Halo Vest Immobilization Research Articles

Halo Vest Immobilization: Is It Still a Valid Treatment for Atlantoaxial Fractures?

IntroductionAtlanto-axial injuries pose a significant threat to morbidity and mortality. This retrospective study aims to analyze clinical and radiological results, failure rates, and complications in a series of patients treated with a halo vest, validating the effectiveness of this device through long-term follow-up. Materials and methodsThis study reviewed adult patients with acute upper cervical spine injuries treated with halo vest immobilization from 1994 to 2022. Fracture types were classified based on Computed Tomography (CT) characteristics. Clinical and radiological follow-ups were performed at the end of treatment and at 3 months after the removal of the system. ResultsMost treated patients were males (70%) with a mean age of 38 years. Car accidents were the primary cause of injury (63%). Among 161 patients, 134 had a C2 fracture, 20 had a C1 fracture, 5 had a C1-C2 rotational dislocation, and 2 had other unclassified combined C1/C2 fractures. Patients without additional injuries or neurological deficits had significantly shorter hospitalization (8 vs. 16 days and 12 vs. 22 days, respectively) compared to those with additional injuries (p value<.00001) or neurological deficits (p value=0.00164). At the 6-month follow-up, radiological and clinical outcomes were available for 147 patients. X-rays in 139 cases showed fracture fusion (94.6%). Clinical follow-up revealed normal or slightly reduced range of motion in 144 cases (98%). Pain was absent or episodic in all the patients except one. In 131 cases (89%), an excellent or good clinical result was achieved. Complications did not impact treatment. ConclusionsBased on our results, the halo vest is a valid treatment for atlanto-axial injuries in selected patients. This includes young and middle-aged individuals (up to 65 years old) with C1 and/or C2 fractures. Halo vest treatment is associated with minor complications and yields a high percentage of excellent/good clinical results.

Risk factors for early mortality in elderly patients with unstable isolated C2 odontoid fracture treated with halo-vest or surgery

The aim of this study was to compare in-hospital mortality of three procedures –halo-vest immobilization, anterior spinal fixation (ASF), and posterior spinal fixation (PSF)– in the treatment of elderly patients with isolated C2 odontoid fracture. We extracted data for elderly patients who were admitted with C2 odontoid fracture and treated with at least one of the three procedures (halo-vest immobilization, ASF, or PSF) during hospitalization. We conducted a generalized propensity score-based matching weight analysis to compare in-hospital mortality among the three procedures. We further investigated independent risk factors for in-hospital death. The study involved 891 patients (halo-vest, n = 463; ASF, n = 74; and PSF, n = 354) with a mean age of 78 years. In-hospital death occurred in 45 (5.1%) patients. Treatment type was not significantly associated with in-hospital mortality. Male sex (odds ratio 2.98; 95% confidence interval 1.32–6.73; p = 0.009) and a Charlson comorbidity index of ≥ 3 (odds ratio 9.18; 95% confidence interval 3.25–25.92; p < 0.001) were independent risk factors for in-hospital mortality. In conclusion, treatment type was not significantly associated with in-hospital mortality in elderly patients with isolated C2 odontoid fracture. Halo-vest immobilization can help to avoid adverse events in patients with C2 odontoid fracture who are considered less suitable for surgical treatment.

Halo Traction Followed by Halo Vest Immobilization for the Treatment of Chronic Atlantoaxial Rotatory Fixation: A Case Report and Tips for Avoiding Complications in Pediatric Patients.

A 4-year-old girl sustained a traumatic atlantoaxial rotatory subluxation. She presented at the treating facility 8 months after injury with cervical deformity, neck pain, gait instability, and decreased cervical motion. Her delay in presentation was partially because of international Corona Virus of 2019 (COVID-19) travel restrictions. The case was successfully treated with halo traction, followed by halo vest immobilization. Chronic atlantoaxial rotatory fixation can be treated nonsurgically with closed reduction and halo traction, but is associated with operative risks. Optimal pin placement is challenging in the pediatric skull and may be improved with a preoperative or intraoperative computed tomography (CT) scan.

