Secondary Logo

Journal Logo

Article

Three Case Studies Involving the Use of a Noninvasive Halo for Cervical Stabilization

Mueller, David G. DPT, CPO, FAAOP; Mueller, Karen PT, PhD

Author Information
JPO Journal of Prosthetics and Orthotics: April 2005 - Volume 17 - Issue 2 - p 40-46
  • Free

TO EARN TWO PCE CREDITS:

  1. Read the article on pages 40–46.
  2. Go to the On-Learning Center at www.oandp.org. and complete the examination.

The traditional halo cervical stabilization orthosis has been the gold standard nonsurgical choice for secure immobilization of the acute fractured cervical spine until osseous healing occurs.1–4 However, patient discomfort/rejection, dermal invasiveness, scarring at the pin sites, pin loosening, infection risk, and practitioner expertise in fitting such halos have complicated their use.5,6

Currently, the use of the Lerman Non-Invasive Halo (LNIH) has been documented in pediatric spine surgery for congenital muscular torticollis release, C1-C2 rotary subluxation reduction, postoperative cervical immobilization, tumor removal, and odontoid fracture.7 Its use has not been documented for traumatic adult cervical fractures at this time. Rigid external immobilization of certain cervical fractures without pin invasion from this orthosis is the subject of these case studies.

In 1933, Crutchfield8 introduced invasive pinned extension tongs into the outer table of the cranium with a pulley and weight system that later became the standard for cervical traction.9,10 This system was the precursor to the pin halo. During that time, the pinless Minerva cast also was introduced as a means to externally stabilize the spine in cases of poliomyelitis and tuberculosis, particularly in children.11

The origin of the Minerva cast’s bulky design is somewhat obscure, except that it was made of plaster without a frontal band and extended to the jaw and occiput. This design apparently reflected the era of English decadence, where fashionable clothing was a reflection of proper posturing, civility, and politesse. If the Minerva had a frontal band, it became known as the “fillet jacket.”12

The mortality rate for spinal fractures at the turn of the century was greater than 70 percent, largely because of a lack of standardized procedures for spinal stabilization and prevention of secondary spinal cord trauma.13 Herbert Burrell, an emergency room physician at Boston City Hospital, was the first to propose immediate immobilization to spinal injuries with a plaster-of-Paris Minerva-type jacket fixation.13 Although Burrell was the first physician to advise turning the body as a whole at the scene of an accident, he failed to relate the types of mechanical fractures to the specific method of stabilization indicated.

The Minerva jacket fell out of favor in 1959 in the United States with the introduction of the halo jacket as a lighter weight alternative for three-directional positioning control and easier postoperative immobilization secondary to poliomyelitis. Nevertheless, the Minerva jacket continues to be used in the United Kingdom as an alternative to halo pin jacket external immobilization of the cervical spine, particularly at levels below C-2.14

Practitioner skill, brace comfort, infection control measures, maintenance, and compliance all influence the decision made by the health care provider and patient. As a result, the ideal rigid external immobilization of certain cervical fractures without pin invasion from an orthosis may fall somewhere between a standard halo and Minerva.

The LNIH, a pinless cervical thoracic orthosis, has been used in the pediatric population, a patient group in which the traditional halo would not be tolerated or compliance would be difficult. At this time, the LNIH has had limited and undocumented use with traumatic adult cervical fractures. This use and application are considered here.

CASE REPORTS

INCLUSION CRITERIA

The primary criteria for the use of the LNIH in this study were roentgenograms displaying nondisplaced or minimally displaced cervical fractures after traumatic injury without neurological involvement. Canale15 reported 360 normal adults in whom fracture widths of less than five millimeters were considered to be within the range classified as “minimal displacement.” Computed tomography (CT) scans displayed prevertebral soft tissue shadowing at the injured sites.

The purpose of this study was to determine the appropriateness of and analyze the rationale for a noninvasive halo in the adult cervical traumatic fracture. The use of a pinless halo, instead of the traditional halo, in the acute care setting was examined in three cases. Similarities in the acute cervical injuries, evidence for effectiveness, and functional outcomes also are discussed.

ORTHOSIS

The pinless, or noninvasive, halo used in all cases was the LNIH. The design consists of a padded carbon composite anterior-only chest plate with two centered connector posts articulated for capital and cervical flexion. These posts attach to an open ring halo-type frontal bone band and floating mandibular sling support (Figure 1). This open ring, known as the facemask, corresponds to the traditional halo ring. The key component to the stability of the facemask is a silicone nonallergenic material that adheres to the skin yet provides transmigratory control of the contact surface areas without tissue breakdown (Figure 2). A posterior occipital support holds the head against the frontal band and mandibular support. Posterior padded thoracolumbar crisscross straps with padded posterior waist strap hold the chest plate against the thorax (Figure 3). The LNIH is compatible with magnetic resonance imaging of 2.

F1-3
Figure 1.:
Frontal view of Lerman Non-Invasive Halo, including chest plate, connectors, and facemask.
F2-3
Figure 2.:
Sagittal view of Lerman Non-Invasive Halo, including chest plate, connectors, occipital piece, and facemask.
F3-3
Figure 3.:
Posterior view of Lerman Non-Invasive Halo, including straps and occipital piece.

