Mr.
Munier Hosssain FRCS(Glasg)
Dr.
Alan N McLean MRCP
Mr.
Mathew H Fraser FRCSEd
Queen
Elizabeth National Spinal Injuries Unit
Correspondence
to: munierh@doctors.org.uk
SMJ 2004 49(3): 90-92
Key
Words. cervical
spine injury, halo jacket, immobilisation,surgical stabilisation,
Abstract:
Study design: Retrospective review
Objectives: To present and discuss the outcome of halo jacket
immobilisation of cervical spine injuries with nurse-led follow-up.
Setting: National Spinal Injuries Unit in a Scottish University teaching
Hospital.
Methods: Retrospective review of case-notes and radiographs of all
patients treated with halo jacket both as primary means of immobilisation or as
adjunct to surgical stabilisation between 1992-1999 and followed up at a weekly
halo clinic.
Results:
Out of a total one hundred and four patients with cervical spine injury,
eighty-six were treated with Halo jacket as primary means of cervical
immobilisation. Halo was used as adjunct to surgical stabilisation for the rest.
There were nine cases of true failure. This is a failure rate of 10 % for
primary halo immobilisation. Of the nine patients who had failure of bony
healing, four had fibrous healing, three had surgery to stabilise spine, two
were subsequently lost to follow-up. The highest incidence of recurrence of
subluxation occurred in patients with fracture/subluxation with a healing rate
of 85%. Patients with ankylosing spondylitis did well. Odontoid fractures had
18% failure rate.. The commonest complication was loss of reduction, followed by
pin-site infection.
Conclusion:
Halo is an effective non-surgical treatment
for the injured cervical spine at both upper and lower levels.
Introduction:
Cervical spine injury is an important cause of post-traumatic morbidity
and can be managed in various ways including prolonged bed rest, orthotic
support and internal surgical stabilisation (1-3). Management is
often dependent on local expertise, expense and available resources. Halo Jacket
Fixation (HJF) is a well-established mode of treatment for cervical spine injury
but there are complications of halo use (4-6) . We are not aware of
any large-scale outcome study from the United Kingdom on HJF treatment of
cervical spine injury. We undertook a retrospective review of the causes and
outcome of cervical spine injuries treated with HJF at the Scottish National
Spinal Injuries Unit from 1992-1999, where all patients were followed up at a
halo clinic. The results of this review are presented and compared with previous
reports.
Patients and Method:
The National Spinal Injuries Unit accepts referrals for all of Scotland
(population 5.1 million) and provides treatment for both neurologically intact
patients and those with neurological deficit. The unit is sited in a university
teaching hospital with computed tomography (CT) scan and magnetic resonance
imaging (MRI) facilities in the same building.
The case notes of all patients treated with HJF between 1992-1999 were
identified using computerised database. Patients not followed up in the unit
were excluded from the study. One company
supplied all the halo apparatus (PMT Corporation, USA). The halo is made up of
carbon fibre ring with titanium pins. The pins are tightened to a torque of
six inch-pound (.69 Newton-meter) every twenty-four to forty-eight hours
for the first week following introduction of HJF and weekly thereafter. All the
patients are followed up at a weekly halo clinic.
The HJF is usually worn for twelve weeks. A lateral x-ray of cervical
spine is performed at the end of ten weeks to check alignment and healing. The
brace is taken off under medical supervision at the end of twelve weeks and
cervical spine x-ray taken in flexion-extension to determine spinal stability
before removing the ring. After removal of the halo patients use a Philadelphia
collar (Medical Specialities Limited, Blackburn, UK) for a further six weeks.
They gradually wean themselves off the collar in the next six weeks.
HJF was used both as a primary mode of immobilisation and as an adjunct to
surgery. Patients from both groups were included in the review. Surgical fusion
was done either as a primary procedure or after halo failure. Halo was also
introduced as adjunct to spinal stabilisation when surgery failed to provide
stability. Neurological status was graded according to ASIA impairment score (7).