Congenital atlanto-occipital dislocation in a patient with Down syndrome: a case report

Down syndrome, also known as trisomy 21, is associated with congenital cervical spine abnormalities, including atlantoaxial instability with or without os odontoideum, atlanto-occipital instability, and hypoplasia of the atlas. Herein, we report a case of Down syndrome complicated by congenital atlanto-occipital dislocation. The patient presented with severe cervical myelopathy at 13 years of age after a 10-year follow-up. Radiography and computed tomography revealed os odontoideum protruding into the foramen magnum and congenital anterior atlanto-occipital dislocation. Additionally, a bifurcated internal occipital crest with a thinned central portion of the occipital bone was noted. Magnetic resonance imaging revealed kyphotic alignment of the spinal cord with severe compression at the foramen magnum level. As the neurological impairment was partially improved by halo vest immobilization, we performed in situ O-C2 fusion with an iliac autograft and decompression of the foramen magnum and posterior arch of C1. An improvement was observed immediately after surgery. Two years after surgery, radiography and computed tomography showed solid O-C2 segment fusion. The accumulation of similar cases is essential for determining the prognosis or optimal treatment for this rare congenital condition.

Surgical Versus Conservative Management for Treating Unstable Atlas Fractures: A Multicenter Study.

This multicenter study compared radiological parameters and clinical outcomes between surgical and nonsurgical management and investigated treatment characteristics associated with the successful management of unstable atlas fractures. We retrospectively evaluated 53 consecutive patients with unstable atlas fracture who underwent halo-vest immobilization (HVI) or surgical fixation. Clinical outcomes were assessed using neck visual analogue scale and disability index. The radiological assessment included total lateral mass displacement (LMD) and the anterior atlantodental interval (AADI). Thirty-two patients underwent surgical fixation and 21 received HVI (mean follow-up, 24.9 months). In the surgical fixation, but not in the HVI, LMD, and AADI showed statistically significant improvements at the last follow-up. The osseous healing rate and time-to-healing were 100% and 14.3 weeks with surgical fixation, compared with 71.43% and 20.0 weeks with HVI, respectively. Patients treated with HVI showed poorer neck pain and neck disability outcomes than those who received surgical treatment. LMD showed an association with osseous healing outcomes in nonoperative management. Clinical outcomes and osseous healing showed no significant differences according to Dickman's classification of transverse atlantal ligament injuries. Surgical internal fixation had a higher fusion rate, shorter fracture healing time, more favorable clinical outcomes, and a more significant reduction in LMD and AADI compared to nonoperative management. The pitfalls of external immobilization are inadequate maintenance and a lower probability of reducing fractured lateral masses. Stabilization by surgical reduction with interconnected fixation proved to be a more practical management strategy than nonoperative treatment for unstable atlas fractures.

Iatrogenic Fracture in a Patient of Ankylosing Spondylitis Planned for Surgical Correction of Chin-on-Chest Deformity

Ankylosing spondylitis (AS) is a progressive systemic chronic inflammatory rheumatic disease that causes arthritis of spine and sacroiliac joints and finally results in contracture or bony fusion of these joints. The ankylosed spine has increased propensity to fracture due to rigidity, long lever arms, and osteoporosis. However, iatrogenic fracture occurring in AS patients with chin-on-chest deformity during positioning has not been reported. A 46-year-old male, known case of AS, presented with progressive deformity of neck for the last 6 months due to C5 fracture with C4/5 dislocation. He had chin-on-chest deformity with chin-brow vertical angle of 106o with spastic tetraparesis (mJOA score 6, Nurick grade-3). The patient was put on sustained halo-gravity traction by gradually increasing the weight up to 30 lbs for 4 weeks and then was planned for deformity correction. After intubation and application of same traction, we found anterior wedge opening and fracture through C6/7 disc space. His neurology was found to be same as in the preoperative state on neural monitoring and wake up test. Front and back instrumented fusion was done with anterior bone grafting. Postoperatively, he was maintained on halo-vest immobilization for three months. By the end of first year, the fracture had united well and he was mobilizing well with mJOA score 13 and Nurick grade-1. AS patients are at higher risk of fracture and need utmost care while positioning during surgery. Traction or any corrective maneuver must be done carefully.

