Halo vest versus spinal fusion for cervical injury: evidence from an outcome study

The indications for surgical fusion, as opposed to halo fixation, in the management of cervical spine injury are still unclear. At St. Louis University Medical Center a conservative protocol has been adopted to treat almost all cervical spine fractures with halo fixation. To determine what factors have contributed to failure of halo fixation, the records and radiographs of all patients with cervical spine injuries who were treated at that institution between 1984 and 1986 were reviewed. During this interval, 124 patients were treated, consisting of 93 men and 31 women between 6 and 94 years old. Of these, 15 (12%) had cervical fusion without preoperative halo device application. This group included eight patients with old injuries and delayed diagnosis, three with nonreducible locked facets, and four with miscellaneous indications. The remaining 109 patients were treated with halo vests. Four died before completing the 3-month standard treatment. Of those completing the treatment, 48 had C1-2 level injuries and 57 had C3-T1 level injuries. Sixteen patients (15%) failed their halo treatments and required surgical fusion: eight while still in halo fixation and eight after they had completed treatment with a halo device. Failure of halo treatment was indicated by recurrent dislocation in 13 patients and increased neurological deficit in three. Thirteen of the patients who failed treatment had C3-T1 injuries and three had C1-2 injuries. Of 27 patients with odontoid fractures, only two (7.4%) failed halo fixation. There were no failures in 11 patients with hangman's fractures. Of the 57 patients with C3-T1 injuries, 13 (23%) failed treatment, nine of whom had locked or "perched" facets. The factors causing failure of halo fixation were analyzed. The overall success rate was 85%, suggesting that the halo vest can be used to treat most patients with cervical spine injuries. Under certain circumstances (in the presence of old injuries, difficult reduction, or locked or "perched" facets), surgery may be indicated to avoid unnecessary delay in definitive management.     

Diving injuries of the cervical spine in amateur divers.

BACKGROUND CONTEXT: Diving injuries are the cause of potentially devastating trauma, primarily affecting the cervical spine. PURPOSE: Our purpose was to describe our experience with diving injuries treatment. STUDY DESIGN: Retrospective review. PATIENT SAMPLE: Twenty patients with diving injuries. OUTCOME MEASURES: Using the American Spinal Injury Association (ASIA) impairment scales as the primary outcome measure, the patients' neurological status before and after treatment was assessed. In this way we were able to draw conclusions about neurological improvement or deterioration in response to conservative or operative treatment. METHODS: We retrospectively reviewed 20 patients with diving injuries of the cervical spine who were admitted to our institute over a 34-year period from 1970 until 2004. RESULTS: The typical patient profile was of a young, healthy, athletic male who suffered an injury to the cervical spine after diving into shallow water. The number of cases corresponds to 2.6% of all admitted cervical spine injuries. All injures occurred between May and September. The most commonly fractured vertebrae were C5 and C6. Four patients were treated operatively and 16 conservatively. The indications for surgical treatment were posttraumatic instability and persistent neurological deficit. The mean follow-up of the patients was 17 years. Five patients died within the first month of their hospitalization and 1 patient died 1 year after his injury. Of the 14 patients who were available for follow-up 5 years past injury time, 6 improved neurologically and 8 remained unchanged in relation to their neurology upon admission. Of the 11 patients who were available for follow-up 10 years past injury time, 9 remained neurologically unchanged, 1 deteriorated, and 1 improved in relation to their neurology in the 5-year follow-up. CONCLUSION: Diving injuries of the cervical spine demonstrate high mortality and morbidity rates. Recovery depends on the severity of the initial neurological damage. Conservative treatment is justified in specific patients and can lead to improvement of the initial neurological deficit.     

Type D fractures of the odontoid process

Type D fractures of the odontoid process are rare and usually occur in the elderly. The mechanism of fracture is unclear. Non-operative treatment is indicated provided that adequate immobilization using skull traction followed by either a collar or a halo vest can be achieved. The prognosis is usually favorable for this type of fractures. We present six patients with complex (type D) fractures of the odontoid process admitted and treated at our institution since 1970. There were five men and one woman with a mean age of 57.7 years (range, 16–81 years). Although there were concomitant injuries, no neurological deficits due to the odontoid process fracture was detected. All patients were treated non-operatively using skull traction or a halo vest for 8–12 weeks. One patient deceased 2 days after the injury. At the latest examination, all the remaining five patients had complete union of the odontoid process fracture; three of them had excellent range of motion and two had painful or restricted range of motion of the upper cervical spine.     

