Halo Orthosis Immobilization

Author: David Abbasi

Topic updated on 05/15/13 6:50pm

Introduction

Fixes skull relative to torso
- provides most rigid form of cervical spine external immobilization
- ideal for upper C-spine injury
Allows intercalated paradoxical motion in the subaxial cervical spine
- therefore not ideal for lower cervical spine injuries (lateral bending least controlled)
  - "snaking phenomenom"
    - recumbent lateral radiograph shows focal kyphosis in midcervical spine
    - yet, upright lateral radiograph shows maintained lordosis in midcervical spine

Indications

Indications
- definitive treatment ofcervical spine trauma including
  - occipital condyle fx
  - occiptiocervical dislocation
  - stable Type II Atlas fx (stable Jefferson fx)
  - type II odontoid fractures in young patients
  - type II and IIA hangman’s fractures
- preoperative reduction in the patients with spinal deformity
- adjunctive postoperative stabilizationfollowing cervical spine surgery
Contraindications
- absolute
  - cranialfracture
  - infection
  - severe soft-tissue injury
    - especially near proposedpin sites
- relative
  - polytrauma
  - severe chest trauma
  - barrel-shaped chest
  - obesity
  - advanced age
    - recent evidence demonstrates an unacceptably high mortality rate in patients aged 79 years and older (21%)
CT scan prior to halo application
- indications
  - clinical suspicion for cranial fracture
  - children younger than 10 to determine thickness of bone

Application

Adults
- total of 4 pins
  - 2 anterior pins
    - safe zone is a 1 cm region just above the lateral one third of the orbit (eyebrow) at or below the equator of the skull
      - this is anterior and medial to temporalis fossa/temporalis muscle
      - this is lateral to supraorbital nerve
  - 2 posterior pins
    - placed on opposite side of ring from anterior pins
- tighten to 8 inch-pounds of torque
  - can have patient return on day 2 to tighten again
- proper pin and halo care can be done to minimize chance of infection
Pediatrics
- best construct involves more pins with less torque
  - total of 6-8 pins
  - lower torque (2-4 in-lbs or "finger-tight")
- indications
  - children > 2 yrs with suitable cervical spine injury
  - children <2 yrs should use Minerva cast

Complications

Loosening (36%)
- can be treated with retightening
- if continues to loosen should be treated with pin exchange
Infection (20%)
- can especially occur with posterior pin in temporalis fossa because
  - pins hidden in hairline
  - bone is thin
  - temporalis muscle moves with chewing
- can be treated with oral antibiotics if pin not loose
  - if pin infection and loose then pin should be removed
Discomfort (18%)
- treated by loosening skin around pin
Dural puncture (1%)

Abducens nerve palsy
- is most commonly injured cranial nerve with halo
- is identified by loss of lateral gaze
Supraorbital nerve palsy
- injured by medially placed anterior pins
Supratrochlear nerve palsy
- injured by medially placed anterior pins
Medical complications

pneumonia
ARDS
arrythmia

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Qbank (5 Questions)

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(OBQ11.38) A 27-year-old male is an unrestrained passenger in a motor vehicle accident. He was medically stabilized in the emergency room. His initial injury CT scans are seen in Figures A and B. He is neurologically intact and placed in a halo fixator prior to surgical treatment. What is the most common neurologic complication with halo traction? Topic

Review Topic

FIGURES: A

1. Weakness in biting and chewing strength
2. Deficit in medial and downward eye movement
3. Deficit in lateral eye movement
4. Inability to close eyes against resistance
5. Tongue deviation toward the affected side

PREFERRED RESPONSE ▶

DISCUSSION: Figures A and B depict a patient with an Type II odontoid fracture. Cranial nerve VI palsy is the most common nerve palsy associated with halo cervical traction. A cranial nerve VI palsy would result in paralysis of the lateral rectus, causing a deficit in lateral eye movement. The cranial nerves and functions are in Illustration A.