Temporary Posterior C1-C2 Instrumentation without Fusion for Treatment of Displaced Atlantoaxial Fractures

To describe open reduction internal fixation (ORIF) with posterior C1-C2 instrumentation without fusion to treat displaced atlantoaxial fractures with later instrumentation removal. A retrospective review identified 14 patients (mean age 44 years) with displaced atlantoaxial fractures treated with ORIF without fusion. Patient demographics, fracture morphology, trauma etiology, instrumentation levels, timing of hardware removal, and complications were collected. Patients were maintained in a cervical collar, and healing was confirmed via imaging before instrumentation removal. Fractures included type III odontoid, C2 pars, C1 ring, and complex C1 or C2 fractures. All cases used C1 lateral mass screws and C2 pars or pedicle screws with a C1 cross-link. Two patients had C3 lateral mass screws. All patients showed fracture healing on imaging within 4 months after ORIF. Instrumentation removal was performed in 13 patients. No complications were noted. Displaced atlantoaxial fractures have been traditionally managed with halo-vest immobilization closed reduction or ORIF with fusion. ORIF without fusion and subsequent hardware removal is an alternative approach. This strategy preserves mobility at C1-C2, avoids halo-vest immobilization, and appears to be a safe option for treatment of atlantoaxial fractures.

Diagnosis and management of isolated C1 fractures: A systematic review.

ObjectiveAtlas fractures are a common craniocervical injury, often resulting from trauma. However, diagnosis and management of atlas fractures continues to be the subject of controversy. We aimed to characterize the factors related to diagnosis of atlas fractures, delineate important considerations in selecting the optimal management for a patient with an atlas fracture, and compare outcomes of surgical and conservative management.Methods:We performed a systematic review using PubMed, Embase, and Scopus to identify articles that analyzed diagnosis and management of isolated atlas fractures published between 2013 and 2020. Titles and abstracts were screened. Studies meeting prespecified inclusion criteria were reviewed in full.Results:Of 305 resultant articles, 13 were included. C1:C2 ratio and lateral mass displacement (LMD) were used to predict transverse atlantal ligament (TAL) injury. Surgery promoted high fusion rates overall. Stable atlas fractures achieved high fusion rates with conservative management, while spinal fusion promoted greater fusion rates than halo vest immobilization management for unstable fractures. Visual Analog Scale scores, range of motion, and/or LMD improved after surgery. LMD increased for unilateral sagittal split fractures with TAL injury after conservative treatment.Conclusion:Stable atlas fractures can be sufficiently treated conservatively. Unstable atlas fractures can be managed both conservatively and surgically, while surgery is associated with favorable outcomes for unstable isolated atlas fractures. Future studies are necessary to further guide risk stratification and treatment approaches in management of the patients with isolated atlas fractures.

Complications of Posterior Fusion for Atlantoaxial Instability in Children With Down Syndrome.

ObjectiveTo clarify the complications of posterior fusion for atlantoaxial instability (AAI) in children with Down syndrome and to discuss the significance of surgical intervention.MethodsTwenty pediatric patients with Down syndrome underwent posterior fusion for AAI between February 2000 and September 2018 (age, 6.1±1.9 years). C1–2 or C1–3 fusion and occipitocervical fusion were performed in 14 and 6 patients, respectively. The past medical history, operation time, estimated blood loss (EBL), duration of Halo vest immobilization, postoperative follow-up period, and intra- and perioperative complications were examined. ResultsThe operation time was 257.9±55.6 minutes, and the EBL was 101.6±77.9 mL. Complications related to the operation occurred in 6 patients (30.0%). They included 1 major complication (5.0%): hydrocephalus at 3 months postoperatively, possibly related to an intraoperative dural tear. Other surgery-related complications included 3 cases of superficial infections, 1 case of bone graft donor site deep infection, 1 case of C2 pedicle fracture, 1 case of Halo ring dislocation, 1 case of pseudoarthrosis that required revision surgery, and 1 case of temporary neurological deficit after Halo removal at 2 months postoperatively. Complications unrelated to the operation included 2 cases of respiratory infections and 1 case of implant loosening due to a fall at 9 months postoperatively. ConclusionThe complication rate of upper cervical fusion in patients with Down syndrome remained high; however, major complications decreased substantially. Improved intra- and perioperative management facilitates successful surgical intervention for upper cervical instability in pediatric patients with Down syndrome.

