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Brakopp FH, Mendel T, Klauke F, Hofmann GO, Schenk P, Bäumlein M, Ullrich B. The Halofixator for the Treatment of Unstable Fractures of the Upper Cervical Spine - Our Own Experience and Narrative Review. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2024; 162:199-210. [PMID: 36657453 DOI: 10.1055/a-1957-6053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION In the treatment of upper cervical spine injuries, the semiconservative procedure of the halofixator is now of only secondary importance. Older studies from the 2000 s showed unsatisfactory rates of consolidation as well as high rates of complications. However, due to current data on therapy effectiveness, the literature is inconsistent. The aim of this work is to compare our own experiences and results of treatment with the current literature and to help to clarify the role of the halofixator. MATERIAL AND METHODS In a monocentric retrospective cohort study, patients with unstable injuries of the axial cervical spine who were to be treated in the halofixator were investigated. Individual variables (sex, age, concomitant diseases, Charlson Comorbidity Index) and treatment characteristics (duration of treatment, consolidation status, complications) were recorded using the electronic medical record. Injuries were classified based on CT data at the time of the accident and at the end of treatment, using common classification systems, and assessed with respect to the rate of consolidation. Possible factors influencing bony consolidation as well as complications were statistically analysed. RESULTS A total of 54 patients met the inclusion criteria. The median duration of treatment was 83 days. The most common injuries were isolated atlas fracture type III (7; 13%) and isolated dens fracture type III (24; 44%). Bony consolidation was demonstrated in 34 cases (63%) and tight pseudarthrosis in 13 cases (24%). Secondary surgical stabilisation was performed in 6 cases (11%). Isolated type III atlas fractures and type III dens fractures had very high consolidation rates of 86% and 92%, respectively. In the subgroups of patients older than 65 years or with a CCI ≥ 4, unstable pseudarthroses were found more frequently. Complications included pin infection (6%), pin dislocation (9%), and pressure ulceration from the halo vest (6%). Cardiopulmonary complications did not occur. No patient died. DISCUSSION Good rates of bony consolidation were seen for atlas fractures type III as well as dens fractures type III, which correlate with data in the literature. Dens fractures type II (isolated and combined) and atlas fractures type III in combination with dens fractures showed a worse radiological outcome, which is also unsatisfactory compared to the literature. The rates for procedure-specific complications were relatively low. In particular, work from recent years has demonstrated very good rates for bony consolidation and low complication rates for the treatment of atlas and/or dens fractures with the halofixator, which are confirmed by our results. In contrast, however, a significantly higher cardiac/respiratory complication rate has been reported than occurred in our own patient population.
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Affiliation(s)
- Florian Hans Brakopp
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle, Halle, Deutschland
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Jena, Jena, Deutschland
| | - Thomas Mendel
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle, Halle, Deutschland
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Jena, Jena, Deutschland
| | - Friederike Klauke
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle, Halle, Deutschland
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Jena, Jena, Deutschland
| | - Gunter O Hofmann
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle, Halle, Deutschland
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Jena, Jena, Deutschland
| | - Philipp Schenk
- Koordinationsabteilung Wissenschaft, Forschung und Lehre, BG Klinikum Bergmannstrost Halle, Halle, Deutschland
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Jena, Jena, Deutschland
| | - Martin Bäumlein
- Zentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Gießen und Marburg GmbH Standort Gießen, Marburg, Deutschland
| | - Bernhard Ullrich
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle, Halle, Deutschland
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Jena, Jena, Deutschland
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Azurdia AR, Walters J, Mellon CR, Lettieri SC, Kopelman TR, Pieri P, Feiz-Erfan I. Airway risk associated with patients in halo fixation. Surg Neurol Int 2024; 15:104. [PMID: 38628525 PMCID: PMC11021081 DOI: 10.25259/sni_386_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 12/30/2023] [Indexed: 04/19/2024] Open
Abstract
Background The halo fixation device introduces a significant obstacle for clinicians attempting to secure a definitive airway in trauma patients with cervical spine injuries. The authors sought to determine the airway-related mortality rate of adult trauma patients in halo fixation requiring endotracheal intubation. Methods This study was a retrospective chart review of patients identified between 2007 and 2012. Only adult trauma patients who were intubated while in halo fixation were included in the study. Results A total of 46 patients underwent 60 intubations while in halo. On five occasions, (8.3%) patients were unable to be intubated and required an emergent surgical airway. Two (4.4%) of the patients out of our study population died specifically due to airway complications. Elective intubations had a failure rate of 5.8% but had no related permanent morbidity or mortality. In contrast to that, 25% of non-elective intubations failed and resulted in the deaths of two patients. The association between mortality and non-elective intubations was statistically highly significant (P = 0.0003). Conclusion The failed intubation and airway-related mortality rates of patients in halo fixation were substantial in this study. This finding suggests that the halo device itself may present a major obstacle in airway management. Therefore, heightened vigilance is appropriate for intubations of patients in halo fixation.
