Indications for halo immobilization of the cervical spine

Summary In the United States, cervical spine injuries are routinely immobilized with the halo apparatus. In Europe, this device is seldom used except in the treatment of spinal deviations. Based on studies of five cases the authors discuss the indications for use of the halo device in cervical spine injuries.     

Failure of immobilization of the cervical spine by the halo vest. A report of five cases

The halo vest is considered by us, as well as by the majority of orthopaedic surgeons, to be the best commercially available orthosis for control of the cervical spine. However, we have seen five patients with posterior ligament injury of the neck who sustained a recurrence of facet dislocation or subluxation while in a halo vest.     

Management of post-traumatic cervical spine instability: operative fusion versus halo vest immobilization. Analysis of 49 cases

A 5-year retrospective analysis was conducted for all cervical spine fractures associated with neurologic deficit initially treated at the University of Michigan Hospitals. Forty-nine cases of lower cervical spine fracture (C3-C7) were reviewed. Twenty-eight patients underwent early operative fusion followed by immobilization with either halo vests, or hard cervical collars, and 20 patients were initially immobilized in halo vests only. One patient refused treatment and was kept in a hard cervical collar. The average period of immobilization was 3 months. Eight patients in the halo vest group demonstrated radiographic evidence of spinal instability following immobilization (40%). Five of these eight patients subsequently required operative stabilization. Two of these five suffered progression of neurologic deficit secondary to loss of reduction while immobilized. Spinal instability occurred in two of the 28 patients initially fused (7%) (p less than 0.01), and in the patient treated in a collar. The findings indicate: 1) the halo vest does not protect patients with cervical instability from neurological injury, nor does it absolutely immobilize the cervical spine; 2) surgery may be required to provide spinal stability, even after a 3-month orthotic treatment period; and 3) there appears to be an increased rate of spinal stability with fusion and immobilization versus immobilization alone.     

Fixation of the cervical spine with a new halo fixation system

The stable fixation of the cervical spine by means of a halo external fixator is superior in terms of stability compared with alternative methods. A new Halo external fixator system is being introduced which enables uncomplicated handling with which optimal possibilities for positional correction are achieved by means of lockable ball joints. By using carbon enhanced connection rods radiolucency is given.     

Application of the halo device for immobilization of the cervical spine utilizing an increased torque pressure

The rates for loosening and infection of the pins used in the halo apparatus are unfortunately high. The commonly recommended amount of torque to be used in applying the pins is 0.68 newton-meter (six inch-pounds). Forty-two adult patients underwent application of a halo device for immobilization of the cervical spine using an increased torque of 0.90 newton-meter (eight inch-pounds). The rate for loosening of the pins and the rate for infection at the pin site dropped from 36 per cent to 7 per cent and 20 per cent to 2 per cent, respectively.     

Conservative fracture treatment of the cervical spine with halo fixation

A differentiated therapeutic approach is necessary in discoligamentous or osseous lesions of the cervical spine. Whereas lesions with neurological disturbances are stabilised by operation almost in all cases--and extensive lesions of the lower cervical spine (C3 to C7) quite frequently--, conservative treatment is the order of the day in sequels to trauma at the upper cervical spine (C1 and C2) as well as in mild lesions of all sections of the cervical vertebral column. Fractures of the dens of Types II and III (after Anderson and d'Alonzo) are the exception, since they are now being stabilized by surgery on a large scale. The advantages of the halo-fixateur therapy compared against extension and immobilization in Minerva gypsum are that secondary correction of positioning is possible; that functionally disturbing and extended spondylodeses are avoided; that care of the polytraumatized patient is facilitated; that X-ray films are easy to assess; and that the period of hospitalization is greatly reduced. Successful treatment is possible only of the possible complications are known. Failures are possible if the head screws become loose, if there are pin-trac infections, if dislocations and fractures are redislocated, and if there are points of pressure beneath the jacket.     