Cervical spine fractures in the elderly: morbidity and mortality after operative treatment

Purpose

Although there are currently many different strategies and recommendations in the therapy of cervical spine fractures in elderly patients, there are still no generally accepted treatment algorithms. The aim of the present study was to analyze the morbidity, mortality, and outcome of operated cervical spine injuries in the elderly.

Methods

This study presents a retrospective review of 69 patients aged 65 years or older admitted to our level I trauma center with cervical spine injury, who had undergone surgical treatment. The data were acquired by analysis of the hospital inpatient enquiry system and radiological review.

Results

The ratio between male and female patients was 37:32. The average age of the patients was 76 years (ranging from 65 to 96 years) for males and 80 years (ranging from 66 to 93 years) for females. Injury to the cervical spine was caused by low-energy trauma in 71 % and high-energy trauma in 29 %, respectively. 55.1 % sustained isolated cervical spine injuries, 39.1 % injuries to two adjacent vertebrae, 2.9 % injuries to three adjacent vertebrae, and 2.9 % an odontoid fracture combined with associated fracture(s) in non-contiguous vertebra(e). Isolated spine injury level was dominated by C2 (47.8 %). The most common site for injuries to two adjacent vertebrae was observed at C6/C7 (14.5 %). The morbidity included cerebral complications, respiratory complications, Clostridium difficile-associated disease, heart failure, and acute renal failure. Operative complications included dislocation/malposition, neurovascular lesions, wound infection, and transient swallowing difficulty. The mortality rate at 3 months was 26.1 %, with an in-hospital mortality of 21.7 %. Age was associated with mortality at 3 months. A cervical fracture-induced neurological deficit was documented in 26.1 %, resulting in a mortality of 44.4 % (8/18). Twenty-seven of 33 patients living at home/nursing home at the time of injury returned to their home/nursing home after their hospitalization. The overall outcome was predominantly related to age and the severity of neurological deficit.

Conclusions

In elderly patients with cervical spine fractures, the hospital course is complicated by medical issues and early mortality rates are significant. Therefore, treatment strategies should be carefully individualized to the patients and their comorbidities.     

Pediatric cervical spine injuries: defining the disease

BACKGROUND/PURPOSE: Pediatric cervical spine injuries are uncommon. Most previous studies have been hampered by the small number of patients available for evaluation. The purpose of this study is to determine the incidence and characteristics of pediatric cervical spine injury utilizing a multiinstitutional pediatric trauma database, and to assess the impact of age and level of spine injury on mortality rate. METHODS: All children with cervical spine injury entered into the National Pediatric Trauma Registry over a consecutive 10-year period were identified. Patients were stratified by age, mortality, presence or absence of bony injury, level of cervical spine injury, and presence of neurologic deficit. Data were analyzed utilizing Student's t test for continuous variables and chi(2) analysis for categorical variables. Statistical significance was accepted at the P less than .05 level. RESULTS: From a database of 75,172 injured children, 1,098 were identified with cervical spine injury, overall incidence 1.5%. The mean age of the study group was 11 +/- 5 years, and 61% were boys. Nine hundred eight children (83%) had bony spine injury. Distribution of bony injury among upper cervical spine, lower cervical spine, or both was 52%, 28%, and 7%, respectively. The remaining 13% comprised unspecified levels of injury. Upper cervical spine injuries were prevalent among all age groups (42%, age < or = 8; 58%, age > 8), whereas lower spine injuries predominated in older children (85%, age > 8). One third of children in the study group had neurologic injury, and half of these had no radiographic evidence of bony injury. Ninety-four children (24%) had a complete cord injury, and the remaining 76% had an incomplete spinal cord injury. One hundred eleven children (23%) with upper spine injury died compared with 11 children (4%) with lower spine injury. Mortality rate was highest (48%) in those with atlanto-occipital dislocation. CONCLUSIONS: From this, the largest experience with pediatric cervical spine injury, several conclusions can be drawn. (1) Cervical spine injury occurs in 1.5% of injured children. (2) Upper cervical spine injuries are not limited to younger children but are equally prevalent in both age groups. (3) Associated mortality rate is nearly 6-fold higher in patients with upper cervical injury. (4) Seventeen percent of children with cervical spine trauma show no radiologic anomaly, yet 50% of children with cervical spinal cord injury have no initial radiologic abnormalities. (5) Of those in whom cervical spine injury is associated with a neurologic deficit, the deficit is complete in 24% of children.     