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Affiliation(s)
- Adrienne R. Azurdia
- Department of Emergency Medicine, HonorHealth Osborn, Scottsdale, United States
| | - Jarvis Walters
- Department of Surgery, Division of Trauma, Valleywise Health Medical Center, Phoenix, United States
| | - Chris R. Mellon
- Department of Trauma Surgery and Surgical Critical Care, HonorHealth Osborn, Phoenix, United States
| | - Salvatore C. Lettieri
- Department of Surgery, Division of Plastic Surgery, Valleywise Health Medical Center, Phoenix, United States
| | - Tammy R. Kopelman
- Department of Surgery, Division of Trauma, Valleywise Health Medical Center, Phoenix, United States
| | - Paola Pieri
- Department of Surgery, Division of Trauma, Valleywise Health Medical Center, Phoenix, United States
| | - Iman Feiz-Erfan
- Department of Surgery, Division of Neurosurgery, Valleywise Health Medical Center, Phoenix, United States
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Domenech P, Mariscal G, Marquina V, Bas P, Bas T. Efficacy and safety of halo-gravity traction in the treatment of spinal deformities: A systematic review of the literature. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024; 68:159-167. [PMID: 37230411 DOI: 10.1016/j.recot.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVE To determine, through a systematic review, the effects of halo gravity traction in spinal deformity. METHODS Prospective studies or case series of patients with scoliosis or kyphosis treated with cranial halo gravity traction (HGT) were included. Radiological outcomes were measured in the sagittal and/or coronal planes. Pulmonary function was also assessed. Perioperative complications were also collected. RESULTS Thirteen studies were included. Congenital etiology was the most frequent etiology observed. Most studies provided clinically relevant curve correction values in the sagittal and coronal planes. Pulmonary values improved significantly after the use of HGT. Finally, there were a pool of 83 complications in 356 patients (23.3%). The most frequent complications were screw infection (38 cases). CONCLUSIONS Preoperative HGT appears to be a safe and effective intervention for deformity that allows correction prior to surgery. However, there is a lack of homogeneity in the published studies.
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Affiliation(s)
- P Domenech
- Department of Orthopedic Surgery and Traumatology, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - G Mariscal
- Department of Orthopedic Surgery and Traumatology, La Fe University and Polytechnic Hospital, Valencia, Spain.
| | - V Marquina
- Department of Orthopedic Surgery and Traumatology, Valencia General University Hospital, Valencia, Spain
| | - P Bas
- Department of Orthopedic Surgery and Traumatology, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - T Bas
- Department of Orthopedic Surgery and Traumatology, La Fe University and Polytechnic Hospital, Valencia, Spain
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Domenech P, Mariscal G, Marquina V, Bas P, Bas T. Efficacy and safety of halo-gravity traction in the treatment of spinal deformities: A systematic review of the literature. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024; 68:T159-T167. [PMID: 38000543 DOI: 10.1016/j.recot.2023.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/17/2023] [Indexed: 11/26/2023] Open
Abstract
OBJECTIVE To determine, through a systematic review, the effects of halo-gravity traction (HGT) in spinal deformity. METHODS Prospective studies or case series of patients with scoliosis or kyphosis treated with cranial HGT were included. Radiological outcomes were measured in the sagittal and/or coronal planes. Pulmonary function was also assessed. Perioperative complications were also collected. RESULTS Thirteen studies were included. Congenital etiology was the most frequent etiology observed. Most studies provided clinically relevant curve correction values in the sagittal and coronal planes. Pulmonary values improved significantly after the use of HGT. Finally, there were a pool of 83 complications in 356 patients (23.3%). The most frequent complications were screw infection (38 cases). CONCLUSIONS Preoperative HGT appears to be a safe and effective intervention for deformity that allows correction prior to surgery. However, there is a lack of homogeneity in the published studies.
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Affiliation(s)
- P Domenech
- Department of Orthopedic Surgery and Traumatology, La Fe University and Polytechnic Hospital, Valencia, España
| | - G Mariscal
- Department of Orthopedic Surgery and Traumatology, La Fe University and Polytechnic Hospital, Valencia, España.
