Rheumatol Int (2006) 26: 622626
DOI 10.1007/s00296-005-0035-x
O R I GI N A L A R T IC L E
Bulent Ozturk Osman Hakan Gunduz
Kursat Ozoran Sevinc Bostanoglu
Effect of continuous lumbar traction on the size of herniated disc
material in lumbar disc herniation
Received: 16 November 2004 / Accepted: 28 July 2005 / Published online: 25 October 2005

Springer-Verlag 2005
Abstract We investigated the eects of continuous lum-
bar traction in patients with lumbar disc herniation on
clinical ndings, and size of the herniated disc measured
by computed tomography (CT). In this prospective,
randomized, controlled study, 46 patients with lumbar
disc herniation were included, and randomized into two
groups as the traction group (24 patients), and the
control group (22 patients). The traction group was gi-
ven a physical therapy program and continuous lumbar
traction. The control group was given the same physical
therapy program without traction, for the same duration
of time. Data for the clinical symptoms and signs were
collected before and after the treatment together with
calculation of a herniation index, from the CT images
that showed the size of the herniated disc material. In
the traction group, most of the clinical ndings signi-
cantly improved with treatment. Size of the herniated
disc material in CT decreased signicantly only in the
traction group. In the traction group the herniation in-
dex decreased from 276.6129.6 to 212.584.3 with
treatment (p<0.01). In the control group, pretreatment
value was 293.4112.1, and it decreased to
285.4115.4 after the treatment (p>0.05). Patients with
B. Ozturk K. Ozoran
Department of Physical Medicine and Rehabilitation, Institution
of Origin, Ankara Numune Education and Research Hospital,
Ankara, Turkey
O. H. Gunduz (&)
Department of Physical Medicine and Rehabilitation, Marmara
University School of Medicine, Barbaros Mahallesi, Veysi Pasa
Sokak, Site 62, No: 18/21, Altunizade, Uskudar, 34662 Istanbul,
Turkey
E-mail: drhakang@hotmail.com
Tel.: +90-216-3263443
Fax: +90-216-3263444
S. Bostanoglu
Department of Radiology, Ankara Numune Education
and Research Hospital, Institution of Origin, Ankara, Turkey
greater herniations tended to respond better to traction.
In conclusion, lumbar traction is both eective in
improving symptoms and clinical ndings in patients
with lumbar disc herniation and also in decreasing the
size of the herniated disc material as measured by CT.
Keywords Lumbar disc herniation Conservative
treatment Physical therapy Traction Computed
tomography
Introduction
Low back pain is quite common and eects 65 to 80% of
the population. Disc herniations comprise about 5% of
patients with back or low back pain [1, 2]. In the man-
agement of lumbar disc herniation, conservative treat-
ment including physical therapy and lumbar traction is
indicated and traction is an eective part of the treat-
ment program [35]. However, the eects of traction on
the herniated disc material are not known well. In this
study, we investigated the eect of continuous traction
in patients with lumbar disc herniation on the size of the
herniated disc material on computed tomography (CT).
Materials and methods
Forty-six patients (22 men and 24 women) who were
hospitalized with the diagnosis of lumbar disc herniation
participated in the study. The study was conducted
according to good clinical practice guidelines and local
ethics committee approval was obtained.
Patients with the following criteria were included: (1)
low back pain or sciatica due to lumbar disc herniation
and L3-S1 radiculopathy; (2) duration of pain less than
6 months; (3) lumbar disc herniation veried by CT
scan; (4) consistency in the pattern of pain complaint,
neurological, and radiological ndings; (5) no history of
previous physical therapy in the past; (6) willing to take
part in the study by signing a written informed consent.
 623

Exclusion criteria were: (1) low back pain due to neo- and expert radiologist assessed all the CTs. The disc and
plastic, inammatory, infectious, or metabolic causes; canal measurements were done in the axial slice, in
(2) indication of urgent surgery (Cauda equina syn- which there was greatest encroachment of the disc.