Complications of halo treatment for cervical spine injuries in patients with ankylosing spondylitis--report of three cases

BACKGROUND: Patients suffering from ankylosing spondylitis are prone to injuries of the cervical spine even with minor trauma. Although the fractures are markedly unstable, nonsurgical treatment using a halo-thoracic plaster or jacket is a common approach. METHODS: We present three patients with cervicothoracic fractures of the ankylosed spine to describe problems and complications inherent in this type of treatment. In two, pin track infections and pin protrusion through the skull occurred, leading in one case to an intracerebral hemorrhage. In the third patient, the halo had to be removed after 8 months, just early enough to prevent the pins from cutting through. RESULTS: One patient required craniotomy. The second one could be resolved by local revision. In the third case, the fracture eventually united after using a stiff collar for 2 years. CONCLUSION: Halo treatment for cervical spine fracture in patients with ankylosing spondylitis is a challenging task for orthopedic surgeons and neurosurgeons.     

Complications of halo fixation of the cervical spine

Halo fixators play an integral role in stabilizing the cervical spine. They are most widely used after upper cervical to midcervical spine fractures and dislocations and as a supplement to various surgical fixation techniques. Compared with supine cervical traction techniques, halo fixators allow early patient mobilization and shorten hospital stays. The incidence of halo-fixator complications remains high. Minor complications include pin loosening, localized infection, periorbital edema, superficial pressure sores, and unsightly scars. Major complications include pin penetration, osteomyelitis, subdural abscess, nerve palsies, fracture overdistraction, and persistent instability. Many of these potential complications can be avoided with proper pin placement and meticulous pin care.     

The halo brace in unstable fractures of the cervical spine: a review of 14 cases

A series of 14 patients with unstable fractures of the cervical spine, treated initially with skull traction and a few days later with a halo-thoracic brace, is described. Nine of the injuries were fractures of the odontoid process and the rest were at various levels. No patient with major neurological defects was included in the halo brace treatment. The halo brace provides significant advantages, including immediate mobilization with less time in hospital and less nursing. The results of the present series are encouraging; stable conditions were achieved in all cases.     

The treatment of multiple myeloma of the cervical spine with a halo vest

Two patients with multiple myeloma involving the cervical spine and causing instability were treated in a halo vest while radiotherapy and chemotherapy were instituted. Further instability and neurological loss were prevented while continuing this treatment. The bony lesions eventually healed and mechanical stability was restored in both patients. Temporary halo vest placement with concurrent chemo- and/or radiotherapy can be a reasonable and safe alternative to surgery in those patients with multiple myeloma involving the cervical spine, and often results in bone reconstitution and stability.     

Treatment of fractures of the cervical spine with external halo fixation

15 serious injuries of the cervical spine were treated by Halo-fixation devices. Practical procedure as well as advantages in clinical application are dealt with. This method seems to be a good alternative to surgical stabilisation.     

Simple cervical spine traction using a halo vest apparatus: technical note

BACKGROUND: A halo vest apparatus, commonly used for external immobilization and protection of the cervical spine, offers several advantages. We present here a simple, accurate, easy, and safe cervical traction technique using a halo vest apparatus. METHODS: The distinguishing feature of our technique is that, after application of a halo vest apparatus, the halo crown is distracted gradually and stepwise by turning the bilateral screw bolts that hold the halo crown over a period of one to several weeks. After each of these steps, care must be taken to check neurologic, radiologic, and skin conditions, as well as cranial pin tightening. CONCLUSIONS: This distance control technique can provide a strong and accurate traction force by simply turning the bolts without the risk of overdistraction or the need for bed rest, and can be used in conjunction with radiologic examination and transportation of patients, even those unable to walk. The Sugita head fixation system constitutes a safe and easy way to facilitate surgical management after correction of cervical dislocation.     

A halo jacket for stabilisation of the paediatric cervical spine

Summary Stabilisation of the paediatric cervical spine may be necessary in the management of trauma, infection and deformity. Surgery is technically difficult due to the immaturity of the bony elements and therefore external support is generally preferred. Our experience of halter traction and Minerva casts is that they either fail to achieve stability or are poorly tolerated. Halo pins are associated with significant pin tract complications in children. The technique for application of a plaster halo jacket is presented, together with the results of its use in eight children. Attention is drawn to the ease of application, tolerance by the patients and absence of significant complications.     