Halo vest immobilization – an institutional review of safety in acute cervical spine injury from 2013 to 2017

Objective: Halo vest immobilization (HVI) remains an important treatment option for occipital-cervical injuries. It provides the surgeon with a safe and effective medical treatment options for challenging patients. The aim of this study was to evaluate the safety of HVI in these patients. Methods: This retrospective study identified adult patients treated with Halo vests immobilization (HVI) for acute cervical spine injury at our metropolitan level 1 trauma center from 2013 to 2017. This heterogenous cohort included 67 consecutive patients with acute cervical spine injury secondary to trauma or iatrogenic injury following surgical intervention with a mean age of 52 and a mean injury severity score (ISS) of 18. Forty-six percent of patients were treated with HVI as an adjunct therapy to surgical fixation (both short- and long-term immobilization), 45% of patients were treated with HVI as a primary medical treatment, and 9% of patients were treated with HVI instead of failed conservative medical treatment, such as cervical braces. Results: Pneumonia during the initial hospital stay was the most common complication (25%), followed by the correction of loose pins (22%) and pin site infections (18%). Overall, 51% of patients experienced at least one of these complications. There were significant associations between low initial GCS scores and the development of pneumonia (p < 0.001), high ISS scores and the development of pneumonia (p < 0.01), and duration of HVI and the occurrence of loose pins (p < 0.05). Four patients initially treated with HVI as primary medical treatment was converted to surgical treatment due to an intolerance of HVI or non-healing injuries. Conclusions:The HVI is a safe and effective treatment modality in a subset of patients with complex cervical junction and subaxial cervical spine pathology.

Complications of Halo Vest Orthosis: A Narrative Study

Background and Aim: Perry and Nickel introduced the halo vest in 1959. It is the most common immobilization device for the unstable cervical spine. In the literature review, most articles review the beneficial effects of the halo vest, and a few report its complications. This study aims to evaluate the complications associated with halo orthosis. Methods and Materials/Patients: This is a narrative study about halo vest complications. To provide up-to-date information, we reviewed the articles written about halo complications. All relevant articles were retrieved from Google Scholar, Medline, PubMed, etc., using the keywords of “halo vest orthosis”, “unstable cervical spine fracture”, “halo vest complications”, “halo vest immobilization”, “pin-site-related complications”, and “vest-related complications”. Afterward, we reviewed and critically analyzed the articles. Results: At first, the halo vest was used for postoperative paralyzed poliomyelitis patients, and later, it was also used for traumatic injury of the cervical spine or postoperatively in cervical spine reconstructive surgery. Compared to other orthoses, the halo vest provides a more effective external fixation and maintains normal anatomic alignment of the cervical spine without impacting jaw motion and resulting in eating problems. However, it has many temporary complications. To prevent halo vest complications, experienced people should apply it, and the patients should be regularly followed up for early detection and treatment of complications. Conclusion: Our review is the starting point for the evaluation and investigation of halo vest complications. Because of the high incidence of pin loosening and infection, it is better to evaluate the design and application of halo pin. Since the initial design of the halo vest, only its superstructure has been redesigned without any significant change in other parts of it.

Treatment of Unstable Occipital Condylar Fractures in Children—A STROBE-Compliant Investigation

Background and objectives: Occipital condyle fractures (OCF) occur rarely in children. The choice of treatment is based on the Anderson–Montesano and Tuli classification systems. We evaluated the outcome of unstable OCF in children and adolescents after halo-vest therapy. Materials and Methods: We treated 6 pediatric patients for OCF, including 3 patients (2 girls, 1 boy) with unstable OCF. Among the 3 patients with unstable OCF, 2 patients presented with an Anderson–Montesano type III and Tuli type IIB injury, while 1 patient had an Anderson–Montesano type I fracture (Tuli type IIB) accompanied by a C1 fracture. On admission, the children underwent computed tomography (CT) of the head and cervical spine as well as magnetic resonance imaging (MRI) of the cervical spine. We treated the children diagnosed with unstable OCF with halo-vest immobilization. Before removing the halo vest at the end of therapy, we applied the CT and MRI to confirm OCF consolidation. At follow-up, we rated functionality of the craniocervical junction (CCJ) based on the Neck Disability Index (NDI) and Questionnaire Short Form 36 Health Survey (SF-36). Results: All children achieved OCF consolidation after halo-vest therapy for a median of 13.0 weeks (range: 12.5–14.0 weeks). CT and MRI at the end of halo-vest therapy showed no signs of C0/C1 subluxation and confirmed the correct consolidation of OCF. The only complication associated with halo-vest therapy was a superficial infection caused by a halo-vest pin. At follow-up, all children exhibited favorable functionality of the CCJ as documented by the NDI score (median: 3 points; range: 3–11 points) and SF-36 score (median: 91 points; range: 64–96 points). Conclusions: In our small case series, halo-vest therapy resulted in good mid-term outcome in terms of OCF consolidation and CCJ functionality. In pediatric patients with suspected cervical spine injuries, we recommend CT and MRI of the CCJ to establish the diagnosis of OCF and confirm stable fracture consolidation before removing the halo vest.

