ali Gur, Aysegul Jale Sarac, Hidir Yildiz, Kemal Nas, Adnan
Ceviz, and Yasar Bukte. 2007. Effect of new traction technique of prone position
on distraction of lumbar vertebrae and its relation with different application of
heating therapy in low back pain. Journal of Back and Musculoskeletal
Rehabilitation. 20: 71-77.
26

27. Chanda, Mona Lisa, Matthew D. Alvin, Thomas J. Schnitzer, and A. Vania Apkarian.
2011. Pain characteristic differences between subacute and chronic back pain.
Journal of Pain. 12(7): 792-800.
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3130842/>
Chiu, Thomas TW, Joseph Kim-Fai Ng, Barbro Walther-Zhang, Rex JH Lin, Luc Ortelli,
and Siew Kuan Chua. 2011. A randomized controlled trial on the efficacy of
intermittent cervical traction for patients with chronic neck pain. Clinical
Rehabilitation. 25(9): 814-822.
Cutts, Steven, and Darren Clark. 2004. Back pain—and its management. Practice Nurse.
28(10):38-46. <http://proxy.avila.edu:2054/ehost/detail?vid=4&sid=097b6088-
8a8a-42e5-8c6e-
39d98a0c3093%40sessionmgr198&hid=118&bdata=JnNpdGU9ZWhvc3QtbGl2
ZQ%3d%3d#db=aph&AN=15582944>
Daniel, Dwain M. 2007. Non-surgical spinal decompression therapy: does the scientific
literature support efficacy claims made in the advertising media? Chiropractic
and Osteopathy. 15: 7.
Doi, Toshio, Katsumi Harimaya, Yoshihiro Matsumoto, Osamu Tono, Kiyoshi Tarukado,
and Yukihide Iwamoto. 2011. Endoscopic decompression for intraforaminal and
extraforaminal nerve root compression. Journal of Orthopaedic Surgery and
Research. 6: 16.
Fehlings, Michael G., Alexander Vaccaro, Jefferson R. Wilson, Anoushka Singh, David
W. Cadotte, James S. Harrop, Bizhan Aarabi, Christopher Shaffrey, Marcel
Dvorak, Charles Fisher, Paul Arnold, Eric M. Massicotte, Stephen Lewis, and
Raja Rampersaud. 2012. Early versus Delayed Decompression for Traumatic
Cervical Spinal Cord Injury: Results of the Surgical Timing in Acute Spinal Cord
Injury Study (STASCIS). PLoS One. 7(2):e32037.
Gay, Ralph E., Gert Bronfort, Roni L. Evans. 2005. Distraction manipulation of the
lumbar spine: a review of the literature. Journal of Manipulative and
Physiological Therapeutics. 28(4): 266-273.
Guvenol, Kemal, Cigdem Tuzun, Ozlen Peker, and Yigit Goktay. 2000. A comparison of
inverted spinal traction and conventional traction in the treatment of lumbar disc
herniations. Physiotherapy Theory and Practice. 16: 151- 160.
Hampton, Tracy. 2004. Back pain is a money drain. JAMA: Journal of the American
Medical Association 291(4): 415. http://proxy.avila.edu:2054/ehost/detail?
sid=097b6088-8a8a-42e5-8c6e-
39d98a0c3093%40sessionmgr198&vid=3&hid=118
27

28. Haufe, Scott, Anthony Mork, Morgan Pyne, and Ryan Baker. 2010. Percutaneous laser
disc decompression for thoracic disc disease: report of 10 cases. International
Journal of Medical Sciences. 7.
Kapoor, Sudhir, Saurabh Kapoor, Mayank Agrawal, Pankah Aggarwal, and Brijesh Jain
Jr. 2012. Thoracoscopic decompression in Pott’s spine and its long-term follow-
up. International Orthopaedics. 36: 331-337.
Kim, Sung-Duk, Ho-Gyun Ha, Cheol-Young Lee, Hyun-Woo Kim, Chul-Ku Jung, and
Jong Hyun Kim. 2014. Cervical cord decompression using extended anterior
cervical foraminotomy technique. Journal of Korean Neurosurgical Society.
56(2): 114-120.
Kleinstueck, F. S., T. Fekete, D. Jeszenszky, A. F. Mannion, D. Grob, FLattig, U. Mutter,
F. Porchet. 2011. The outcome of decompression surgery for lumbar herniated
disc is influenced b the level of concomitant preoperative low back pain.
European Spine Journal. 20:1166-1173.
Lauryssen, Carl, Sigurd Berven, Ronnie Mimran, Christopher Summa, Michael
Sheinberg, Larry E. Miller, Jon E. Block. 2012. Facet-sparing lumbar
decompression with a minimally invasive flexile MicroBlade Shaver versus
traditional decompression: quantitative radiographic assessment. Clinical
Interventions in Aging. 7:257-266.
Macario, Alex and Joseph V. Pergolizzi. 2006. Systematic literature review of spinal
decompression via motorized traction for chronic discogenic low back pain. Pain
Practice. 6(3):171-178.
Mannion, Anne F., R. Denzler, J. Dvorak, D. Grob. 2010. Five-year outcome of surgical
decompression of the lumbar spine without fusion. European Spine Journal.
19:1883-1891.
Mannion, Anne F., R. Denzler, J. Dvorak, M. Muntener, D. Grob. 2007. A randomized
controlled trial of post-operative rehabilitation after surgical decompression of the
lumbar spine. European Spine Journal. 16: 1101-1117.
Mekhail, Nagy, Shrif Costandi, Benjamin Abraham, and Samuel Wadie Samuel. 2012.
Functional and patient-reported outcomes in symptomatic lumbar spinal stenosis
following percutaneous decompression. Pain Practice. 12(6): 417-425.
Onel, Dilek, Muhlis Tuzlaci, Hidayet Sari, Kemal Demir. 1989. Computed tomographic
investigation of the effect of traction on lumbar disc herniations. Spine. 14:82-90
Popov, Victor, and David G. Anderson. 2012. Minimal invasive decompression for
lumbar spinal stenosis. Advances in Orthopedics. doi: 10.1155/2012/645321.
28