Halo fixation is indicated for a number of conditions in the cervical spine including definitive treatment for fractures and preoperative reduction. In adults, four pins are placed at 6-8in/lbs. The safe zone is defined 1cm superior to the outer 2/3 of the orbit. Absolute contraindications include active infection, cranial fractures and severe soft-tissue injury at pin sites. Pin loosening is the most common complication in adults, followed by pin site infection.

Wilkens et al investigated cranial nerve complications with halo immobilization and traction in 70 patients. They found the sixth cranial nerve was most commonly affected by distraction and resulted in weakness in lateral gaze. They emphasize that frequent monitoring of the patients in skeletal traction is necessary, and prompt recognition of the clinical signs of these complications must be stressed.

Bono et al report halo immobilization can be used for the definitive treatment of cervical spine trauma, preoperative reduction in the patient with spinal deformity, and adjunctive postoperative stabilization following cervical spine surgery. They state skull fracture, infection, and severe soft-tissue injury at the pin sites as absolute contraindications. Relative contraindications include severe chest trauma, obesity, advanced age, and a barrel-shaped chest.

Figure A shows a sagittal CT showing a Type II odontoid fracture with anterior displacement. Figure B is an axial CT at the level of the odontoid again showing anterior diplacement of the dens. Illustration A lists the cranial nerve. Illustration B & C illustrate how to place a halo fixator. Illustration D shows the safe zone for placement of your anterior halo pin.

Illustrations: A

REFERENCES:

1. Wilkins C, MacEwen GD. Cranial nerve injury from halo traction. Clin Orthop Relat Res. 1977 Jul-Aug;(126):106-10. PubMed PMID: 598096. PMID:598096 (Link to Abstract)

2. Bono CM. The halo fixator. J Am Acad Orthop Surg. 2007 Dec;15(12):728-37. Review. PMID:18063713 (Link to Abstract)

Question Authors:

Terrill Julien MD, Jan Szatkowski MD, Dave Marcu MD,

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(OBQ10.99) With halo immobilization the anterior pin should be placed in which of the following regions in Figure A to avoid injury to the supraorbital nerve and optimize stability? Topic

Review Topic

FIGURES: A

1. Region A
2. Region B
3. Region C
4. Region D
5. Region E

PREFERRED RESPONSE ▶

DISCUSSION: The safe zone for anterior pin insertion with halo immobilization is an approximately 1-cm region just above the lateral one third of the orbit (eyebrow) at or below the equator of the skull. More lateral pin insertion risks penetration of the thin temporal bone. More medial positioning risks injury to the supraorbital and supratrochlear nerves (see Illustration A). An injury to the supraorbital nerve may lead to pain and numbness over the medial one third of the eyebrow. The supratrochlear nerve supplies sensation medial and inferior to the supraorbital sensory distribution. Regions A, B, and C are all above the equator of the skull and would not be ideal from a biomechanical perspective. The review article by Bono explains the history, indications, proper placement, and complications of halo immobilization.

Illustrations: A

REFERENCES:

1. Bono CM. The halo fixator. J Am Acad Orthop Surg. 2007 Dec;15(12):728-37. PMID:18063713 (Link to Abstract)

Question Authors:

Derek Moore, Patrick McCulloch MD,

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(OBQ09.110) The halo vest is most effective at controlling which of the following spinal motions? Topic

Review Topic

FIGURES: A

1. Rotation at the atlantoaxial joint
2. Flexion and extension in the subaxial cervical spine
3. Rotation in the subaxial cervical spine
4. Lateral bend in the subaxial cervical spine
5. Flexion and extension at the cervicothoracic junction

PREFERRED RESPONSE ▶

DISCUSSION: The Halo vest immobilizes the skull relative to the torso. Therefore is is ideal for controlling motion at upper cervical spine (occipitocervical junction and atlantoaxial junction. Halo immobilization allows for intercalated paradoxical motion in the subaxial cervical spine, and is therefore less ideal for lower cervical spine injuries.