EVALUATION OF FIXATION OF ATLANTOAXIAL SUBLUXATION USING HARMS' TECHNIQUE

Background: The placement of C1 lateral mass, C2 pedicle screw screws provide a useful alternative method to achieveatlantoaxial fixation. Aim of the work: This study aims at evaluation of Posterior Atlantoaxial fixation using Harms' technique in atlantoaxial subluxation regarding neck pain, fusion rates, neurological and radiographic outcomes.Patients and Methods: This method achieves immediate rigid stabilization of the atlantoaxial joint and obviates the need for halo vest immobilization. This technique may be used in certain cases as an alternative to occipitocervical fusion, and may also be used to increase construct stability when occipitocervical fixation is used. Results: We thus advocate that this procedure only be performed by surgeons who are highly experienced in the treatment of atlantoaxial instability, and who have an intimate understanding of the anatomy of this region. Further biomechanical analysis of this technique should be performed to quantify the strength of constructs employing C1 lateral mass, C2 pedicle screws as compared with otherfixation methods. Conclusion: Further biomechanical analysis of this technique should be performed to quantify the strength of constructs employing C1 lateral mass, C2 pedicle screws as compared with other fixation methods.

Atlantoaxial subluxation in the pediatric patient: Case series and literature review

Objective: Atlantoaxial subluxation (AAS) occurs when there is misalignment of the atlantoaxial joint. Several etiologies confer increased risk of AAS in children, including neck trauma, inflammation, infection, or inherent ligamentous laxity of the cervical spine. Methods: A single-center, retrospective case review was performed. Thirty-four patients with an ICD-10 diagnosis of S13.1 were identified. Demographics and clinical data were reviewed for etiology, imaging techniques, treatment, and clinical outcome. Results: Out of thirty-four patients, twenty-two suffered cervical spine trauma, seven presented with Grisel’s Syndrome, four presented with ligamentous laxity, and one had an unrecognizable etiology. Most diagnoses of cervical spine subluxation and/or instability were detected on computerized tomography (CT), while radiography and magnetic resonance imaging (MRI) were largely performed for follow-up monitoring. Six patients underwent cervical spine fusion, five had halo traction, twelve wore a hard and/or soft collar without having surgery or halo traction, and eight were referred to physical therapy without other interventions. Conclusion: Pediatric patients with atlantoaxial subluxation may benefit from limited 3D CT scans of the upper cervical spine for accurate diagnosis. Conservative treatment with hard cervical collar and immobilization after reduction may be attempted, but halo traction and halo vest immobilization may be necessary. If non-operative treatment fails, cervical spine internal reduction and fixation may be necessary to maintain normal C1-C2 alignment.

