2: Halo Placement in the Pediatric and Adult Patient

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Procedure 2 Halo Placement in the Pediatric and Adult Patient

Neil A. Manson, Howard S. An

Indications

image Jefferson fracture

image Odontoid fracture: type III or specific type II

image Hangman’s fracture: type II

image One-column bony cervical spine fracture

image Fracture in ankylosing spondylitis

image Preoperative traction or stabilization

image Postoperative stabilization of arthrodesis, infection, tumor resection

Indications Pitfalls

• Skull injury

• Skin injury

• Sensory loss (spinal cord injury)

• Associated injury: thoracic, abdominal, musculoskeletal

Treatment Options

• Consider rigid collar immobilization in a compliant, young, healthy patient with a minimally displaced, stable fracture.

• Consider surgical intervention in an elderly or noncompliant patient with an unstable or displaced fracture, a fracture of high nonunion potential, ligamentous injury, or associated injury.

• Move to surgical intervention for failure of halo fixation: loss of fracture alignment, symptomatic nonunion, neurologic deterioration.

Examination/Imaging

image Computed tomography (CT) is required to define fracture morphology and stability and rule out adjacent or noncontiguous injuries (Como et al, 2009) (Figure 2-1, A–C).

image Radiographs confirm fracture reduction and cervical alignment following halo application, and maintenance of these parameters during treatment (Figure 2-2).

image image image

FIGURE 2-1, A-C

Courtesy Dr. G. Kolyvas.

image

FIGURE 2-2

Courtesy Dr. G. Kolyvas.

Surgical Anatomy

image Relevant anatomy pertains to pin placement. Correct placement prevents direct neural or vascular injury, inner calvarial plate penetration, and pin migration, while providing adequate strength of fixation.

image Anterior pins

• Safe zone of placement: anterolateral skull, 1 cm superior to the orbital rim (eyebrow), above the lateral two-thirds of the orbit, and below the greatest circumference of the skull
• Structures to avoid (medial to lateral): frontal sinus, supratrochlear nerve, supraorbital nerve, zygomaticotemporal nerve, temporal artery, temporalis muscle (Kang et al, 2003) (Figure 2-3, A and B)

image Posterior pins

• Placement: posterolateral skull, at 4 o’clock and 8 o’clock positions or approximately diagonal to the corresponding contralateral anterior pins, below the greatest circumference of the skull and above the upper helix of the ear.
• There are no specific structures to avoid.
image

FIGURE 2-3 A, Anterolateral view. B, Posterolateral view.

Pearls

• It is preferable if the patient is awake and responsive to report any progression of pain or neurologic loss. Light sedation (midazolam) may be provided for comfort.

• Crash-cart access should be assured during halo application.

Equipment

• Ensure that all necessary equipment is available before halo application (adapted from Botte et al, 1995):

• Sterile halo ring/crown in preselected size
• Sterile halo pins
• Halo torque screwdrivers or breakaway wrenches
• Halo-pin locknuts
• Halo vest in preselected size
• Halo upright post and connecting rods
• Headboard
• Spanners or ratchet wrenches
• Iodine solution
• Iodine ointment
• Sterile gloves
• Syringes
• Needles
• Lidocaine for injection
• Crash cart (including airway supplies, endotracheal tube)

• Three people are recommended during application.

• Measure head and chest circumference and obtain appropriate size halo and vest before halo application.

Positioning

image Typical halo application is performed in the supine position utilizing in-line cervical stabilization by a knowledgeable care provider while two providers apply the apparatus.

image For stable fractures or nonfracture treatment, halo application in the upright position is preferred to optimize cranial-cervical-thoracic alignment and patient comfort.

image A cervical collar can provide additional stability until the halo construct is completed.

Positioning Pearls

• Before supine halo application, consider positioning the vest’s posterior shell under the patient to minimize movements during the application process. This could take place, for example, when transferring the patient to an operating room table for the application process.

Positioning Pitfalls

• The patient’s eyelids should be closed and relaxed during application. Pin malposition or sliding during insertion may tent the periorbital tissues and limit eyelid closure. This should be avoided.

Controversies

• The traditional construct utilizes four pins of 8 inch-pounds torque each. Cadaver and clinical studies have demonstrated improved stability and decreased pin-site complications with six- and eight-pin constructs.