Results:
The case notes of one hundred and four patients (seventy-six male) were
reviewed. The mean age was forty-nine years.
Hospital stay varied from one day to more than a year (mean
thirty-one days). Follow-up ranged from
four to twenty-eight months. In eighty-six patients the halo jacket was used as
the primary mode of immobilisation.
Anatomy of injury:
Sixty-nine patients had fracture only, twenty-nine patients had
fracture-dislocation and six patients presented with disco-ligamentous
subluxation without any fracture. Five patients had non-contiguous cervical
spine fracture. There were fifty-one cases involving the axis, thirty-four of
which involved the odontoid .
Causes and associated injuries:
The most common causes of injury were falls and road traffic accidents (RTA).
The driver of a car was most commonly injured in a RTA. Twenty-three patients
were documented to be under the influence of alcohol at the time of injury.
Thirty-nine patients had associated injuries . Long bone fracture was the
commonest associated injury. All of the patients with neurological deficit had
serious associated injury (2- long bone fracture, 2- head injury, 4- multiple
injuries, 1- thoracic vertebrae injury).
Most of the patients suitable for HJF treatment were neurologically intact
at presentation.
Complications of HJF:
The commonest complication associated with the use of HJF was loss of
reduction, followed by superficial pin-site infection (Table1). One patient
suffered from pin penetration through inner table of skull confirmed on x-ray
but there was no leakage of cerebro-spinal fluid. The pin was re-sited and he
was treated with antibiotics. This again resulted in skull penetration; the halo
was withdrawn and he was treated with an external orthosis and made an
uneventful recovery. Dysphagia in one patient required re-adjustment of the
headpiece. The halo required repositioning in one patient immediately after
fixation because check x-ray taken
the day after HJF showed loss of reduction.
Outcome of HJF :
Post-traumatic radiculopathy was the commonest neurological sequelae
(Table 2). Five of the patients with post-traumatic radiculopathy were
neurologically intact immediately following injury. Only one of these patients
had healing in mal-alignment. One patient underwent microforaminectomy at C3/4
level fifteen months after injury due to persistent neck pain and post-traumatic
radiculopathy. One patient had a post-traumatic syrinx, which required surgical
decompression at a later stage.
Six patients had continuing instability on flexion/extension at the
injured level. Two of them had poor reduction, two proceeded to surgery at a
later stage while the rest had movement up to four millimeters on
flexion/extension, which was accepted as stable. None of the patients treated
conservatively have had neurological deterioration on follow-up.
There
were seventeen cases of primary halo treatment where outcome has not been
satisfactory (nine with fibrous union, six with continuing instability and two
cases where halo was withdrawn), however the true number of primary halo
treatment failure is nine (five cases of late surgery, two cases of non-union
lost to follow-up and two cases where halo had to be prematurely withdrawn).
This is a failure rate of 10% for eighty-six cases of primary halo
immobilisation.
Outcome of specific injuries:
a. Odontoid fracture:
Thirty-four odontoid fractures were treated primarily with HJF of which
fourteen achieved uncomplicated healing (Table 3). Eleven patients had stable
mal-union, six patients had fibrous healing and three had persistent
instability, which required surgical fixation at a later date. The
pseudoarthrosis rate was 18 %.
b. Co-existing ankylosing spondylitis:
There were eight patients with ankylosing spondylitis in this series.
Minor low-energy impact was the mode of injury. One patient presented without
any preceding history of trauma. All but one were treated conservatively and had
good outcome (Table 4).
c. Non-contiguous fractures:
The outcome of non-contiguous fractures was favourable (Table 5). Three
patients had an unstable injury at one level and a stable one at the other
level. Both the injuries were stable in the other two patients. All of the
patients were neurologically intact pre and post HJF.
d. Fracture-subluxation injuries:
The highest
incidence of recurrence of subluxation in the present study occurred in this
group (Table 6). Besides odontoid fracture, this type of injury produced the
other two cases of non-union. Fifteen of the twenty-nine cases of fracture-subluxation
treated primarily with HJF had uncomplicated healing.
