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Use of Halo Vest for Neck Injuries Based on Age

Posted on: 06/11/2009
Fractures of the upper cervical spine (C1-C2) can be stabilized without surgery by using a special apparatus called a halo vest. The vest is made of durable plastic that fits over the chest with a supportive collar around the neck. Four long, vertical metal rods attach the vest to a crown around the entire head. Metal screws hold the halo portion to the skull.

The halo has a few problems of its own, but it eliminates the need for surgery with all its potential complications. The device is attached under local anesthesia. The patient's stay in the hospital is much shorter. The patient can get up and move about right away. The downside of a halo vest is the weight and of course, the fact that it cannot be removed. As intended, neck motion is not allowed while the fracture heals. Some say that is the blessing and the curse.

In this study, surgeons at the Hannover Medical School in Germany take a look back at 29 patients who were fitted with a halo vest after an upper cervical spine injury with fracture. They wanted to know if there is a difference in results using the halo vest based on age. The patients were divided in two groups: age over 65 and age under 65.

Different types of upper cervical spine fractures are treated using a halo vest. Burst fractures, hangman's fractures, odontoid fractures, comminuted fractures or any combination of these types will need the external fixation the halo vest provides. Burst fractures are a type of crush or compression injury that fractures the vertebral body so that it spreads out in all directions. They are usually the result of a car accident or fall.

Hangman's fractures are named for the type of injury (forcible extension of the head and neck from hanging). Fracture of both pedicles or pars interarticularis (supportive column of bone) of the axis vertebra (C2) occurs. Today we see hangman's fractures in sports injuries and traffic accidents.

Odontoid fractures occur when the odontoid (a vertical bony peg of the second cervical vertebra (C2)) breaks. The odontoid fits up inside the open hole formed by the first cervical vertebra (C1). Together these two vertebrae stabilize the upper cervical spine and form the connection for the skull to attach to the spine.

A comminuted fracture refers to the bone breaking into many tiny little pieces. Usually this type of fracture is the result of a high impact force or stress but bones weakened by osteoporosis or cancer can also develop comminuted fractures.

There are some problems that can develop while wearing a halo vest. The pins or screws can get infected or come loose. In rare cases, a brain abscess can form. The halo ring can break or dislocate. Sometimes patients develop sores under the vest. And probably most distressing is when the fracture fails to heal. In those cases, surgery is needed to fuse the spine with bone graft and instrumentation (metal plates and screws).

The patients in this study were treated over a period of four years and ranged in age from 17 to 82. Most of the fractures in the younger years were the result of car, motorcycle, or bike accidents. Older adults were more likely to suffer injuries from falls.

Once the halo vest was applied, patients were helped to get up and start moving again. X-rays and CT scans were used to check the position of the halo and assess the status of the fracture. The average time for wearing the vest was 15 weeks. Some patients had it removed as early as nine weeks after it was applied. Others had to wait as long as 29 weeks (seven and a half months).

When they looked at the ages of patients in relation to the time it took to heal, there was a tendency for older adults to take longer to heal. Analysis of the data didn't show that the difference was really statistically significant. There were some complications with pin infections, ring dislocation, and failure of the fracture to heal. Again, these were evenly distributed between the two groups. Age did not seem to make a difference.

The authors point out that some of the complications with pin loosening or infection can be avoided with proper care. Patients are shown how to clean the skull screws. They are told to do this everyday. They are supposed to see the surgeon on a regular basis for check-ups. Screws are tightened at these follow-up visits.

Ring dislocations are more difficult to prevent. These usually occur as the result of some other trauma (e.g., asthmatic coughing attack, fall after a stroke). Usually, the halo device can be reattached easily. Failure of the fracture to heal (called a nonunion) was not a factor of age as much as it was related to more severe injuries to begin with in patients who smoked. Use of tobacco products has been shown in many studies to delay and even prevent wound or bone healing.

Based on the results from this study, the authors say that using a halo vest is not limited by age. This study was limited by its small number of patients (total of 29) and the fact that it was a retrospective study. That means the data was collected and analyzed after patients completed their treatment. The biggest finding was that complications could be prevented with better patient self-care.

Dorothea Daentzer, MD, and Thilo Flörkemeier, MD. Conservative Treatment of Upper Cervical Spine Injuries with the Halo Vest: An Appropriate Option for All Patients Independent of Their Age? In Journal of Neurosurgery: Spine. June 2009. Vol. 10. No. 6. Pp. 543-550.

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