Procedure: Halo Application

Step 1: Crown and Pin Placement

image Identify proper crown size: small for 48- to 58-cm head circumference, large for 58- to 66-cm head circumference. Choose the smallest crown size that allows at least 1 cm of space between head and crown.

image Identify proper pin sites as previously described in the “Surgical Anatomy” section of this chapter.

image Shave hair at posterior sites and cleanse skin at all sites with Betadine or alcohol preparation.

image Instruct patient to keep eyes closed and face musculature relaxed.

image Utilize positioning pins to align and maintain halo position: 1 cm above eyebrow and top of ear and below largest circumference of the head.

image Inject 1% lidocaine with epinephrine at the intended pin sites. Pass the needle through the pin holes of the halo ring to optimize anesthetic positioning. Inject from skin though to periosteum for patient comfort during pin placement.

image Traditionally, four pins provide halo fixation.

image Initial skin incision at the pin sites is not necessary and does not influence scar formation.

image Placement of all pins should occur simultaneously to maintain halo position and balance pin forces. Simultaneous advancement to the skin, through the soft tissue, and to the skull should occur, with final security achieved with release of the breakaway torque-limiting caps (Figure 2-4) (Depuy Spine Bremer Halo Systems technical monograph).

image Confirm torque to 8 inch-pounds utilizing a torque wrench.

image With pins secure to the skull, tighten the locking nuts to secure the pins to the halo ring.

image Areas of tethered or tented skin surrounding the pins can be released using a scalpel as needed.

image

FIGURE 2-4

Step 2: Vest Application

image Identify proper vest size based on chest circumference 5 cm below the xiphoid process and patient height: short vest for circumference of 70 to 97 cm and height less than 170 cm, large vest for circumference up to 112 cm and height greater than 170 cm.

image In-line cervical stabilization is maintained as required.

image Logrolling or trunk elevation allows placement of the posterior shell of the vest (Magnum and Sunderland, 1993) (Figure 2-5).

image The anterior shell is positioned and secured to the posterior shell.

image The vertical bars are secured on the vest and positioned for fixation to the crown.

image

FIGURE 2-5

Step 2 Pitfalls

• Patient obesity may necessitate custom vest sizing or preclude halo management altogether.

Step 3: Construct Alignment

image Each posterior vertical bar is attached to its ipsilateral anterior bar by the horizontal crown connector. Loosen all joints within the construct to allow appropriate alignment of the bars relative to the crown.

image Time spent in optimizing bar position before attachment to the crown will minimize patient discomfort and risk of loss of cervical alignment, which can occur when adjustments are made with the construct secured to the crown (Magnum and Sunderland, 1993) (Figure 2-6).

image Ensure symmetry between left and right bar constructs.

image Final tightening of all joints of the crown and vest construct should provide security with no concern for loosening.

image Only when final stability is obtained may the rigid collar be removed and in-line stabilization released.

image Final cranial-cervical-thoracic alignment is crucial to: (1) maintain fracture alignment, (2) provide patient comfort, and (3) optimize patient function, specifically concerning normal vision and swallowing ability.

image

FIGURE 2-6

Step 3 Pitfalls

• A linear correlation has been demonstrated between increased cervical extension and increased risk of laryngeal penetration and aspiration, secondary to swallowing dysfunction. Optimizing sagittal alignment can limit this significant complication.

Step 3 Pearls

• Application tools should be kept at the bedside or taped to the vest in case emergency removal of the vest is required.

Step 4: Follow-up

image Immediate follow-up

• Imaging is required to confirm cervical alignment and/or fracture alignment. Lateral radiograph is standard.
• If possible, sit patient upright to assess cervical alignment, construct security, and patient comfort.

image Short-term follow-up

• Further imaging (radiographs or computed tomography) is obtained as needed.
• Retightening of pins is performed at 24 hours after halo application. Locking nuts are first loosened and each pin is retightened to 8 inch-pounds utilizing the torque wrench. Locking nuts are retightened. All joints of the crown-vest construct are retightened.