Zur Problematik des Halofixateurs beim alten Patienten

INTRODUCTION: The treatment of unstable cervical spine injuries with the halo vest represents an established procedure. So far no data reflecting the quality of life of patients following a halo vest treatment are available. Elderly people make up a large part of the inpatients in our hospital. Therefore special attention is payed to this group of patients in this study. METHODS: In this study 41 patients (average age of 51.8 +/- 23.5 years) with an unstable injury of the upper cervical spine were investigated. All of them underwent a halo vest therapy in our hospital during 1988-2003. The health-related quality of life was assessed in the mean 8.0 years after the trauma by using the SF-36 Health Survey. Additionally, the incidence of complications and the union rate over time were observed. RESULTS: The evaluation of the data obtained from the SF-36 revealed a reduced quality of life in the patient group in comparison to the reference population. This was particularly apparent in patients older than 60 years. The fracture healing under halo vest treatment was comparably slow. In 17% of the cases no fracture union was obtained after 12 weeks. This was only seen for patients older than 60 years. The complication rate associated to the halo vest amounted to 43% and was independent of age. CONCLUSION: The treatment of unstable fractures of the upper cervical spine with a halo vest results in a prolongated fracture healing for elderly people. Furthermore a halo vest therapy reduces the health related quality of life. Therefore, even for elderly patients an internal osteosynthetic stabilization of an unstable injury of the upper cervical spine should be considered if indicated.     

Halo-vest immobilization increases early morbidity and mortality in elderly odontoid fractures

BACKGROUND: Odontoid fractures are the most common cervical spine fractures in elderly patients. Treatment options included operative fixation (OP) or nonoperative management with either a halo-vest (HV) or rigid cervical orthosis (CO). Our previous study suggested increased morbidity and mortality with the use of HV in the treatment of elderly patients with cervical spine fractures. We review a series of odontoid fractures in elderly patients and evaluate for predictors for in-hospital morbidity and mortality. METHODS: There were 78 patients >65 years of age who sustained a type II or III odontoid fracture from January 1997 to June 2004 identified from the Rhode Island Hospital Trauma registry. Demographic, mechanism, injury pattern, treatment, and outcome data were recorded. Patients were analyzed according to treatment method. RESULTS: The mean age was 80.7 +/- 0.9 years. There were 50 type II, 17 type III, and 11 combined fractures. There were 38 (49%) patients treated with HV: 34 with halo alone, and 4 after OP; 40 (51%) patients were treated without HV: 27 with CO, and 13 with OP. There was no difference in injury severity or baseline medical condition between HV and non-HV patients. There were 24 (31%) patients who died during their hospital stay. Of the HV patients, 42% died compared with 20% in the non-HV group (p = 0.03). Major complications occurred in 66% of HV patients compared with 36% of non-HV patients (p = 0.003). CONCLUSION: Odontoid fractures are associated with significant morbidity and mortality in elderly patients. Outcomes after treatment with HV appear inferior to those achieved with CO or OP.     

老年颈椎损伤的特点及治疗

目的：评价老年人颈椎损伤的特点与治疗方法。方法：对31例老年颈椎损伤进行回顾性分析。结果：本组老年颈椎损伤发生率5．47％,其原因多为跌落伤,损伤类型以颈椎过伸性损伤和中央脊髓损伤综合征为常见。77．42％的患者伴有脊髓损伤,病死率为9．67％,保守治疗的骨折不愈合率为18．57％,21．43％的患者神经功能无改善,手术治疗后仍有14．28％患者神经功能无明显改善。结论：老年颈椎损伤死亡率及骨折不愈合率较高,手术治疗应在伤后早期进行。     