| | - V Marquina
- Department of Orthopedic Surgery and Traumatology, Valencia General University Hospital, Valencia, España
| | - P Bas
- Department of Orthopedic Surgery and Traumatology, La Fe University and Polytechnic Hospital, Valencia, España
| | - T Bas
- Department of Orthopedic Surgery and Traumatology, La Fe University and Polytechnic Hospital, Valencia, España
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Schnadthorst PG, Lankes C, Schulze C. [Conservative treatment of trauma-associated fractures of the cervical spine with orthoses-A review]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:943-950. [PMID: 36469100 DOI: 10.1007/s00113-022-01261-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Traumatic injuries of the cervical spine are common and can significantly differ in the prognosis and treatment depending on the structure affected. We present the current evidence for conservative treatment of these fractures with orthoses in this review. METHODOLOGY The literature search followed the PRISMA protocol. The risk of bias was assessed using ROBINS‑I and evidence levels were determined according to AHCPR. RESULTS A total of 22 studies were identified. The level of evidence according to AHCPR is limited (IIb, III and IV) and every study had a serious risk of bias in at least one subdivision. Of the authors 11 presented conservative treatment concepts for C2 dens fractures, 7 studies focussed on vertebral arch fractures and 9 on vertebral body fractures. Radiological parameters (kyphosis angle, bone consolidation) and the neurological status were frequently reported as endpoints. CONCLUSION Stable C2 dens fractures without relevant clinical restrictions allow conservative treatment in a rigid cervical orthosis under radiological monitoring every 1-4 weeks. Type II fractures require special attention due to the risk of instability. Hangman's fractures can be safely treated in rigid cervical orthoses. The current state of knowledge does not allow any recommendation for conservative treatment of Hangman's fractures with orthoses. Stable vertebral body fractures without involvement of the spinal canal can also be treated conservatively with orthotic devices. Randomized controlled studies are required to develop a secure state of evidence and are currently not available.
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Affiliation(s)
| | - Celine Lankes
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, Doberaner Str. 142, 18057, Rostock, Deutschland
| | - Christoph Schulze
- Zentrum für Sportmedizin der Bundeswehr, Dr.-Rau-Allee 32, 48231, Warendorf, Deutschland
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, Doberaner Str. 142, 18057, Rostock, Deutschland
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Steiner J, Kimmel LA, Tomkins JB, Wheeler KN, Liew S. Outcomes after application of halothoracic orthosis for cervical spine trauma. Prosthet Orthot Int 2022; 46:505-509. [PMID: 35333834 DOI: 10.1097/pxr.0000000000000116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 01/06/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Cervical spine fractures can be managed operatively or nonoperatively, considering injury type and patient factors. Nonoperative management may include application of a halothoracic orthosis (HTO). The aim of our study was to describe our patients managed with HTO, review their 6-month and 12-month outcomes, and identify associated factors. METHODS Patients fitted with an HTO at our institution in 2014 were included. Data collected included patient demographics, hospital-related data, and radiological union. Injury detail and 6-month and 12-month patient-reported outcomes (Glasgow Outcomes Scale Extended and return to work [RTW]) were accessed through Victorian Orthopedic Trauma Outcomes Registry. Factors related to these outcomes were included in a mixed-effect regression model for each outcome. RESULTS Eighty-six patients (median age 46.5 years) of whom 52 (60%) were male individuals were included. Two-thirds (57 patients) were road trauma patients, and 58 patients (67%) experienced an isolated injury. Thirty-seven patients (43%) experienced a C2 fracture and 27 (31%) experienced a facet fracture. Twelve-month follow-up was completed for 78 patients (91%) with 27 (35%) reporting a good recovery, and 65% (31/48) patients returned to work. Factors associated with lower odds of RTW included compensation, a facet joint fracture, and experiencing comorbidities. No factors were significantly associated with functional outcome, although female individuals exhibited a slower recovery trajectory than male individuals. CONCLUSION Many patients reported poor 12-month outcomes after HTO for traumatic injury. Factors associated with worse outcomes should be considered when deciding on management of patients with cervical spine fractures.
