halo orthosis immobilistion and cervical spine closed reduction

Question 1

What is the halo do?

Answer 1

• Fixes skull relative to torso
  
  • provides most rigid form of c spine external immobilisation
  • ideal for upper C spine injury
• Allows intercalated paradoxial motion in the subaxial c spine
  
  • Not ideal for lower c spine injuries ( lateral bend least control)

Question 2

What are the adult indications for a halo ?

Answer 2

• definitiv tx of c spine trauma including
  
  • occiptal condyle fx
  • occiptiocervical dislocation
  • stable type 2 atlas fx- jefferson’s
  • type 2 odontoid fx - young pts
  • type 2/2a hangman spondylolithesis fx
• adjunct post op stabilisation following c spine surgery

Question 3

What are the paediatric indications for halo?

Answer 3

• definitive tx
• Jefferson fx- atlas burst fx
• atlas fx
• **unstable odontoid **
• perisitent atlanto-axial rotational subluxation
• C1-2 dissociation
• subaxial c spine trauma
• preop reduction in pt with spinal deformity

Question 4

What are the contraindications for halo tx?

Answer 4

Absolute

• Cranial fx
• infection
• sever soft tissue injury

​Relative

• Polytrauma
• severe chest trauma
• barrel shaped chest
• obesty
• adv age- 21% mortality aged 79 years +

CT prior to application in clinical suspicion of cranial fx and child <10 yrs- see thickness of bone

Question 5

Describe the application to an adult of a halo?

Answer 5

• torque = 8 inch pounds of torque
• location
  
  • 4 pins
  • 2 anterior
  • SAFE ZONE= 1cm region just above lateral one third of the orbit( eyebrow) at or below the equator of the skull
    
    • ant & medial to temporalis m
    • lateral to supraorbital n
  • 2 posteriorly
    
    • placed on opposite sides of ring from anterior pin
  • tighten in sequential manner
  • can have pt return day 2 for tightened again

Question 6

How does the application of halo vary in children?

Answer 6

• best construct = more pins less torque
• total 6-8 pins
• lower torque 2-4 lbs- finger tight
• location
  
  • place ant pins lateral enough to avoid frontal sinus, supratrochlear and supraorbital nerves
  • place ant to avoid temporalis
  • place post pins opposite anterior
  • custom fit best for children >2 years/ minerva for those <2 yrs
  • Ct scan may help pin placement

Question 7

What are the complications of halo vest?

Answer 7

• Loosening 3%
  
  • retightened
  • pin exchange
• Infection 20%
  
  • esp post pin in temporalis fossa as
  • pins hidden in hairline
  • bone is thin
  • temporalis m moves with chewing
  • tx oral antibiotics if not loose
  • if infected and loose remove
• Discomfort 18%
  
  • tx by loosening skin aroound pin
• Dural puncture 1%
• Abducens Nerve palsy
  
  • most common nerve palsy
  • traction injury to CN VI-> lateral rectus m
  • causes diplopia, loss of lateral gaze om affected side
  • tx by observation, most resolve
• Supraorbital nerve palsy
  
  • injured by medially placed ant pins
• Supratrochlear n palsy
  
  • injured by medially placed ant pins
• medical complications
  
  • Pneumonia
  • ARDS
  • arrthymias

Question 8

What are the indications for closed cervical traction?

Answer 8

• subaxial cervical fractures with malalignment
• unilateral and bilateral facet dislocations
• displaced odontoid fractures
• select hangman’s fractures
• C1-2 rotatory subluxation

Contraindications

• patient who is not awake, alert, and cooperative
• presence of a skull fracture may be a contraindication

Question 9

Decribe the pt setting for closed reduction of cervical spine?

Answer 9

• emergency room/operating room
• pt supine with reverse trendlenberg or use or arm/legs weights prevents pt migrating up bed
• Diazepam to aid muscle relaxant
• Pt must remain awake
• enought room for xray

Question 10

Describe the technique for closed reduction of c spine?

Answer 10

Pin placement (Garner-Wells pins)

• pin placement is 1 cm above pinna in line with external auditory meatus and below the equator of the skull.
• if the pin is placed too anterior the temporalis musles and superficial temporal artery and vein are at risk
• an anterior pin will apply an extension moment to the cervical spine
• if the pin is placed too posterior it can apply a flexion moment to the cervical spine
• a posterior pin with a flexion moment may facitilitate reduction of a facet dislocation.
• stainless steel pins > cut out strength than Ti & MRI compatible graphite.

Pin tightness

• On Gardner-Wells tons pins are tightened until spring loaded indicator protrudes 1 mm above surface
• this is the equivalent of 139 newtons (31 lbs) of force
• overtightening by 0.3 mm leads to 448 newtons (100 lbs)

Then start adding weight

• an intital 10lbs is added.
• weights are increased at 10lb increments every 20 minutes
• serial exams and radiographs are taken after each weight is placed
  maximal weight is controversial
• some authors recommend weight limits of 70 lbs
• recent studies report up to 140 lbs is safe

Question 11

Describe the reduction maneover of a unilater facet dislocation with the Garden - weils pins?

Answer 11

Uilateral

• reduction maneuver performed after facet is distracted to a perched position using Garden- wells pins
• maintain axial load and rotate head 30-40 degree past midline in the direction of the dislocation
• stop once resistance is felt and confirm with radiographs

Question 12

Describe the reduction maneover of a bilateral facet dislocation with the Garden - weils pins?

Answer 12

• reduction maneuver performed after facet is distracted to a perched position using Garden wells pins
• palpate the stepoff in the spinal process posteriorly and apply an anterior directed force caudal to the level of the dislocation
• rotate the head 40 degree beyond midline in one direction, and then rotate 40 degreee in the other direction while axial traction is maintained.

Question 13

What are the complications of closed cervical spine reduction?

Answer 13

• Failure of reduction
  
  • MRI obtained and then to open surgery
• worsen neurology
  
  • remove weight and obtain MRI