drome or progressive motor decit); (3) spinal stenosis; Sagittal distance of herniated material (maximum ante-
(4) pregnancy, postpartum period, and postoperative roposterior disc length, AB) and the sagittal length of
3 months; (5) previous vertebral surgery; (6) gross the spinal canal (maximum anteroposterior canal length,
structural abnormalities (e.g. spondylolisthesis); (7) EF) were measured (Fig. 1). A line was drawn which
being unable to tolerate physical therapy due to car- divided the herniated material into anterior and pos-
diovascular reasons; (8) presence of signicant degen- terior halves. The width of the herniated material (CD)
erative changes in lumbosacral vertebrae on X-rays; (9) and the width of the spinal canal (GH) were measured at
duration of low back pain of more than 6 months. the level of this line. The following formula was used for
The patients were randomly divided into two groups. the calculation of the herniation index [6]: (AB CD)/
The treatment group (Traction group) included 24 pa- (EF GH) 1,000. Repeat lumbar CTs were obtained
tients (14 men and ten women; mean age 40.211.4 (16 and the same measurements were done after the treat-
65) years), and they were given a physical therapy pro- ment.
gram including hotpack (for 15 min), continuous ultra- Statistical evaluations were made by students t-test
sound (to lumbar paravertebral muscles, 1.5 W/cm2 for and Mc Pearson correlation analysis, and p<0.05 was
5 min), and diadynamic currents (with intermittently considered signicant.
changed diadynamic current forms and polarities, the
current intensity adjusted below the pain threshold, total
duration of treatment 10 min) and traction (as contin- Results
uous lumbar traction for 15 min). The control group
included 22 patients (eight men and 14 women; mean Disc herniations were found in 50 levels in these 46
age 52.78.8 (3570) years) and the same physical patients. There were 12 L3-L4, 23 L4-L5, and 15 L5-S1
therapy program was given without traction. Each pa-
tient was given a total of 15 sessions of physical therapy,
a session each weekday by the same physical therapist
during the treatment period. Lumbar traction was ap-
plied only to the rst group. Enraf Nonius Traction
Eltrac 439 was used. Traction was started with 25% of
patients body weight, and increased with the same
increment everyday to 50% of the patients body weight
at the tenth session, and continued at this level to the
end of the treatment. Ibuprofen 400 mg tid and a muscle
relaxant preparation (mephenoxalone 200 mg + par-
acetamol 450 mg) tid were given to all subjects during
the treatment period. Ibuprofen was discontinued in two
patients due to gastrointestinal side eects.
A 10-cm visual analog scale (VAS) was used to
evaluate the pain intensity. Unbearable pain intensity
was accepted as 10, and 0 indicated no pain at all. All
patients were let to decide their pain levels. For lumbar
motion assessment, modied Schober test was done.
Straight leg raising (SLR) test was done, and the angle at
which the test was positive was measured with a goni-
ometer (SLR angle). Motor decits were determined
by clinical examination bilaterally. Motor decits were
recorded as % loss. L4, L5, and S1 dermatomes were
examined for evaluation of sensory decits. Patella and
Achilles reexes were also examined and recorded as
normal, decreased, and absent. The VAS, modied
Schober test, SLR measurements, and clinical examin-
ations were performed before and after the treatment.
After the initial clinical examination, CT scans of L3-
S1 intervertebral disc levels were obtained. The CT scans Fig. 1 Schematic diagram of the CT measurements. AB =
were made on a General Electric Sytec SRI spiral maximum anteroposterior disc length, CD = width of the
herniated material at the level of the mid AB distance, EF =
tomography, using 3-mm thick slice sections at 3 mm maximum anteroposterior canal length, GH = width of the spinal
intervals. Images were viewed with a window width of canal at the level of the mid AB distance. The herniation index is
300 and a window level of 80 Hounseld units. A blind calculated as: (AB CD)/(EF GH) 1,000
624
herniations. Two level herniations were found in four
patients.
Clinical characteristics of the traction and control
groups, before and after the treatment period are given
in Table 1. The dierence between the two groups with
treatment was not signicant in relation to presence of
low back pain, VAS, number of patients with presence
of motor decits, and sensory decits (p>0.05). How-
ever, for the presence of sciatica, SLR angle, and degree
of motor loss (%) between before and after the treat-
ment, the dierence between the traction and control
groups was statistically signicant (p<0.05).
Patella reex was decreased in four (9%) of all pa-
tients included. Three had L3-L4 herniation and the
other had L4-L5 herniation. Eleven patients had
diminished Achilles reex. Of these, seven had L5-S1
herniations, one had L4-L5 herniation, three had two-
level herniations (one had L4-L5 and L5-S1 herniations;
two had L3-L4 and L4-L5 herniations). In the traction
group, while seven patients had diminished reexes be-
fore the treatment, we observed full recovery in four and
partial recovery in one patient after the treatment. In the
control group, the number of patients with diminished
reexes was eight, and none of them had improvement.
