Halo-thoracic Brace Research Articles

Outcomes of halo immobilization in the management of subaxial cervical facet fractures.

Spinal injury causes a significant burden on patients, families and health services. Cervical facet fractures are uncommon, and there is a paucity of functional and health-related quality-of-life data in patients who are managed non-operatively for this injury. Victorian State Trauma Registry patients managed in a halothoracic brace for cervical facet injuries from August 2006 to June 2013 were included. Health status (12-item Short-Form health survey), function (Glasgow Outcome Scale-Extended), pain and return to work outcomes were assessed at 6, 12 and 24 months post-injury. Subgroup analysis was performed for age, sex, comorbidity, compensable status, Injury Severity Score (ISS) and education. Outcome data were available for 54 patients, with road trauma being the most common mechanism (69%), followed by a fall from height (18%). Overall, good 24-month function was achieved in 35% of patients, and 51% and 77% of patients reported good physical and mental health status, respectively. Ongoing moderate-severe neck pain was present in 19% of patients. Poorer function was associated with compensable status (P = 0.05), an ISS > 12 (P = 0.001) and a lower level of education (P = 0.04). Poorer physical health status was associated with age ≥50 (P = 0.05), pre-existing comorbidities, an ISS > 12 (P = 0.04) and a lower level of education (P = 0.03). Although many patients achieved good function and health status by 24 months, neck pain remains prevalent. A number of demographic factors were associated with a poorer outcome. This understanding helps to inform prognosis when managing this injury.

Non‐surgical interventions for the management of type 2 dens fractures: a systematic review

Non-surgical immobilization strategies for type 2 odontoid fractures vary considerably, with some surgeons preferring rigid collars, halothoracic bracing or the Minerva brace. Choice of device should be informed by the effectiveness in achieving union, whilst minimizing mortality and complications. Perform a systematic review evaluating the efficacy of non-surgical interventions for type 2 odontoid fractures. MEDLINE (OvidSP), EMBASE (OvidSP) and The Cochrane Library, ClinicalTrials.gov, Current Controlled Trials. We conducted a systematic review of studies directly comparing the halothoracic brace and cervical collars or the Minerva brace for union, mortality and complications. Studies were appraised for quality and bias, and results were pooled for analysis. Our search identified 1794 citations, 13 of which met inclusion criteria. There were no randomized or prospective studies. All studies were small, retrospective and observational. Our results demonstrate a greater likelihood of developing stable union (osseous and fibrous); relative risk (RR) 1.27 (95% confidence intervals (CI) 1.03 to 1.57; P = 0.03); and airway complications; RR 7.52 (95% CI 1.39 to 40.83; P = 0.02) with halothoracic bracing compared with cervical collar. In patients >65, there was a greater risk of airway complications; RR 7.50 (0.96-58.36; P = 0.05). No other significant differences were identified. Evidence to support selection of non-surgical immobilization in type 2 odontoid fractures is poor. Osseous union has traditionally been the benchmark for 'successful' treatment; however, evidence of association between union and improved outcomes is lacking. We highlight the need for a randomized study to promote evidence-based decision-making in the non-surgical management of this injury.

Understanding post-hospital morbidity associated with immobilisation of cervical spine fractures in older people using geriatric medicine assessment techniques: A pilot study

IntroductionThere is a paucity of research into the outcomes and complications of cervical spine immobilisation (hard collar or halothoracic brace) in older people. AimsTo identify morbidity and mortality outcomes using geriatric medicine assessment techniques following cervical immobilisation in older people with isolated cervical spine fractures. Patients and methodsWe identified participants using an injury database. We completed a questionnaire measuring pre-admission medical co-morbidities and functional independence. We recorded the surgical plan and all complications. A further questionnaire was completed three months later recording complications and functional independence. ResultsSixteen patients were recruited over a three month period. Eight were immobilised with halothoracic brace, 8 with external hard collar. Three deaths occurred during the study. Lower respiratory tract infection was the most common complication (7/16) followed by delirium (6/16). Most patients were unable to return home following the acute admission, requiring sub-acute care on discharge. The majority of patients were from home prior to a fall, 6/16 were residing there at 3 months. Most participants had an increase in their care needs at 3 months. There was no difference in the type or incidence of complications between the different modes of immobilisation. ConclusionsGeriatric medicine assessment techniques identified the morbidity and functional impairment associated with cervical spine immobilisation. This often results in a prolonged length of stay in supported care. This small pilot study recommends a larger study over a longer period using geriatric medicine assessment techniques to better define the issues.