Complications associated with the halo-vest. A review of 245 cases

The cases of all patients treated with halo-vests for cervical trauma at the University of Virginia since 1977 were analyzed retrospectively. A standardized chart and radiographic review protocol were used to identify complications associated with the use of the orthosis. Two hundred and forty-five patients satisfied the criteria for inclusion in the study. No patient developed or suffered progression of a neurological deficit while immobilized. Complications included: pneumonia causing death (one patient); loss of reduction or progression of the spinal deformity (23 patients); spinal instability following orthotic immobilization for 3 months (24 patients); pin-track infection (13 patients); migration of anteriorly placed iliac-strut grafts (two patients); cerebrospinal fluid leakage from a halo pinhole (one patient); and miscellaneous (seven patients). The findings indicate several conclusions. The halo-vest protects patients with cervical instability from neurological injury. It does not absolutely immobilize the cervical spine nor does it prevent progressive deformity of malpositioned strut grafts. Even after a 3-month orthotic treatment period, surgery may be required on ligamentous and osseous injuries to provide spinal stability. Elderly kyphotic patients may require custom-made vests. A small subset of patients exists for whom the confining nature of the halo-vest is intolerable for 3 months.     

Management of athletic injuries of the cervical spine and spinal cord

Injuries to the cervical spine among athletes present inherent difficulties, especially in advising for return to contact sports. Experience with the acute care of 63 patients who sustained cervical spine injuries while participating in organized sporting events is analyzed. Forty-five patients had permanent injury to the vertebral column and/or spinal cord, while 18 suffered only transient spinal cord symptoms. Football mishaps accounted for the highest number of injuries, followed by wrestling and gymnastics. Twelve patients had complete spinal cord injury, 14 patients had incomplete spinal cord injury, and 19 patients had injury to the vertebral column alone. The majority of the spinal cord lesions occurred at the C4 and C5 levels, while bony injuries of C4 through C6 predominated. Twenty-five patients required surgical stabilization, and 20 were treated with orthosis only. There was no instance of associated systemic injuries, and hospital complications were few. The mean time of hospitalization was 19.1 days for injured patients and 3.0 days for patients with transient symptoms. A classification was developed to assist in the management of these patients: Type 1 athletic injuries to the cervical spine are those that cause neurological injury; patients with Type 1 injuries are not allowed to participate in contact, competitive sporting events. Type 2 injuries consist of transient neurological deficits without radiological evidence of abnormalities; these injuries usually do not prohibit further participation in contact sports unless they become repetitive. Type 3 injuries are those that cause radiological abnormality alone; these represent a heterogeneous group.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Acute stabilization of the cervical spine by halo/vest application facilitates evaluation and treatment of multiple trauma patients.

The management of acute cervical spine injuries has traditionally used bed-based skeletal traction until all non-neurologic injuries have been evaluated. This treatment method substantially hinders the ability to transport patients and to perform imaging studies and surgical procedures. In contrast, early application of a halo/vest apparatus provides immediate cervical stabilization and facilitates the diagnostic work-up and treatment of the patients with multiple injuries. The records of all 78 patients admitted from February 1988 through June 1991 who had acute cervical spine fractures, subluxations, or both with a risk of instability were reviewed. All patients were treated with halo/vests and no patient deteriorated neurologically following halo/vest application. Twenty-nine patients (37%) had a total of 55 associated injuries including long bone/pelvic fractures in 17, thoracic injuries in 13, closed head injuries in 11, facial fractures in 6, noncontiguous spinal fractures in 5, and abdominal injuries in 3. The mean injury Severity Score (ISS) was 18 (range, 9-54). While in the halo/vest, 43 patients (55%) had a total of 99 diagnostic studies completed and 46 patients (59%) had a total of 76 surgical procedures performed. There were 35 neurosurgical procedures on 32 patients and 41 non-neurosurgical surgical procedures on 24 patients. Over the past year, 20 of 21 patients (95%) had their halo/vest placed in the emergency department. The data demonstrate that many diagnostic and surgical procedures need to be performed on patients with unstable cervical spine injuries.(ABSTRACT TRUNCATED AT 250 WORDS)     

Non-missile penetrating injuries of the spine

Summary Non-missile penetrating injuries of the spine accounted for 7% of all spinal injuries admitted to this Institute during the last 10 years. Young males were most commonly affected and 73% of the injuries involved the upper dorsal und cervical spine. They presented with varying degrees of neurological deficit. Plains x-rays revealed the bony injury and/or the retained foreign body satisfactorily. Myelography (with or without CT scan) was performed in patients with progressive neurological deterioration and those not responding to conservative therapy. Surgery remained the mainstay of treatment and improved neurological function in 7 out of 9 cases. Conservative management resulted in complications such as persistent CSF fistula, uncontrolled fulminant meningitis and septicaemia, with 100% mortality. Early surgical intervention is, therefore, recommended in all penetrating injuries of the spine.     