Procedure: Halo Application in the Child or Infant

image Relevant differences in halo application in the pediatric population pertain to skull thickness, skull hardness, and the presence of open cranial sutures. Cranial penetration must be avoided.

image Consider general anesthesia depending on age and diagnosis. Although an anesthetized patient cannot provide feedback regarding neurologic status, this may be irrelevant in the very young child or infant.

image A custom crown and vest may be necessary, although pediatric sizes are available.

image Consider preapplication computed tomography to identify cranial sutures and plan pin placement (Mubarak et al, 1989) (Figure 2-7).

image Eight to 10 pins are utilized to provide stable fixation at lower torque forces.

image Torque to 2 inch-pounds utilizing a torque wrench. Consider torquing to finger tightness only in the very young child or infant.

image

FIGURE 2-7

Pitfalls

• Beware of halo use in the extremes of ages. In the very young, skull thickness and frequent falls during typical pediatric ambulation increase complications. In the elderly, cardiopulmonary dysfunction leads to significantly increased morbidity and mortality. Some clinicians question the safety of this tool in the elderly (Majercik et al, 2005).

Postoperative Care and Expected Outcomes

image Long-term follow-up

• Pin retightening at 1 week after halo application
♦ Pins require removal and replacement at a new site for infection or if no resistance is met within the first few turns during retightening.
• Pin-site care twice daily
♦ Inspection for crusting, drainage, redness, or swelling
♦ Cleansing using hydrogen peroxide (full or half strength)
♦ Reporting any changes to the care team
• Patient education regarding self-care and independence: Magnum and Sunderland (1993) provides valuable information.
• Complications are high but manageable through meticulous care and awareness.

image Final care

• One third of patients regard their pin scars as severe. During removal of the halo, the pin sites should be massaged with peroxide-saturated gauze to loosen adhesions between skin and bone. The patient should move the skin over the pin holes for several days to prevent reattachment of adhesions and thus minimize scarring.

Postoperative Pearls

• Careful halo application emphasizing pin placement, torque, and reevaluation combined with diligent pin-site care has been proven to decrease the rate of complications associated with halo fixation.

Postoperative Pitfalls

• Complications, although virtually ensured during the treatment period, are most often minor and can be well controlled with diligent care.

• Complications related to halo application include the following (adapted from Botte et al, 1995):

• Pin loosening: 36%-60%
• Pin-site infection: 20%-22%
• Severe pin discomfort: 18%
• Ring migration: 13%
• Pressure sores: 4%-11%
• Redislocation: 10%
• Restricted breathing from the vest: 8%
• Difficulty with arm elevation from the vest: 23%
• Pneumonia: 5%
• Nerve injury: 2%
• Bleeding at pin sites: 1%
• Dural puncture: 1%
• Neurologic deterioration: 1%

Evidence

Botte MJ, Byrne TP, Abrams RA, Garfin SR. The halo skeletal fixator: current concepts of application and maintenance. Orthopedics. 1995;18:463-471.

Como JJ, Diaz JJ, Dunham CM, et al. Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee. J Trauma. 2009;67:651-659.

Kang M, Vives MJ, Vaccaro AR. The halo vest: principles of application and management of complications. J Spinal Cord Med. 2003;26:186-192.

Letts M, Girouard L, Yeadon A. Mechanical evaluation of four versus eight-pin halo fixation. J Pediatr Orthop. 1997;17:121-124.

Magnum S, Sunderland PM. A comprehensive guide to the halo brace. AORN J. 1993;58:534-546.

Majercik S, Tashjian RZ, Biffl WL, Harrington DT, Coiffi WG. Halo vest immobilization in the elderly: a death sentence? J Trauma. 2005;59:350-357.

Manthey DE. Halo traction device. Emerg Med Clin North Am. 1994;12:771-778.

Morishima N, Ohota K, Miura Y. The influence of halo-vest fixation and cervical hyperextension on swallowing in healthy volunteers. Spine. 2005;30:e179-e182.

Mubarak SJ, Camp JF, Vuletich W, Wenger DR, Garfin SR. Halo application in the infant. J Pediatr Orthop. 1989;9:612-614.

Nemeth JA, Mattingly LG. Six-pin halo fixation and the resulting prevalence of pin-site complications. J Bone Joint Surg Am. 2001;83:377-382.

Polin RS, Szabo T, Bogaev CA, Replogle RE, Jane JA. Nonoperative management of types II and III odontoid fractures: the Philadelphia collar versus the halo vest. Neurosurgery. 1996;38:450-457.

Product monograph. Bremer Halo Crown Traction Set. Bremer Halo Systems, Raynham, Mass., 2003.

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