Ivancic et al performed an invitro study measuring motion of cervical spine specimens with the variables of a normally applied halo, a loose vest, a loose superstructure, and an absent posterior uprights. They found that lateral bending was increased at the C6-7 level when there was a loose superstructure.

Johnson et al evaluated the ability of different cervical orthoses to control cervical range of motion at each cervical intervertebral joint. At the atlanto-axial joint, the halo vest restricted flexion-extension by 75%, which compared to only 45% by conventional cervical braces. The halo vest was less effective at controlling motion in the subaxial cervical spine below C3.

Bono et al reviews the literature and discusses the indications, contraindications, and complications for halo immobilization. They recommend the halo can be used for definitive treatment of C1 burst (Jefferson) fracture and type II and III odontoid fractures. Absolute contraindications include cranial fracture, infection, and severe soft-tissue injury at the proposed pin sites. They discuss the high mortality rate associated with using halo immobilization in the elderly population.

Illustration A shows the table from the Johnson articles that compares the effectiveness of different orthosis at controlling different types of motion (combined measurement from occiput to T1)

Incorrect Answers:
Answers 2,3,4,5: The halo vest is less effective at controlling motion in the subaxial cervical spine and cervicothoracic junction than at the atlanto-axial joint.

Illustrations: A

REFERENCES:

1. Ivancic PC, Beauchman NN, Tweardy L. Effect of halo-vest components on stabilizing the injured cervical spine. Spine (Phila Pa 1976). 2009 Jan 15;34(2):167-75. PMID:19139667 (Link to Abstract)

2. Johnson RM, Hart DL, Simmons EF, Ramsby GR, Southwick WO. Cervical orthoses. A study comparing their effectiveness in restricting cervical motion in normal subjects. J Bone Joint Surg Am. 1977 Apr;59(3):332-9. PMID:849944 (Link to Abstract)

3. Bono CM. The halo fixator. J Am Acad Orthop Surg. 2007 Dec;15(12):728-37. Review. PMID: 18063713 (Link to Abstract)

Question Authors:

Derek Moore,

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Evidence & References Show References

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

Wilkins C, MacEwen GD. Cranial nerve injury from halo traction. Clin Orthop Relat Res. 1977 Jul-Aug;(126):106-10. PubMed PMID: 598096. PMID:598096 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Bono CM. The halo fixator. J Am Acad Orthop Surg. 2007 Dec;15(12):728-37. PMID:18063713 (Link to Abstract)
Bono CM. The halo fixator. J Am Acad Orthop Surg. 2007 Dec;15(12):728-37. Review. PMID:18063713 (Link to Abstract)
Ivancic PC, Beauchman NN, Tweardy L. Effect of halo-vest components on stabilizing the injured cervical spine. Spine (Phila Pa 1976). 2009 Jan 15;34(2):167-75. PMID:19139667 (Link to Abstract)
Johnson RM, Hart DL, Simmons EF, Ramsby GR, Southwick WO. Cervical orthoses. A study comparing their effectiveness in restricting cervical motion in normal subjects. J Bone Joint Surg Am. 1977 Apr;59(3):332-9. PMID:849944 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Dormans JP et al. “Complications in Children Managed with Immobilization in a Halo Vest”. J Bone Joint Surg Am. 1995; 77: 1370-1373. PMID:7673288 (Link to Abstract)
Botte MJ, Byrne TP, Abrams RA, et al: Halo skeletal fixation: Techniques of application and prevention of complications. J Am Acad Orthop Surg 1996;4:44-53 PMID:10795038 (Link to Abstract)
Garfin SR, Botte MJ, Waters RL, et al: Complications in the use of the halo fixation device. J Bone Joint Surg Am 1986;68:320-325 PMID:3949826 (Link to Abstract)
Vaccaro AR et al. “Pediatric Cervical Spine Trauma”. OKU: Spine 3. 2006: 397-405.

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Halo Orthosis Immobilization

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