The dierence of improvement regarding the reex
ndings between the traction and control groups was
statistically signicant (p<0.01).
When the CT ndings were evaluated, the relative
size of the herniated disc material, that is, the hernia-
tion index was 276.6129.6 in the traction group be-
fore the treatment, and it decreased to 212.584.3 with
the treatment. The dierence between before and after
the treatment in traction group was found signicant
(p<0.01). In the control group, pretreatment value was
293.4112.1, and it decreased to 285.4115.4 after the
treatment. This decrease was not signicant (p>0.05).
The mean improvement in traction group was 63.7
(23%), whereas it was eight (2.7%) in the control group
(Table 1).
The degree of improvement in CT was accepted as
the dierence between pre and posttreatment herniation
indices. In the traction group, there was a signicant
positive correlation between the degree of improvement
in CT and the relative size of herniated disc (r=0.763;
Table 1 Clinical ndings and comparison of the size of the herniated material as calculated by the index in CT in patients in traction and
control groups before and after treatment
Traction group
Before treatment
Presence of low back pain [n (%)] 19 (79)
Presence of sciatica [n (%)] 20 (83)*
VAS for pain (cm) [mean (SD)] 6.3 (1.4)
SLR angle () [mean (SD)] 42.7 (18.8)*
Presence of motor decit [n (%)] 21 (88)
Degree of motor decit (% loss) [mean (SD)] 18.8 (8)**
Presence of sensory decit [n (%)] 14 (58)
Herniation index [mean (SD)] 276.6 (129.6)**
VAS visual analogue scale; SLR straight leg raise * p<0.05 compared to after treatment; ** p<0.01 compared to after treatment
p<0.01). Hence, the improvement was better in patients
with relatively larger herniations in CT before the
treatment. A similar relation was not present in the
control group (p>0.05).
We divided the patients in the traction group into
two, according to the mean size of herniated disc
material (mean herniation index: 276.6), 15 patients had
small and nine had large disc herniations. The mean
herniation index value of patients with small disc her-
niations were 203.316.6, and of patients with large
hernias were 398.023.9. The decrease in the herniation
index of patients with smaller hernias was 17.4 (8.5%)
with treatment. However, in patients with larger herni-
ations, this decrease was 140.8 (35.3%), and the dier-
ence between these decrements in the two groups was
signicant (p<0.01).
In the traction group, 19 (79.2%) patients had de-
crease in the size of the hernia in CT, whereas only two
patients did not show any dierence.
Discussion
Regression of herniation by CT with conservative
treatment was rst shown in 1984. In 1985, regression or
total disappearance of herniation was shown by CT in
11 patients. Maigne and Deligne [7] has shown in ve
patients that herniations did not change or even increase
in size by CT after the treatment, without any worsening
in clinical ndings. However, many investigators have
reported improvements in CT or MRI images of lumbar
disc herniations with conservative treatment. In our
study, of the two groups, signicant decrease in the size
of disc herniation by CT with conservative treatment
was only seen in the traction group. This indicated that
one of the eective components for decreasing the size of
herniated disc in the conservative treatment is lumbar
traction. In previous studies, with adequate traction
forces, decrease in lumbar lordosis, 2030% decrease in
intradiscal pressure, increase in disc height, separation
of vertebral bodies, widening in the apophyseal joint
spaces and intervertebral foramina and reduction of
trapped capsular fold were reported. It was also stated
that blood ow to nerve roots increases with the de-
Control group
After treatment Before treatment After treatment
7 (29) 20 (91) 8 (36)
8 (33) 22 (100) 16 (73)
2.4 (1.7) 6.8 (1.1) 3.6 (2.7)
69.1 (17.8) 53.6 (16.4)* 64 (18.3)
16 (67) 20 (91) 20 (91)
11.3 (9.5) 21.3 (9.5) 19 (11.3)
6 (25) 14 (64) 12 (55)
212.5 (84.3) 293.4 (112.1) 285.4 (115.4)

crease in the pressure to the nerve roots [4, 810]. It has
been found in myelography that the size of the lling
defect can be decreased with traction [11]. It is estimated
that traction exerts its eect by creating a negative in-
tradiscal pressure and tightening the posterior longitu-
dinal ligament [9]. Cyriax has shown that during
vertebral traction a negative pressure was generated in
the disc, and so protrusion was reversed [8]. These re-
sults together with ours indicate that lumbar traction is
eective in decreasing the size of the herniated material
in lumbar disc herniation through these mechanisms,
and lumbar traction should be used in the conservative
treatment of lumbar disc herniation beginning in the rst
days of treatment. In our study there was a statistically
signicant decrease in the size of herniation in the
traction group. Detailed evaluation revealed that
symptomatic improvement of the patients was better
than the decrease in size of the herniated material seen
by CT. The reason for this might be related to the fact
that herniations cause clinical symptoms after a certain
degree, and clinical improvements are seen when the size
of the herniation decreases below that degree. So small
disc herniations on CT may be associated with vague
symptoms or even may be asymptomatic. In our study
although traction decreased the size of herniation by
about 23%, the improvement in symptoms and signs
were much better.