Volume-outcome relationship in halo vest utilization for C2 fractures

The prevalence of C2 fractures has increased in recent years. The treatment of these fractures include halo-vest immobilization (HVI), rigid cervical collar, or spinal fusion. There is controversy regarding the management of these fractures with different institutions having their own protocols based on individualized experience. The volume-outcome relationship of HVI use for C2 fractures has not been studied. Evaluation of such relationships are important as they suggest that patients may benefit from referral to and treatment at high-volume institutions. To evaluate the volume-outcome relationship in HVI use for C2 fractures in New York State. Retrospective analysis of a statewide database. We queried the New York Statewide Planning and Research Cooperative System database for the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code 805.02 (closed fracture of second cervical vertebra) and procedure code 029.4 (insertion or replacement of skull tongs or halo traction device) to identify all patients who received HVI for a fracture of the second cervical vertebra between the years 2001 and 2014. Those who had isolated C2 fractures were selected. Outcomes of interest included resource utilization characteristics (hospitalization charges and length of stay), perioperative complications, comorbidities, 30-day mortality, any readmission, and any future cervical fusion surgery. The 2001 to 2014 Statewide Planning and Research Cooperative System database was used to identify patients with C2 fractures who received HVI. Our key independent variable was institution volume modeled as high- (>25 halos/year), medium-, (10-25 halos/year), or low-volume (<10 halos/year) based on the total number of HVI procedures reported by hospitals during the study period. We compared outcomes with respect to hospital volume. We also compared patients by age groups: <40, 40 to 60, 60 to 80, and >80. Multivariate logistic regressions were performed for the binary variables any complication and any readmission while controlling for covariates hospital volume, age, sex, race, insurance status, and Elixhauser comorbidity mean. Statistical significance was set at a value of p<.05 for all analyses. In all, 625 patients with C2 fractures managed with HVI were included. Most patients were male (53%) and Caucasian (76%) with a mean age of 57. Patients at high-volume hospitals were younger (52 vs. 59 and 60 for medium- and low-volume, respectively; p<.01) and had fewer future readmissions (40% vs. 54% and 84% for medium- and low-volume, respectively; p<.01). On multivariable analysis, those with private insurance and worker's compensation had lower likelihood of future readmission compared to Medicaid patients. Patients >80 had higher rates of major in-hospital complications (52% vs. 40%, 18%, and 19% for groups 60-79, 40-59, and <40, respectively; p<.01), mortality (14% vs. 5%, 1%, and 1% for groups 60-79, 40-59, and <40, respectively; p<.01), and readmissions after the initial HVI (62% vs. 50%, 54%, and 37% for groups 60-79, 40-59, and <40, respectively; p<.01). The annual rate of HVI use for C2 fractures decreased significantly from 2001 to 2014 (0.32 to 0.06 HVI procedures per 100,000 people; p<.01) with the rate of decline being less pronounced in high-volume institutions (70% decrease vs. 85% and 90% for medium- and low-volume, respectively). Halo vest utilization for C2 fractures in New York State has been declining over the past decade, with the decline being less pronounced in high-volume hospitals. Our hospital volume analysis suggests that HVI use in high-volume institutions is associated with a lower rate of future readmissions. This finding suggests that patients with C2 fractures may benefit from treatment at high-volume institutions. Further research to help improve referral of appropriate patients and increase access to such institutions is warranted.

Management of Combined Atlas Fracture with Type II Odontoid Fracture: A Review of 21 Cases.

Purpose:To evaluate the therapeutic effects of combined atlas fracture with type II (C1-type II) odontoid fractures and to outline a management strategy for it.Patients and Methods:Twenty three patients with C1-type II odontoid fractures were treated according to our management strategy. Nonoperative external immobilization in the form of cervical collar and halo vest was used in 13 patients with stable atlantoaxial joint. Surgical treatment was early performed in 10 patients whose fractures with traumatic transverse atlantal ligament disruption or atlantoaxial instability. The visual analog scale (VAS), neck disability index (NDI) scale, and American Spinal Injury Association (ASIA) scale at each stage of followup were then collected and compared.Results:Compared to pretreatment, the VAS score, NDI score, and ASIA scale were improved among both groups at followup evaluation after treatment. However, in the nonsurgical group, one patient (1/11) developed nonunion which required surgical treatment in later stage and one patient (1/13) with halo vest immobilization had happened pin site infection. Two patients of the surgical group (2/11) had appeared minor complications: occipital cervical pain in one case and cerebrospinal fluid leakage in one case. Two patients (2/23) were excluded from nonsurgical treatment group because their followup period was less than 12 months. Twenty one patients were followed up regularly with an average of 23.9 months (range 15–45 months).Conclusions:We outlined our concluding management principle for the treatment of C1-type II odontoid fractures based on the nature of C1 fracture and atlantoaxial stability. The treatment principle can obtain satisfactory results for the management of C1-type II odontoid fractures.

An Approach to Primary Tumors of the Upper Cervical Spine With Spondylectomy Using a Combined Approach: Our Experience With 19 Cases.

