[Music] or that you can do it in an awake patient which allows you to know instantly if they have any neurologic changes and you can reverse whatever you have just done if they have a neurologically changed you know you take the weight off or whatever um and that basically is never possible in the operating room under anesthesia there's always going to be a delay and you're never going to quite know what you're doing to the patient it can also be done faster than you know going to the operating room you just have to bring your materials and set up in the in the icu room that the patient is in and you can almost instantly decompress the core and allow for later less urgent surgical stabilization but there are risks of course as well as important contraindications and also understanding the mechanisms of injury can be helpful in reducing the fracture because you'll be able to understand what needs to occur anatomically to re-establish alignment now there is a debate about getting an mri before versus after traction there's a small but real risk of displacing or dragging disc material posteriorly into the spinal canal with any method of reduction possibly causing neurological compromise an mri before traction can alert you to that possibility and might possibly cause you to just go straight to surgery instead but there's also a likelihood that the actual traction reduction itself can create a new disc herniation as you drag the bone back with the traction and so you wouldn't necessarily know that if you got at the mri beforehand and it's not necessarily reasonable to get an mri before and after traction so in my practice i tend to get the mri after traction not before because the patient exam in my mind is better than the mri before traction and here's a brief list of tips and protocols for um cervical traction of another good textbook and so we'll just go through each thing briefly to explain it so first you want to rule out skull fractures that's because you don't want to put the pins directly into the brain so that's that's important um and then you know particularly for halo the second one is mainly for a halo but you want to always place the pins with the eyes closed because you put them just lateral to the eyes and if the patient's eyes are open you can pin the eyes open and that's that's sub-optimal um again closed reduction is contraindicated if you get an mri before traction you see a big disc herniation i usually use the exam for that and then occasionally depending on the type of fracture you either want to pull the patient in axial traction and flexion or axial traction and extension and so that you actually do that um relevant to the external auto permeator so if you want to do traction and extension you're going to put it a little bit anterior to the external auditory meatus so that they lift their chin up if you want to put an extension you're going to put it a little bit behind the extra auditory medius to put the chin down and then when you're starting the weight you start with a very low weight and you obtain an initial x-ray and that initial x-ray is making sure that you don't have any atlanta occipital dislocation or anything like that and then you increase your weight for each weight increase you check an x-ray so when you're a resident you want to have the x-ray machine in the room you don't just want lateral films do you want the x-ray machine right there so they can take repeated x-rays for each weight increase and then once the ejection reduction is achieved you generally will leave the patient in traction until definitive treatment is done and that's usually going to be b surgery and then you want to stop your reduction if you if you reduce it you want to stop it if you get distraction of the atlanta um server or the occipital cervical junction um or if any disc disc height is greater than 10 millimeters that's over distraction or if you have any neurological changes it would be unusual to have sscps or meps during um you know closed reduction in an awake patient maybe some centers do it but you can just follow the exam for those patients hey everyone ryan rad here from neurosurgery neurosurgerytraining.org if you like that video subscribe and donate to keep our content available for medical students across the world