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Recent Sightings in Health Care
Exerpts from "The Practice of Minimally Invasive Spinal Technique," on sale now in Our Store!
Vertical Axial Decompression
Reduction of nuclear protrusion by spinal distraction was practiced even before the intervertebral disc was recognized. A 14th Century translation of Albucasia’s Surgery illustrates lumbar manipulation during spinal traction Appolonius of Kitium describes a form of distraction 2000 years ago. Guidi (1544) illustrates a traction table in his Cirugia, and one of his tables can be found in the Wellcome Historical Museum of London. In their book on manipulation past and present, Cyriax and Schotz illustrate the employment of traction by Hippocrates (400 BC), Galen (131-202 AD), and the Spanish-Arabian physician Abu’ L Qasim(1013-1106).
Today, two methods of performing traction are practiced – the sustained manner preferred by Cyriax and various forms of intermittent traction. Intermittent traction can be done electronically, manually (therapist), or by the patient (autotraction). The effects of sustained traction have been investigated. An increase in body length of 10-30 mm was demonstrated in healthy males when a sustained force of 60kg was applied for 1 hour and was lost at 4mm/hr.
In the excised spine the greatest separation was in those subjects with wide disc spaces and least where there is evidence of disc degeneration. Other investigators confirmed an increase in stature over and above that known to occur when the load is taken off the spine by lying down.
The findings suggest that most of the vertebral separation takes place within the first 30 minutes. During normal traction, the enlargement between two consecutive lumbar endplates is between 1.0 and 1.5 mm. Other studies have demonstrated a widening of the lumbar intervertebral space of between 3 to 8 mm measured radiographically due to gravitational traction.
Anderson et al have shown an increase in intradiscal pressure with certain traction techniques. The heavy lumbar paravertebral muscles exert resistance to distraction, and at least 30-35kg of force is required to influence the lumbar spine.
Others have shown that a force of at least 25% of body weight is necessary to achieve lumbar distraction. With the split table, designed by Dr. Allan Dyer, he demonstrated that 25% of the traction force is required for distraction to occur.
The effects of distraction include tightening of the posterior longitudinal ligament which exerts a centripetal force at the back of the joint. This maneuver may be of therapeutic value, particularly if the protrusion is located anterior and remains in close contact with the ligament. On the basis of biomechanical calculations significant intradiscal negative pressure may be achieved during sustained traction.
One study has shown that a traction load of 30 kg causes intradiscal pressure to lower from 30 kp to 10 kp in the L3 intervertebral disc. Improvement in nutrition and deposition of reparative collagen and healing of annular tears and fissures has been suggested as a benefit of axial distraction.
Dr. Allan Dyer, former Deputy Minister of Health from Ontario, Canada a pioneer in the development of the external cardiac defibrillator, designed the VAX-D Therapeutic Table to apply distraction tension to the patient's spine without eliciting reflex paravertebral muscle contractions. A harness is attached to a tensionometer during separation of the movable pallet of the table. The distraction-relaxation cycles are automated or variable. Distraction tensions and rates are continuously monitored and measured by the tensionometer, and the output is shown on a digital gauge and captured on written printout.