Non-operative treatment of injuries of the upper cervical spine: our experience with a new carbon fibre halo system

Fractures of the upper cervical spine account for about 20% of all cervical spinal injuries. Only in a minority of cases a neurological damage occurs. With exception of the type-2-dens fracture the treatment of choice is non-operatively in the halo-thoracic brace. We report about our experience with Bremer® Halo System, an open ring carbon fibre design which especially facilitates the treatment of head injured patients in bed. We treated 13 patients (m/w 9/4), mean ages 40 years (range 18–73) with 10 dens fractures Anderson and d’Alonzo-type III and 3 hangman’s fractures Effendi-type I. Five patients had additional head injury. Two of them were unconscious at the time of application of the halo-device. Our routine follow-up included roentgenograms after halo-application and 6 weeks later. After 3 months CT-scans were performed to evaluate fracture union. After 12–20 weeks the halo-device could be removed. We observed one halo ring loosening in a patient with oversize skull resulting in earlier removal in presence of an already established union. In one case we had a delayed union which eventually united in stiff collar after 6 month. No pin tract infection was observed. All patients returned to their pre-injury activities. A slightly limited rotation of the head was observed in most of the patients. The Bremer® Halo System proved to be a reliable unsophisticated halo system in the treatment of upper cervical spinal injuries. The feature of the open ring design especially facilitates the treatment of an accompanying head injury. We experienced a problem with a limited size of the halo ring.

Pin-site complications of the halo thoracic brace with routine pin re-tightening.

Retrospective analysis with historic controls. To analyze pin-site complications in a large series of halo thoracic braces in which regular re-tightening of the pins was performed. Perry and Nickel first described the use of the halo thoracic brace in 1959 for cervical immobilization. Its use has been extended successfully to cervical fracture management. A total of 266 commercially available halo thoracic braces were fitted using a standard technique. All pins were tightened routinely at 24 hours and at 1 week after application. Two data sources, prosthetic department records and patients' medical records, were analyzed. Six percent of patients had a pin-site infection; 3.7% had loose pins, and 1.1% reported pin-site pain. No subdural, intradural, or extradural abscess or cerebrospinal fluid leaks occurred. A total of 2.6% of halo rings slipped off, and 2.3% of patients experienced severe headaches. Low rates of pin-site infection, loosening, and pain were achieved through routine re-tightening of the pins. Pin re-tightening, at 24 hours and at 1 week after application, is a safe and effective method to decrease pin-site complications.

Möglichkeiten und Grenzen der Therapie von Halswirbelverletzungen mit dem Halo-Fixateur

74 patients were treated with a Halo-thoracic brace in the Department of Traumatology of the AK St. Georg between 1980 and 1986. Of these, 61 had fractures of the cervical spine, nine had tumor-osteolysis, and four had inflammatory destructions of the vertebrae. In almost all cases of fractures of the upper cervical spine (C0-C2) bone healing occurred with applying the Halo fixation alone. In the middle and lower cervical spine, however, secondary operative measures were often necessary because of persistent instabilities, redislocations or neurologic disturbances. New experience in the palliative treatment of malignant osteolysis of the cervical spine shows, that restabilisation of the segments concerned can be achieved by the combined use the Halo apparatus, surgical resection of the involved vertebral bodies with bone grafting and radiotherapy. A new radiolucent Halo apparatus broadens diagnostic and therapeutic facilities.

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.

Dislocations of the Lower Cervical Spine

In 34 cases of cervical spine facet dislocation treated between 1975 and 1979, the dislocations were reduced by closed methods and immobilized in the halo thoracic brace. If closed reduction was unsuccessful, open reduction and fusion were performed. There is a high incidence of failure of closed reduction and halo thoracic immobilization in patients with minimal or no neurologic deficit. Bilateral facet dislocation was more frequently associated with severe neurologic injury than was unilateral facet dislocation, Use of closed reduction is time consuming, often unsuccessful, and may result in neurologic deterioration. Patients with facet dislocations and minimal neurologic injury are at risk of late instability following halo thoracic brace immobilization, and therefore open reduction and posterior cervical fusion may be advisable for them. However, surgical fusion carries a high incidence of long-term neck pain and stiffness, and is indicated only in patients at risk of developing late instability.

Halo-thoracic brace management of odontoid fractures.

Thirteen patients with fracture of the odontoid were treated with halo-thoracic brace. Major trauma was responsible for the fracture in only 5. Neither the degree nor the direction of displacement prevented union, which occurred in all 13. All patients were treated for least 60 days; 11 were treated longer. No complications occurred. The method is recommended based on the results.

The Fractured Cervical Spine Rendered Unstable by Anterior Cervical Fusion

Anterior interbody grafts are prone to displacement if there is posterior instability or gross deformity of the vertebral body. Twenty-one patients treated with anterior interbody fusion for cervical vertebral fractures and dislocations were studied. Twelve of the fractures were considered unstable preoperatively, and 50% of this group treated with anterior stabilization had graft migration postoperatively. If anterior fusion is used in unstable cervical fractures then posterior stabilization or complete bed rest with effective external stabilization (i.e., tongs or Halo-thoracic brace) for 4 weeks is mandatory. The other alternative is posterior stabilization before anterior decompression. In the presence of posterior instability, anterior interbody fusion alone cannot be recommended as the treatment of choice for cervical fractures.