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Affiliation(s)
- Joel Steiner
- Department of Orthopedic Surgery, The Alfred, Melbourne, Victoria, Australia
| | - Lara A Kimmel
- Department of Physiotherapy, The Alfred, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jonathan B Tomkins
- Department of Physiotherapy, The Alfred, Melbourne, Victoria, Australia
- Department of Physiotherapy, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Karly N Wheeler
- Department of Orthotics, The Alfred, Melbourne, Victoria, Australia
| | - Susan Liew
- Department of Orthopedic Surgery, The Alfred, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
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Cloney MB, El-Tecle N, Dahdaleh NS. Traumatic atlas fracture patients comprise two subpopulations with distinct demographics and mechanisms of injury. Clin Neurol Neurosurg 2022; 221:107414. [PMID: 35987045 DOI: 10.1016/j.clineuro.2022.107414] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/10/2022] [Accepted: 08/13/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Atlas fractures account for as much as 13% of cervical fractures, yet their epidemiology and its implications remain under-examined. METHODS We retrospectively analyzed 97 consecutive cases of isolated, traumatic atlas fractures at our institution over a 17-year period with respect to demographic, clinical, and outcomes data. Unique patient subsets were identified and compared across these parameters. RESULTS The age of atlas fracture patients showed a bimodal distribution and strong goodness of fit, with one mean centered at an age of 30 years for patients age< 50 (R=0.9409) and mean age of 74 among patients age≥ 50 (R=0.8584). Young patients were more likely to have a high-risk mechanism of injury (57.8% vs. 11.5%, OR=10.49 [3.59, 29.65], p < 0.0001) and injuries while intoxicated (13.3% vs. 0%, OR ∞ [1.704, ∞], p = 0.0082). A greater portion of young patients were managed with halo (33.3% vs. 13.5%, OR=3.21 [1.20, 8.13, p = 0.0281]). Among patients who were managed with halo, a greater proportion had halo-related complications among patients age≥ 50 (57.1% vs. 6.7%, OR=18.67 [1.55, 239.1], p = 0.0207). The median age of atlas fractures increased by ~2.6 years annually (slope 2.637, p < 0.0001, R=0.8079). CONCLUSIONS The atlas fracture patient population may comprise two distinct subpopulations, distinguished by differences in age and mechanism of injury that lead to divergent management decisions. While halo immobilization has a low rate of complications among patients age< 50, the complication among patients age≥ 50 was significantly higher. The median age of atlas fracture patients increased linearly during the study period, highlighting the importance of age-related differences in management.
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Affiliation(s)
- Michael Brendan Cloney
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.
| | - Najib El-Tecle
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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Odontoid Fractures: A Standard Review of Current Concepts and Treatment Recommendations. J Am Acad Orthop Surg 2022; 30:e561-e572. [PMID: 35266921 DOI: 10.5435/jaaos-d-21-00165] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 11/08/2021] [Indexed: 02/01/2023] Open
Abstract
Odontoid fractures represent the most common fractures involving C2 and the most common cervical spine fractures in patients older than 65 years. Despite their increasing frequency, optimal management of these injuries remain a subject to debate. Although types I and III injuries have relatively good healing potential with nonsurgical treatment, type II fractures carry a higher risk for nonunion. In particular, elderly patients are at risk for nonunion or fibrous malunion after nonsurgical treatment; however, increased medical comorbidities and poor bone quality also increase the risks of surgery in this cohort. The high morbidity and mortality associated with these injuries has made it an area of particular interest among spine surgeons. The purpose of this review was to summarize the pathophysiology, evaluation, and diagnosis of these injuries and to review controversies in management and considerations for treatment based on the most recent available literature.
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Malnik SL, Scott KW, Kuhn MZ, Alcindor D, Tavanaiepour K, Tavanaiepour D, Crandall M, Rahmathulla G. Halo vest immobilization - an institutional review of safety in acute cervical spine injury from 2013 to 2017. Br J Neurosurg 2021; 35:639-642. [PMID: 34319211 DOI: 10.1080/02688697.2021.1947976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Samuel L Malnik
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Kyle W Scott
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - M Zino Kuhn
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Dunbar Alcindor
- Department of Neurosurgery, College of Medicine, University of Florida, Jacksonville, FL, USA
| | - Kourosh Tavanaiepour
- Department of Neurosurgery, College of Medicine, University of Florida, Jacksonville, FL, USA
| | - Daryoush Tavanaiepour
- Department of Neurosurgery, College of Medicine, University of Florida, Jacksonville, FL, USA
| | - Marie Crandall
- Department of Surgery, College of Medicine, University of Florida, Jacksonville, FL, USA
| | - Gazanfar Rahmathulla
- Department of Neurosurgery, College of Medicine, University of Florida, Jacksonville, FL, USA
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AlSaleh K, Abulras M, Alrehaili O. Temporary spanning internal fixation for management of complex upper cervical spine fractures. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:10-14. [PMID: 33850376 PMCID: PMC8035578 DOI: 10.4103/jcvjs.jcvjs_118_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 11/22/2020] [Indexed: 11/09/2022] Open
Abstract
Introduction: Fractures of the upper cervical spine are often but not always amenable to either internal fixation or conservative management using a rigid cervical collar. For all other fractures in this area, management with a halo-vest orthosis is indicated, but it also has limitations. Here, we present an operative alternative to the halo-vest orthosis that provides more secure stability and less complications. Methods: Three patients presented to our hospital with atypical fractures of C1 and C2 and were given the choice of either a halo-vest orthosis or secure internal fixation without fusion and accepted the latter. Internal fixation without fusion from occiput to the subaxial spine was performed for all three and then removed-6 months later -after radiologic confirmation of healing. Results: All three patients underwent the procedure successfully and achieved and maintained acceptable alignment. Range of motion was preserved, and no intermediate-term issues were observed. Conclusion: Spanning internal fixation provides a safe and effective technique in the management of complex upper cervical spine injuries without the drawbacks of using a halo-vest orthosis.