SUBJECTS

The three subjects reported here all presented to the emergency department after motor vehicle accidents that resulted in fractures of the cervical spine without neurological impairment.

Subject 1 (WE) is a 20-year-old man who was involved in a rollover motor vehicle accident, resulting in acute nondisplaced cervical C1-C2 fracture. WE was neurologically intact, alert, oriented, and cooperative at the accident scene. WE’s medical history was unremarkable.

Subject 2 (WB) is a 20-year-old man who was involved in a multiple-vehicle rollover accident, resulting in an acute lateral mass cervical C6-C7 fracture. WB was neurologically intact, but he was disoriented and displayed acute amphetamine intoxication at the accident scene. In addition to his cervical fracture, WB sustained bilateral pulmonary contusions that required intubation by paramedics, along with pharmacologically induced paralysis with a nondepolarizing agent for safety during air transport. WB’s medical history was significant for closed head injury and seizure disorder.

Subject 3 (SB) was a 47-year-old man who was involved in a rollover motor vehicle accident resulting in a minimally displaced type III odontoid fracture. SB was neurologically intact except for left scalp numbness. He was alert, oriented, and cooperative at the accident scene. SB’s medical history was unremarkable.

PROCEDURES

Each of the subjects underwent CT scans and lateral cervical x-rays in the emergency department.

WE’s x-ray demonstrated a C1-C2 bilateral neural arch fracture with slight anterior subluxation (2 mm) on the left and nondisplaced on the right.

The CT scan of WE’s cervical spine showed a coronal split into the C2 body extending through the transverse processes, foramina transversaria and left pedicle. An anterior superior margin vertebral body fracture of C3 was nondisplaced.

WB’s x-ray (Figure 4) demonstrated an articular facet fracture at C6 and anterolisthesis of C6 relative to C7. The CT scans of WB’s cervical spine (Figures 5–7) showed a nondisplaced left C6 fracture to the inferior and superior facetal articular surfaces.

F4-3
Figure 4.:
X-ray of subject 2 demonstrating articular facet fracture at C6 and anterolisthesis of C6 to C7.
F5-3
Figure 5.:
Two CT scans (sagittal view) of subject 2 (WB) demonstrating presence of cervical fracture.
F6-3
Figure 6.:
Two CT scans of subject 2 (WB) demonstrating C6 fracture.
F7-3
Figure 7.:
Two CT scans of subject 2 demonstrating articular facet fractures.

SB’s x-ray demonstrated an odontoid fracture with slight anterior subluxation.

The CT of SB’s cervical spine showed an oblique coronal plane fracture to the anterolateral side of the vertebral body with mild anterior displacement of the dens to the left relative to the anterior arch of C1. There was no narrowing of the central canal with mild thickening of the prevertebral soft tissues.

LNIH APPLICATION

The LNIH orthosis was applied to each subject after x-ray and CT scan confirmation of the existence of a cervical fracture. This application generally occurred within 24 hours of the traumatic incident. In all three cases, the LNIH was applied with subjects in the supine position using nontong traction. The application procedure was completed without the use of sedation. The neurosurgeon positioned the head, and the orthotist applied the device without log rolling.

After the application procedure of the LNIH, an additional x-ray was taken of each subject to confirm adequate fracture stabilization within orthosis. WB’s x-ray is shown in Figure 8. All three subjects attained adequate fracture stabilization within the LNIH orthosis.

F8-3
Figure 8.:
X-ray of subject 2 (WB) after application of LNIH.

Physician orders for getting out of bed with the orthosis were written immediately after confirmation of fracture stability. Physical therapy consults were requested for WE and SB, whereas WB was mobilized by the nursing staff. All three subjects were instructed in safe techniques for getting out of bed and for ambulation without assistive devices. The functional progress of the three subjects is illustrated in Table 1.

T1-3
Table 1:
Interdisciplinary outcomes for the three subjects from orthotic application to hospital discharge

DISCUSSION

In three case studies, the LNIH was used as an alternative to the traditional halo for post-traumatic stabilization of cervical fractures. The cervical fractures presented were nondisplaced or minimally displaced fractures without neurological deficits.

Initial x-rays and CT scans confirmed findings of a C1- C2 arch fracture with slight anterior subluxation and C2-C3 coronal split vertebral body fractures in subject 1 (WE), C6 articular facet fractures in subject 2 (WB), and a Type III odontoid with slight anterolateral subluxation in subject 3 (SB).

In the intensive care or orthopedic wing, the neurosurgeon positioned the head and the orthotist applied the halo. All subjects were supine, not log rolled, not tong tractioned, and not sedated. Once applied, the halo was on at all times. Follow-up x-rays and CT scans were performed and confirmed anatomical alignment and/or stable positioning.