Airway management in acute tetraplegics: a retrospective study

The objective of this study was to develop an evidence-based airway management protocol for patients with acute tetraplegia. The method consisted of an analysis of the medical records of patients (September 1997–December 2002) with a spinal cord injury and a neurological deficit less than 8 weeks old. Of the 175 patients, 72 (41, 14%) were tracheotomised. This was influenced by the origin of the paralysis, Frankel score, and number of cervical spine operations, accompanying injuries and accompanying illnesses. Tracheotomy did not affect the duration of treatment, duration of ventilation or length of stay in the intensive care unit. The need for a tracheotomy was able to be predicted in 73.31% with neurological level, Frankel score and severity of accompanying injuries. In patients with acute tetraplegia, primary tracheotomy is indicated in sub C1–C3 with Frankel stage A/B, sub C4–C6 with Frankel stage A/B with trauma and accompanying injuries/accompanying illnesses, and in patients with complex cervical spine trauma that requires a combined surgical approach. In other patients, an attempt at extubation should be made.     

Simultaneous noncontiguous cervical spine injuries in a pediatric patient: case report

OBJECTIVE AND IMPORTANCE: Noncontiguous traumatic injuries of the cervical spine in children are rare. We present the case of a child who simultaneously sustained a separation of the odontoid synchondrosis and a C6-C7 dislocation with a complete spinal cord injury. The management of simultaneous cervical spine injuries is discussed. CLINICAL PRESENTATION: A boy aged 4 years and 2 months was a restrained back-seat passenger involved in a head-on motor vehicle accident. The patient lacked neurological function below C7. Imaging studies revealed a separation of the odontoid synchondrosis as well as a traumatic dislocation of the spine at C6-C7. INTERVENTION: The patient was placed in a halo vest shortly after admission. Four days after his injury, he underwent a posterior wiring and fusion of C6 to C7. As the C6-C7 dislocation was reduced by posterior element wiring, intraoperative x-rays showed a gradual increase in the subluxation of C1 on C2. This increase in C1-C2 subluxation required intraoperative repositioning of the halo crown on the ventral halo vest posts to maintain acceptable C1-C2 alignment. Postoperatively, ideal alignment of the odontoid peg on the body of C2 could not be achieved by halo adjustments alone. The patient required a custom-made posterior neck cushion attached to the halo vest to maintain cervical lordosis and good alignment of the odontoid peg on the body of C2. CONCLUSION: Simultaneous traumatic cervical spine injuries in pediatric patients are rare. The intraoperative reduction of one spine injury can affect the alignment at the location of the second injury. In this case, a custom adjustment of the halo vest improved the alignment of the odontoid peg on the body of C2.     

Influence of halo vest treatment on vital capacity

Respiratory function (vital capacity) was studied in 20 consecutive patients with unstable cervical spine injuries treated with a halo vest. Eight patients were neurologically intact. Twelve patients had incomplete spinal cord injuries that were classified on a neurologic function scale (Sunny-brook) immediately and 3 months after injury. Spirometric tests were done within 1 week of halo vest fixation, after 3 months of treatment, and 1 week after dismounting of the halo vest. The results showed that initial vital capacity was smaller than predicted normal in all patients and 30% less in neurologically impaired patients. Both groups improved during the treatment and somewhat more after removal of the halo vest. In neurologically intact patients, the halo vest caused a respiratory restriction of 10%, which was fully regained after removal of the halo vest. The difference between the groups remained throughout the study. There was no evidence that the halo vest itself affects the vital capacity more in patients with incomplete cord lesions than in neurologically intact patients. All of the cervical spine injuries healed uneventfully.     

Brachial plexus injuries associated with cervical spine fractures

The concomitant occurrence of brachial plexus injuries and cervical spine fractures in three recent patients is reviewed. The injuries included a fracture or dislocation of the upper portion of the cervical spine and damage to the upper roots of the brachial plexus. All of the patients had associated head injuries and two suffered a spinal cord injury. Recognition of the brachial plexus injury was delayed in each case because of the associated injuries. Probable mechanisms of injury include forced lateral bending of the cervical spine, with or without rotation, combined with forcible depression of the shoulder. All three patients required surgical fusion and/or halo bracing. Two have persistent Erb-type palsies. Brachial plexus injuries must be suspected in all cervical spine injury patients.