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Affiliation(s)
- Khalid AlSaleh
- Department of Orthopedics College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Muteb Abulras
- Department of Orthopedics College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Osama Alrehaili
- Department of Orthopedics College of Medicine, King Saud University, Riyadh, Saudi Arabia
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张 宇, 吴 优, 付 索, 夏 虹, 马 向, 章 凯, 艾 福. [Treatment of tuberculosis in craniovertebral junction]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:1507-1514. [PMID: 33319527 PMCID: PMC8171574 DOI: 10.7507/1002-1892.202005087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 09/02/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate the method of treating tuberculosis in the craniovertebral junction and its effectiveness. METHODS The clinical data of 18 patients with tuberculosis in the craniovertebral junction between July 2010 and January 2019 was analyzed retrospectively. There were 14 males and 4 females, aged 21 months to 75 years (median, 35 years). The disease duration ranged from 2 weeks to 60 months (median, 4 months), and the affected segment was C 0-C 3. Preoperative visual analogue scale (VAS) score was 6.7±1.5 and the Japanese Orthopaedic Association (JOA) score was 16.1±1.8. The American Spinal Cord Injury Association (ASIA) grading system was applied to classify their neurological functions, according to which there were 6 cases of grade D and 12 cases of grade E. Among 18 patients, 4 patients underwent conservative treatment, 1 patient removed tuberculosis via transoral approach, 1 patient removed tuberculosis via posterior cervical approach, and 12 patients removed tuberculosis via transoral approach immediately after posterior cervical (atlantoaxial or occipitalcervical) fusion and internal fixation. The VAS score, ASIA grading, and JOA score were applied to evaluate effectiveness. X-ray film, CT, and MRI were taken after treatment to evaluate the tubercular recurrence, cervical stability, and bone healing. RESULTS All the patients were followed up 3 to 42 months (median, 12 months). At 3 months after treatment, the VAS score was 1.7±1.0, showing significant difference when compared with preoperative score ( t=15.000, P=0.000); and the JOA score was 16.7±1.0, showing no significant difference when compared with preoperative score ( t=1.317, P=0.205). According to ASIA grading, 6 patients with grade D before treatment had upgraded to grade E after treatment, while the remaining patients with grade E had no change in grading. The imaging examinations showed the good stability of the cervical spine. All patients had complete tuberculosis resection and no recurrence, and the patients who underwent internal fixation via posterior cervical approach achieved atlantoaxial or occipitalcervical bone fusion. CONCLUSION On the premise of regular chemotherapy, if there is no huge abscess causing dysphagia or dyspnea, atlantoaxial instability, and neurological symptoms, patients can undergo conservative treatment. If not, however, the transoral approach can be used to completely remove the tuberculosis lesion in the craniovertebral junction. One-stage debridement via transoral approach combined with posterior cervical fusion and internal fixation can achieve satisfactory effectiveness.
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Affiliation(s)
- 宇 张
- 中国人民解放军南部战区总医院骨科(广州 510010)Department of Orthopedics, General Hospital of Southern Theater Command of Chinese PLA, Guangzhou Guangdong, 510010, P.R.China
| | - 优 吴
- 中国人民解放军南部战区总医院骨科(广州 510010)Department of Orthopedics, General Hospital of Southern Theater Command of Chinese PLA, Guangzhou Guangdong, 510010, P.R.China
| | - 索超 付
- 中国人民解放军南部战区总医院骨科(广州 510010)Department of Orthopedics, General Hospital of Southern Theater Command of Chinese PLA, Guangzhou Guangdong, 510010, P.R.China
| | - 虹 夏
- 中国人民解放军南部战区总医院骨科(广州 510010)Department of Orthopedics, General Hospital of Southern Theater Command of Chinese PLA, Guangzhou Guangdong, 510010, P.R.China
| | - 向阳 马
- 中国人民解放军南部战区总医院骨科(广州 510010)Department of Orthopedics, General Hospital of Southern Theater Command of Chinese PLA, Guangzhou Guangdong, 510010, P.R.China
| | - 凯 章
- 中国人民解放军南部战区总医院骨科(广州 510010)Department of Orthopedics, General Hospital of Southern Theater Command of Chinese PLA, Guangzhou Guangdong, 510010, P.R.China
| | - 福志 艾
- 中国人民解放军南部战区总医院骨科(广州 510010)Department of Orthopedics, General Hospital of Southern Theater Command of Chinese PLA, Guangzhou Guangdong, 510010, P.R.China
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Kurucan E, Sulovari A, Thirukumaran C, Greenstein A, Molinari R, Mesfin A. Volume-outcome relationship in halo vest utilization for C2 fractures. Spine J 2020; 20:1676-1684. [PMID: 32474222 DOI: 10.1016/j.spinee.2020.05.543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 05/08/2020] [Accepted: 05/19/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT 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. PURPOSE To evaluate the volume-outcome relationship in HVI use for C2 fractures in New York State. STUDY DESIGN Retrospective analysis of a statewide database. PATIENT SAMPLE 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. OUTCOME MEASURES 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. METHODS 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. RESULTS 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). CONCLUSIONS 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.