Functional outcomes were charted by the interdisciplinary team of nursing and physical therapy. Documentation from the halo intervention phase to discharge was obtained. Interdisciplinary documentation demonstrated same-day mobility skills and gait activities with subject 1, same day bed mobility/transfer skills and next day gait activities with subject 2, and next day mobility and following day transfer skills/gait activities with subject 3. Throughout the acute phase, all subjects demonstrated stable vital signs, no neurological impairment, and mobility/gait progression to independent levels.

The resumption of walking from initial injury emergency room intake was 1 day for subject 1, 4 days for subject 2, and 3 days for subject 3. Physical therapy intervention resulted in 1 to 3 days earlier ambulation in subjects 1 and 3 compared with subject 2. Subject 2 had no physical therapy.

Subjects 1 and 3, who were initially alert, oriented, and cooperative, were discharged 1 to 2 days earlier than was subject 2, who was initially disoriented and who had additional complications, including intoxication and pulmonary contusions. Subjects 1 and 3 had physical therapy intervention that demonstrated a 30 to 50% decrease in total hospital stay compared that associated with no intervention. In addition, subjects 1 and 3, who received physical therapy, had higher cervical fractures with slight subluxation, in contrast to subject 2, who had a lower cervical nondisplaced fracture and no physical therapy intervention. The average hospital stay for all three subjects was 6 days.

CONCLUSION

As many as 25 percent of spinal cord injuries occur after the initial injury, either during transport or in the early course of treatment.16 It has been shown that multilevel spinal fractures are estimated to occur in 3 to 5% of patients with spinal fractures and that noncontiguous fractures rarely occur without injury to the spinal cord.15

The case studies presented here demonstrate the efficacy of the LNIH in providing effective external stabilization for neurologically intact nondisplaced or minimally displaced traumatic cervical fractures during osseous healing. X-ray/CT scans aided in confirming stable positioning of the spine during this phase of recovery.17,18 These case studies also suggest that acute phase physical therapy and/or nursing intervention effectively enhanced the early interdisciplinary rehabilitative process for progressing mobility and gait skills.

Although the noninvasive halo restricted cervical motion and allowed for enhanced mobilization, without fluoroscopic motion analysis, the full amount of cervical motion cannot be fully assessed. The acute phase of treatment documentation is without the merit of long-term follow-up after discharge, which in the case of these subjects, was out of state.

In a comprehensive trauma center environment, noninvasive halo compliance and full-time wear are monitored more easily than during the postdischarge phase related to fracture healing time. Education plays an important role for patients and caregivers for best outcomes with this approach. Without compliance, benefits to the patient could be compromised.

REFERENCES

1.Perry J, Nickel V. The halo: a spinal skeletal traction fixation device. J Bone Joint Surg 1968;50:1400–1409.
2.Vaccaro A, Botte M. Cervical orthotics including traction and halo devices. In: Clark CR, ed. Cervical Spine, ed 3. Philadelphia: Lippincott-Raven Publishers; 1998:557–562.
3.Botte M, Byrne P. The halo skeletal fixator: current concepts of application and maintenance: abstract review. Orthopedics 1995;18:463–471.
4.Koch R, Nickel V. The Halo vest: an evaluation of motion analysis and forces across the neck. Spine 1978;3(2):103–107.
5.Rizzolo S, Piazza M. The effect of torque pressure on Halo pin complication rates: a randomized prospective study. Spine 1993;18:2163–2166.
6.Garfin S, Botte M. Complications in the use of the halo fixation device. J Bone Joint Surg 1987;69(6):954.
7.Grippi M, Lerman M. Use of a non-invasive halo in pediatric spine surgery. American Academy of Orthopedic Surgeons–Academy News 2001; poster board PE133.
8.Crutchfield W. Skeletal traction for dislocation of the cervical spine. South Surgery 1933;2:156–159.
9.Crutchfield W. Redesigned Crutchfield skeletal tongs: technical note describing the combined squeeze and hook principle. J Neurosurg 1966;25:656–657.
10.Dawson W. The earliest surgical treatise. Br J Surg 1932;20:34–43.
11.Denis F. The three column injury and its significance in the classification of acute thoracolumbar spinal injuries. Spine 1983;8:817–831.
12.Pringle R. Review article: Halo versus Minerva—which orthosis? Paraplegia 1990;28:281–284.
13.Burrell H. Fracture of the spine: a summary of all cases (224) which were treated at the Boston City Hospital from 1864–1905. Ann Surg 1905;42:481–506.
14.Benzel E, Hadden T. A comparison of the Minerva and Halo jackets for stabilization of the cervical spine. J Neurosurg 1989;70:411–414.
15.Canale S. The spine. In: Canale S. ed. Campbell’s Operative Orthopaedics, ed 10th ed. Volume II. St Louis: Mosby-Yearbook; 2003:1359–1600.
16.National Spinal Cord Injury Statistics Center. Spinal Cord Injury Epidemiology: Facts and Figures. 2001.
17.Harris J. Radiographic examination. Orthop Clin North Am 1986;17:75–86.
18.Noveline R, Rhea J. Helical CAT scan in emergency radiology. Radiology 1999;213:321–339.
Keywords:

non-invasive halo; cervical-thoracic orthoses; non-displaced cervical trauma

© 2005 American Academy of Orthotists & Prosthetists