Bush et al. [12] reported a higher incidence of reso-
lution in patients with larger herniations, with aggressive
conservative management. Clinical progression was also
found better in these patients. In most patients who did
not respond to therapy, size of the herniated disc
materials remained unchanged, whereas in patients with
larger disc herniations the ratio of improvement was
found to be higher. Diuse bulging always remained gical treatment of lumbar disc herniation does carry
the same, and their prognosis was poor [12]. Dullerud
and Nakstad [13] reported an association between the
initial size of the hernias and improvement after treat-
ment, with larger herniations decreasing more in size. In
our study when we evaluated the patients whom traction
was found to be ineective, we saw that the average size
of their herniations was relatively smaller (herniation
index: 183.0) than others. This result may also be re-
lated to personal dierences in the responses to traction.
Greater herniations tend to diminish in size quickly due
to sequestration or dehydration. Another possibility is
the retraction of nuclear material to the annular tear
[12]. The reason for lesser improvement in smaller disc
herniations may be related to denser ber arrangement
in this area, since it prevents neovascularization of her-
niation, and causes lesser passive water loss [7].
In a study conducted by Reust et al. [14], patients
were divided into three groups and were given 5, 15, and
50-kg traction, respectively. They reported no signicant
dierence between the groups in respect to ngertip to
ground distance, pain and SLR test degrees. In our
study, we did not nd any signicant dierence between
change in pain before and after the treatment in both
traction and control groups. But changes in SLR angle
625
and sciatica before and after the treatment were signi-
cant only in the traction group. In the lumbar region,
nerve roots in dural sheath can move about 25 mm
[15]. The SLR test detects loss of this movement of nerve
roots due to disc herniation. The increase in SLR angle
and degree of sciatica in our patients in traction group
was probably a result of the decrease in root irritation
due to the decrease in size of herniated discs.
Disappearance of low back pain or sciatica after
surgery varies between 35 and 95%, and improvements
in lumbar radiculopathy after conservative treatment is
reported to be 3095% [16]. There was no dierence in
the prognosis of neurologic decit between surgical and
conservative treatments [17]. In a retrospective study on
patients with disc herniation without signicant stenosis,
successful responses were seen in 90% of patients with
physical treatment. In over 85% of the patients, re-
sponse is successful immediately after the surgery, and
this is more apparent in patients with severe preopera-
tive radicular pain [5]. Presence of minimal to mild
neurologic decits does not aect the indications for
choosing either surgical or conservative treatments.
Even in patients with signicant neural decits, radi-
culopathies or anatomical defects, total improvements
can be achieved with non-surgical methods [16]. In all of
the patients with relative indications for surgery, it
should be delayed until a successful response is seen after
the conservative treatment [5]. The main importance of
surgery is relieving sciatia, but also relieving low back
pain. About 70% of patients report a decrease in low
back pain [2, 4]. In our study, the ratio of patients who
were relieved from low back pain and sciatica were 63
and 60%, respectively, in patients who were given trac-
tion along with other physical therapy modalities. Sur-
some risks and complications like thromboembolism,
infection, perforation of dura mater, and neurological
complications [2]. Long-term results of patients disco-
genic low back pain without progressive neurologic
decits do not dier between various conservative
treatments [11]. Therefore, in patients without absolute
indications for emergency surgery, traction and other
physical therapy modalities should initially be applied.
The data presented here suggest that continuous
lumbar traction is an eective method of treatment in
patients with lumbar disc herniation. It is one of the
eective components for decreasing the size of the her-
niated disc material. Patients with greater disc hernia-
tions might respond better with traction compared to
those with smaller herniations.
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