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Affiliation(s)
- Etka Kurucan
- Department of Orthopaedics and Rehabilitation, University of Rochester School of Medicine & Dentistry, 601 Elmwood Ave, Box 665, Rochester, NY 14642, USA
| | - Aron Sulovari
- Department of Orthopaedics and Rehabilitation, University of Rochester School of Medicine & Dentistry, 601 Elmwood Ave, Box 665, Rochester, NY 14642, USA
| | - Caroline Thirukumaran
- Department of Orthopaedics and Rehabilitation, University of Rochester School of Medicine & Dentistry, 601 Elmwood Ave, Box 665, Rochester, NY 14642, USA; Department of Public Health Science, University of Rochester School of Medicine & Dentistry, 601 Elmwood Ave, Box 665, Rochester, NY 14642, USA
| | - Alexander Greenstein
- Department of Orthopaedics and Rehabilitation, University of Rochester School of Medicine & Dentistry, 601 Elmwood Ave, Box 665, Rochester, NY 14642, USA
| | - Robert Molinari
- Department of Orthopaedics and Rehabilitation, University of Rochester School of Medicine & Dentistry, 601 Elmwood Ave, Box 665, Rochester, NY 14642, USA
| | - Addisu Mesfin
- Department of Orthopaedics and Rehabilitation, University of Rochester School of Medicine & Dentistry, 601 Elmwood Ave, Box 665, Rochester, NY 14642, USA; Department of Public Health Science, University of Rochester School of Medicine & Dentistry, 601 Elmwood Ave, Box 665, Rochester, NY 14642, USA.
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Yang JJ, Park S, Yoon JY, Mun JW. Temporary Bridge Occipitocervical Fixation for Comminuted Atlantoaxial Fracture. World Neurosurg 2020; 139:330-336. [PMID: 32348894 DOI: 10.1016/j.wneu.2020.04.122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We sought to evaluate the feasibility of temporary bridge occipitocervical fixation temporary bridge occipitocervical fixation (T-BOCF) for comminuted atlantoaxial fractures. METHODS A 57-year-old man presented with multiple trauma including a comminuted, undisplaced atlantoaxial fracture; subdural hemorrhage; skull base fracture; scalp laceration; right second finger tendon injury; and right distal femur open fracture. T-BOCF was performed to preserve neck motion while providing rigid stability to atlantoaxial fracture. Occipital plate and bilateral lateral mass screws were inserted at C3, C4, and C5, avoiding the fracture site; this was followed by rod connection without fusion. The screw-rod construct was removed after confirmation of bone union in the fracture site 12 months after the initial operation. RESULTS Computed tomography performed at 12 months after the operation demonstrated solid bone union. Dynamic radiographs taken 12 months after implant removal demonstrated a flexion-extension range of motion of 16 degrees at C0‒C2 and 19.8 degrees at C2‒C7. The total flexion-extension range of motion was 35.8 degrees. CONCLUSIONS T-BOCF is a viable option for treatment of comminuted, undisplaced atlantoaxial fractures. The technique is easier than direct C1‒C2 fusion and can avoid complications associated with occipitocervical fusion or C1‒C2 screw fixation. The blood supply to the fracture site is preserved by avoiding subperiosteal stripping, and semispinalis cervicis insertion at the C2 spinous process is also circumvented. Furthermore, neck motion is preserved after implant removal.
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Affiliation(s)
- Jae Jun Yang
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Goyangsi, Gyeonggido, Republic of Korea
| | - Sehan Park
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Goyangsi, Gyeonggido, Republic of Korea.