Halo-thoracic brace immobilization in 188 patients with acute cervical spine injuries

The authors report 188 patients with acute cervical spine injury with fracture who underwent Halo-thoracic brace immobilization. The majority of the fractures were considered unstable. Early neurological assessment revealed 24 patients without neurological deficit. There were 164 patients with associated cervical cord injury; 84 patients with incomplete, and 80 patients with complete tetraplegia. Management consisted of skull traction and application of the Halo-thoracic brace about 1.3 weeks after admission. The average radiological union time was 11.5 weeks following a mean of 10.2 weeks of immobilization in a Halo apparatus. Satisfactory restoration of bone and ligament stability, with no significant posttreatment neck pain, was obtained in 168 cases (89%). This is comparable to the fusion rate achieved for cervical fractures in the literature. The follow-up periods range from 1 month to 6 years, with a mean of 10.8 months. The management and results in 73 patients with unilaterally and bilaterally locked facets with or without fractures are discussed. Complete tetraplegia is not considered a contraindication to Halo apparatus immobilization. The multiple factors responsible for overcoming the barrier of anesthetic skin are elucidated. Use of the Halo apparatus offers early mobilization and rehabilitation without neurological deterioration. Complications are few and insignificant.     

A review of halo vest treatment of upper cervical spine injuries

Thirty-five relevant studies involving in total 682 patients with 709 different types of injuries were evaluated in a review to determine the outcomes after immobilisation in a halo vest for various injuries to the upper cervical spine between 1962 and 1998. Studies were analysed according to the type of injury pattern and in terms of the treatment outcomes following primary treatment with a halo vest. The following types of injuries were evaluated: odontoid fractures (n = 420), hangman's fractures (n = 172), other axis fractures (n = 75), Jefferson fractures (n = 26), C1 arch fractures (n = 9), atlantooccipital (n = 2) and atlantoaxial dislocations (n = 5). The ligamentary atlantooccipital dislocations never healed. All isolated Cl ring fractures healed completely. The isolated C1 arch fractures healed in 83% of the cases. The ligamentary atlantoaxial dislocations had a 60% rate of healing. Healing was noted in all isolated odontoid type I fractures, 85% of the isolated odontoid type II fractures, and 67% of the odontoid type II fractures with combined injuries. The isolated odontoid type III fractures had a 97% healing rate. The non-classifiable odontoid fractures had a healing rate of 85%. The stable C2 arch fractures (hangman's fracture) healed consistently in 99%, and 90% success was found for other C2 fractures. A halo vest can be recommended for patients with isolated Jefferson fractures, hangman's fractures, odontoid type III and type II fractures, with a low dislocation rate. The results of treatment with a halo vest were unsatisfactory with regard to combined injuries with an odontoid type II fracture. An overall healing rate of 86%, however, allows one to conclude that this treatment continues to be a good alternative to operative stabilisation of bone injuries to the upper cervical spine.     

Tracheal intubation using a Macintosh laryngoscope or a GlideScope in 15 patients with cervical spine immobilization

Editor—The use of rigid fibrescopes that incorporate trachealtubes does not allow for independent movement of the fibrescopeto allow visualization of the glottis while inserting the tube.^1–3This produces particular problems in patients with cervicalrigidity.⁴ In addition, these devices all suffer from foggingand obstruction of     

Spinal bone mineral density changes following halo vest immobilization for cervical trauma

Summary In this prospective study we followed the bone mineral density (BMD) changes of the injured cervical spine immobilized with the halo vest. In order to define the natural history of cancellous vertebral bone loss and restoration, dual-energy densitometry was used on each of ten selected cervical spines in the lateral view (1) immediately after the application of the device, (2) at the end of the treatment and (3) 3 months after the removal of the halo vest. The halo vest produces local osteoporosis in the immobilized cervical spine with an overall reduction of BMD averaging 2.83% (P < 0.05). The response of the cervical spine to immobilization was only slightly different from patient to patient and between different vertebral bodies in each particular spine. The type and the level of injury of the cervical spine were not related to the changes of BMD, age or gender of the patient, whereas the local osteoporosis was mostly reversible in the follow-up evaluation of 5–6 months.