Discussion:
Epidemiology
of injury:
In
common with previous studies, road traffic accidents and falls caused most of
the injuries (3-5). More back seat passengers than their front seat
counterparts were injured, perhaps reflecting a failure to wear seat belts among
back seat passengers. All the patients with neurological deficit had other
serious injuries. This association has been previously described and emphasises
the need for thorough assessment of such patients (8).
Complications:
The
complication rate of this series is comparable to earlier reports (3,5,6,9).
Odontoid
fractures:
Nine
patients had no radiological evidence of bone healing on follow-u, seven of
these had an odontoid fracture. Treatment failure of HJF in odontoid fracture
varies from 12% to 32% (10,11). There have been reports favouring
high union rate with anterior screw fixation for type II odontoid fractures (12,13)
and others claiming no difference in functional outcome between patients treated
surgically and non-operatively (11).
Five
of the nine patients with non-union in our series were aged sixty-seven or over.
Old age along with displaced fracture have been listed as indications for
surgical stabilisation in odontoid fracture(10,14). Seybold et al
reported higher non-union for type II odontoid fractures compared to type III,
but did not find any statistically significant correlation between fracture
healing and age or degree of displacement (11). Our results also
highlight the high risk of non-union of type II odontoid fractures in elderly
patients.
Hart
et al recently published the results of a small series of elderly patients
treated non-operatively who had non-union of odontoid fracture without
myelopathy and found no increase in instability or neurological deterioration on
follow-up (15). We also treated four of our nine non-unions
non-operatively without any neurological deterioration. This shows that
non-union might not be a significant problem in this group. This issue has been
raised by others before, urging researchers to adopt patient-derived outcome
rather than physician derived ones as parameter of success in treatment of Type
II odontoid fracture (10) .
Fracture-subluxation
injuries:
There
have been previous reports showing poor fusion and loss of reduction after
fracture-subluxation injuries in both surgically and conservatively treated
series (4,16,17). Cooper and co-workers (4)
coined the term “complex fracture”; for fracture-subluxation,
multiple vertebrae fracture or multiple fractures in single vertebra to
emphasise the difficulty in managing this group of patients. After
odontoid fracture, they proved to be the most difficult to manage with HJF.
Their healing rate of 85% with HJF was favourably comparable to previous reports
(4, 16,17).
Co-existing
ankylosing spondylitis:
Early
surgery has been suggested for patients suffering from ankylosing spondylitis
with cervical spine trauma (18,19). Results from the present series
suggest that HJF was effective treatment for these patients.
Non-contiguous
fractures:
Non-contiguous
fracture increases the risk of missed diagnosis (20). We made a
delayed diagnosis in two cases but this did not result in neurological
deterioration. The presence of unstable injuries at two levels can make the
stabilisation difficult. None of our patients had unstable injury at both levels
and all had a good outcome. This suggests that HJF is safe and effective in
selected multiple fractures.
Conclusion:
HJF
is the most effective of the available orthoses for treatment of cervical
injury. Traditionally the upper cervical spine (C1, 2) has been immobilised by
HJF, but later reports put more emphasis on the mechanism of injury rather than
anatomic location to predict successful outcome from HJF treatment (16,17).
Numerous techniques have been developed for surgical stabilisation of the
cervical spine, although there is still no consensus regarding appropriate
operative or non-operative management (1,21). This study presents a
large series of HJF treatment with long-term follow-up and at 10 %, our failure
rate is comparable to previous studies. Patients with complex fractures and
co-existing ankylosing spondylitis did well with HJF. Odontoid fractures
produced the highest non-union, but still had good long-term results. We suggest
that HJF still provides safe and effective treatment for selected cases of
cervical spine injury in conjunction with appropriate surgical services.
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