| | - Jae Youn Yoon
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Goyangsi, Gyeonggido, Republic of Korea
| | - Ji Weon Mun
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Goyangsi, Gyeonggido, Republic of Korea
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Goz V, Spiker WR, Lawrence B, Brodke D, Spina N. Odontoid Fractures: A Critical Analysis Review. JBJS Rev 2019; 7:e1. [PMID: 31389849 DOI: 10.2106/jbjs.rvw.18.00122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Vadim Goz
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
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Isidro S, Molinari R, Ikpeze T, Hernandez C, Mahmoudi MS, Mesfin A. Outcomes of Halo Immobilization for Cervical Spine Fractures. Global Spine J 2019; 9:521-526. [PMID: 31431875 PMCID: PMC6686377 DOI: 10.1177/2192568218808293] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
STUDY DESIGN Retrospective. OBJECTIVES To evaluate complications and outcomes of halo immobilization in patients with cervical spine fractures treated at a level I trauma center. METHODS A retrospective evaluation of patients treated at a single institution with halo immobilization from August 2000 to February 2016 was performed. Demographic information, mechanism of injury, level and type of spine fracture, length of halo immobilization, complications associated with halo immobilization, and length of patient follow-up were collected. RESULTS A total of 189 patients treated with halos were identified. Of the 189 patients, 121 (64%) received halos for the management of cervical spine fractures and were included in the study. A total of 49.6% were males and 50.4% were females. The average age was 50.8 years (range 1-89 years). Overall, 10.7% sustained C1 fractures, 71.1% C2 fractures, and 18.2% subaxial spine (C3-C7) fractures. In all, 47.1% of the upper cervical fractures were either odontoid or hangman-type fractures. A total of 25.1% of patients had multiple cervical fractures. At latest follow-up, 81% had healed fractures with good alignment, minimal pain, and return to normal activities. There was an 8.3% mortality rate. The mortality group had an average age of 64.7 years (range 19-84 years). A total of 10.7% of patients failed halo immobilization and 46.3% of patients had complications such as pin site infections (5.8%), loose pins (1.7%), neck pain (20.7%), decreased range of motion (14%), thoracic skin ulcers (2.4%), and dysphagia (1.7%). CONCLUSIONS The use of halo immobilization for cervical spine fractures resulted in clinical success in 81% of patients. Complication rates in geriatric patients were lower than previously reported in the literature.
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Affiliation(s)
- Stacey Isidro
- University of Rochester Medical Center, Rochester, NY, USA
| | | | | | | | - Mohamed Salah Mahmoudi
- University of Rochester Hajim School of Engineering and Applied Sciences, Rochester, NY, USA
| | - Addisu Mesfin
- University of Rochester Medical Center, Rochester, NY, USA,Addisu Mesfin, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA.
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Bokhari AR, Sivakumar B, Sefton A, Lin JL, Smith MM, Gray R, Hartin N. Morbidity and mortality in cervical spine injuries in the elderly. ANZ J Surg 2018; 89:412-417. [PMID: 30294850 DOI: 10.1111/ans.14875] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 08/11/2018] [Accepted: 08/22/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim of our study was to identify the demographics and complications in elderly cervical spine injuries and predictive factors for surgery, complications and mortality. We hypothesized younger healthier patients were more likely to undergo surgical intervention. METHODS A retrospective review of 225 consecutive patients aged 65 years and over with cervical spine injuries was carried out over a 3-year period. RESULTS There were 113 males and 112 females with an average of 79.7 years (range 65-98). The most common fracture was C2 peg type (21.8%). Five patients had complete spinal cord injury (2.2%), 25 had incomplete spinal cord injury (11.1%) and 84% were neurologically intact. Fifty-four patients were managed operatively (24%), while 171 patients were managed non-operatively (76%). The operative group had higher rates of pneumonia (odds ratio (OR) 5.3, 95% confidence interval (CI) 2.6-10.7, P < 0.01), cardiac arrhythmia (OR 4.1, 95% CI 1.5-11.2, P < 0.01) and respiratory failure (OR 2.6, 95% CI 1.2-5.5, P < 0.05). There was no difference in mortality between the operative and non-operative group (18.5% and 12.9%, P = 0.3). Patients with complete spinal cord injury had 100% mortality. Significant predictive factors for complications and death were neurological deficits, comorbidities and the presence of other injuries (P < 0.05). Surgery was not predictive for death and the operative group was younger than the non-operative group (P < 0.05). CONCLUSIONS In the setting of a high complication rate, consideration should be given to palliation in elderly patients with complete spinal cord injury and there must be good rational for surgery.
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Affiliation(s)
- Ali R Bokhari
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Brahman Sivakumar
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Andrew Sefton
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Juin-Lih Lin
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Margaret M Smith
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Randolph Gray
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Nathan Hartin
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Iyer S, Hurlbert RJ, Albert TJ. Management of Odontoid Fractures in the Elderly: A Review of the Literature and an Evidence-Based Treatment Algorithm. Neurosurgery 2017; 82:419-430. [DOI: 10.1093/neuros/nyx546] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 10/01/2017] [Indexed: 11/12/2022] Open
Abstract
Abstract
Odontoid fractures are the most common fracture of the axis and the most common cervical spine fracture in patients over 65. Despite their frequency, there is considerable ambiguity regarding optimal management strategies for these fractures in the elderly. Poor bone health and medical comorbidities contribute to increased surgical risk in this population; however, nonoperative management is associated with a risk of nonunion or fibrous union. We provide a review of the existing literature and discuss the classification and evaluation of odontoid fractures. The merits of operative vs nonoperative management, fibrous union, and the choice of operative approach in elderly patients are discussed. A treatment algorithm is presented based on the available literature. We believe that type I and type III odontoid fractures can be managed in a collar in most cases. Type II fractures with any additonal risk factors for nonunion (displacement, comminution, etc) should be considered for surgical management. However, the risks of surgery in an elderly population must be carefully considered on a case-by-case basis. In a frail elderly patient, a fibrous nonunion with close follow-up is an acceptable outcome. If operative management is chosen, a posterior approach is should be chosen when fracture- or patient-related factors make an anterior approach challenging. The high levels of morbidity and mortality associated with odontoid fractures should encourage all providers to pursue medical co-management and optimization of bone health following diagnosis.