A retrospective study. To examine the link between major complications, surgical techniques, and perioperative care in the intralesional spondylectomy of the upper cervical spine. Spondylectomy has been demonstrated to prolong cancer-free survival in many patients with locally aggressive spinal tumors. However, the challenging nature of this surgical procedure and the potential for severe complications often limit its application in the upper cervical spine. Nineteen patients with primary upper cervical tumors were treated with spondylectomy from March 2005 to August 2009, using either the anterior-posterior or posterior-anterior approach. Anterior procedures were transmandibular, transoral, or high retropharyngeal. Anterior reconstructions were performed in plates with iliac crest strut grafts, plates with mesh cages, and Harms mesh cages alone. Occipitocervical fixation was performed with Halo-vest application for postoperative immobilization. Vertebral artery injuries occurred unilaterally in 5 cases intraoperatively: 4 occurred in the anterior approach of anterior-posterior procedures. Fusion was achieved in 9 patients with intact internal instrumentation. Fusion with the anterior construct in a tilted position occurred in 3 patients, all of whom underwent anterior-posterior procedures with Halo-vest immobilization for less than 1 month. Nonunion occurred in 3 cases after the posterior-anterior procedure because of anterior bone graft absorption. Prolonged Halo-vest immobilization maintained postoperative stability. Failure of internal instrumentation occurred in 3 cases. Anterior construct dislocation and severe tilting occurred in 2 cases after the anterior-posterior procedure. Five patients had a local recurrence. All recurrent lesions were malignant tumors and occurred in regions where surgical exposure was inadequate with incomplete excision. The order of the surgical approach is a critical determinant of complications, fusion rates, choice of surgical technique, and reconstruction methods. The postoperative use of a Halo-vest is recommended. Local recurrence is associated with tumor malignancy and inadequate excision margin. 4.

Halo-Vest Immobilization in Elderly Odontoid Fracture Patients: Evolution in Treatment Modality and In-Hospital Outcomes.

Retrospective cohort study. To evaluate the utilization and effectiveness of halo-vest (HV) immobilization for type II odontoid fractures from 2004 to 2014. Controversy persists regarding the optimal treatment method for odontoid fractures in the elderly. Management options include immobilization in a cervical orthosis, HV immobilization, and operative intervention. Over the past decade, high mortality and morbidity rates have been reported following HV immobilization in this patient population. In a retrospective study, patient demographics, presentation, Charlson comorbidity index, treatment method, and outcome data for patients over 65 who had suffered type II odontoid fractures from 2004 to 2014 were compared with a historical cohort from 1997 to 2004. One hundred twenty-six patients met inclusion criteria. The mean age was 82.7±8.8 compared with 80.7±0.9 in the 1997-2004 cohort. The in-hospital mortality rate from 2004 to 2014 was 11.1% (14/126) compared with 31% in the historical cohort, and 10 (7.9%) patients were treated with HV compared with 49%. Mortality in the HV group was higher than the surgical group (P=0.01) but no different from the orthosis group (P=0.63).There were no differences in injury severity score, Charlson comorbidity index, or complications between treatment groups. Over the past decade, HV use for elderly odontoid fractures has decreased at our institution. Mortality and morbidity of elderly patients treated with HV has also decreased. These findings are likely the result of improved patient selection and greater attention to respiratory care. This study demonstrates that HV immobilization of odontoid fractures in elderly patients can be as safe as cervical orthosis treatment in select patients.

Predictors of mortality following conservatively managed fractures of the odontoid in elderly patients

Rates of mortality as high as 25% to 30% have been described following fractures of the odontoid in the elderly population. The aim of this study was to examine whether easily identifiable variables present on admission are associated with mortality. A consecutive series of 83 elderly patients with a fracture of the odontoid following a low-impact injury was identified retrospectively. Data that were collected included demographics, past medical history and the results of blood tests on admission. Radiological investigations were used to assess the Anderson and D'Alonzo classification and displacement of the fracture. The mean age was 82.9 years (65 to 101). Most patients (66; 79.5%) had a type 2 fracture. An associated neurological deficit was present in 11(13.3%). All were treated conservatively; 80 (96.4%) with a hard collar and three (3.6%) with halo vest immobilisation. The rate of mortality was 16% (13 patients) at 30 days and 24% (20 patients) at one year after injury. A low serum level of haemoglobin and the presence of a neurological deficit on admission were independent predicators of mortality at 30 days on binary logistic regression analysis. A, low level of haemoglobin, admission from an institution, a neurological deficit and type 3 fractures were independent predictors of mortality at one year. We suggest that these easily identifiable predictors present on admission can be used to identify patients at high risk and guide management by a multidisciplinary team. Cite this article: Bone Joint J 2017;99-B:116-21.

Nonoperative Management of Odontoid Fractures: Is Halo Vest Immobilization Warranted?

Nonoperative Management of Odontoid Fractures: Is Halo Vest Immobilization Warranted?