29. Reindl, Rudolf, Thoams Steffen, Lara Cohen, and Max Aebi. 2003. Elective lumbar
spinal decompression in the elderly: is it a high-risk operation? Canadian Journal
of Surgery. 46(1).
Reinhold, M., C. Knop, R. Beisse, L. Audige, F. Kandziora, A. Pizanis, R. Pranzl, E.
Gercek, M. Schutheiss, A. Weckbach, V. Buhren, M. Blauth. 2010. Operative
treatment of 733 patients with acute thoracolumbar spinal injuries: comprehensive
results from the second, prospective, internet-based multicenter study of the Spine
Study Group of the German Association of Trauma Surgery. European Spine
Journal. 19: 1657-1676. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989217/
Sari, Hidayet, Ulku Akarirmak, Ilhan Karacan, Haluk Akman. 2005. Computed
tomographic evaluation of lumbar spinal structures during traction. Physiotherapy
Theory and Practice. 21(1):3-11.
Schimmel, Janneke J. P., M. de Kleuver, P. P. Horsting, M. Spruit, W. C. H. Jacobs, J.
van Limbeck. 2009. No effect of traction in patients with low back pain: a single
centre, single blind, randomized controlled trial of intervertebral differential
dynamics therapy. European Spine Journal. 18: 1843-1850.
Smith, Zachary A., Geogios A. Vastardis, Gerard Carandang, Robert M. Havey, Sean
Hannon, Nader Dahdaleh, Leonard I. Voronov, Richard G. Fessler, Avinash G.
Patwardhan. 2014. Biomechanical effects of a unilateral approach to minimally
invasive lumbar decompression. PloS One. 9(3): e92611
Son, Seong, Woo Kyung Kim, Sang Gu Lee, Chan Woo Park, and Keun Lee. 2013. A
comparison of the clinical outcomes of decompression alone and fusion in elderly
patients with two-level or more lumbar spinal stenosis. Journal of Korean
Neurosurgical Society. 53: 19-25.
Tsutsui, Shunji, Ryohei Kagotani, Hiroshi Yamada, Hiroshi Hashizume, Akihito
Minamide, Yukiiro Nakagawa, Hiroshi Iwasaki, Munehito Yoshida. 2013. Can
decompression surgery relieve low back pain in patients with lumbar spinal
stenosis combined with degenerative lumbar scoliosis? European Spine Journal.
22: 2010-2014.
Weiner, Bradley K., Nilesh M. Patel, and Matthew A. Walker. 2007. Outcomes of
decompression for lumbar spinal canal stenosis upon preoperative radiographic
severity. Journal of Orthopaedic Surgery and Research. 2: 3.
Yamazaki, Masashi, Akihiko Okawa, Takayuki Fujiyoshi, Takeo Furuy, Masao Koda.
2010. Posterior decompression with instrumented fusion for thoracic myelopathy
caused by ossification of the posterior longitudinal ligament. European Spine
Journal. 19:691-698.
29

30. Yang, Hae-sun, and Won-gyu Yoo. 2014. The effects of stretching with lumbar traction
on VAS and Oswestry Scales of patients with lumbar 4-5 herniated intervertebral
disc. Journal of Physical Therapy Science. 26: 1049-1050.
Yang, Sang-Mi, Hyung-Ki Park, Jae-chil Chang, Ra-Sun Kim, Sukh-Que Park, Sung-Jin
Cho. 2013. Minimum 3-year outcomes in patients with lumbar spinal stenosis
after bilateral microdecompression by unilateral or bilateral laminotomy. Journal
of Korean Neurosurgical Society. 54: 194-200.
30