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Affiliation(s)
- Sravisht Iyer
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - R John Hurlbert
- Spine Program, Department of Surgery, University of Arizona—College of Medicine, Tuscon, Arizona
| | - Todd J Albert
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
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Halo-Vest Immobilization in Elderly Odontoid Fracture Patients: Evolution in Treatment Modality and In-Hospital Outcomes. Clin Spine Surg 2017; 30:E1206-E1210. [PMID: 27906741 DOI: 10.1097/bsd.0000000000000483] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To evaluate the utilization and effectiveness of halo-vest (HV) immobilization for type II odontoid fractures from 2004 to 2014. SUMMARY OF BACKGROUND DATA 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. MATERIALS AND METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Abstract
Although less common than other musculoskeletal injuries, spinal trauma may lead to significantly more disability and costs. During the last 2 decades there was substantial improvement in our understanding of the basic patterns of spinal fractures leading to more reliable classification and injury severity assessment systems but also rapid developments in surgical techniques. Despite these advancements, there remain unresolved issues concerning the management of these injuries. At this moment there is persistent controversy within the spinal trauma community, which can be grouped under 6 headings. First of all there is still no unanimity on the role and timing of medical and surgical interventions for patients with associated neurologic injury. The same is also true for type and timing of surgical intervention in multiply injured patients. In some common injury types like odontoid fractures and burst type (A3-A4) fractures in thoracolumbar spine, there is wide variation in practice between operative versus nonoperative management without clear reasons. Also, the role of different surgical approaches and techniques in certain injury types are not clarified yet. Methods of nonoperative management and care of elderly patients with concurrent complex disorders are also areas where there is no consensus. In this overview article the main reasons for these controversies are reviewed and the possible ways for resolutions are discussed.
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Bui TT, Nagasawa DT, Lagman C, Jacky Chen CH, Chung LK, Voth BL, Beckett JS, Tucker AM, Niu T, Gaonkar B, Yang I, Macyszyn L. Isolated Transverse Process Fractures and Markers of Associated Injuries: The Experience at University of California, Los Angeles. World Neurosurg 2017; 104:82-88. [DOI: 10.1016/j.wneu.2017.04.137] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 04/19/2017] [Accepted: 04/20/2017] [Indexed: 11/28/2022]
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Indications and complications of crown halo vest placement: A review. J Clin Neurosci 2017; 40:27-33. [DOI: 10.1016/j.jocn.2017.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 01/21/2017] [Indexed: 12/28/2022]
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Nagasawa DT, Bui TT, Lagman C, Lee SJ, Chung LK, Niu T, Tucker A, Gaonkar B, Yang I, Macyszyn L. Isolated Transverse Process Fractures: A Systematic Analysis. World Neurosurg 2017; 100:336-341. [DOI: 10.1016/j.wneu.2017.01.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 01/06/2017] [Accepted: 01/09/2017] [Indexed: 01/15/2023]
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Joaquim AF, Brock RS, Guirado VMDP, Sandon LH, Silva OTD, Taricco MA, Teixeira MJ, Figueiredo EG. Reliability and safety of a new upper cervical spine injury treatment algorithm. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:107-113. [PMID: 28226080 DOI: 10.1590/0004-282x20160200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 11/09/2016] [Indexed: 11/22/2022]
Abstract
Methods Thirty cases, previously treated according to the new algorithm, were presented to four spine surgeons who were questioned about their personal suggestion for treatment, and the treatment suggested according to the application of the algorithm. After four weeks, the same questions were asked again to evaluate reliability (intra- and inter-observer) using the Kappa index. Results The reliability of the treatment suggested by applying the algorithm was superior to the reliability of the surgeons' personal suggestion for treatment. When applying the upper cervical spine injury treatment algorithm, an agreement with the treatment actually performed was obtained in more than 89% of the cases. Conclusion The system is safe and reliable for treating traumatic upper cervical spine injuries. The algorithm can be used to help surgeons in the decision between conservative versus surgical treatment of these injuries.
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Affiliation(s)
- Andrei Fernandes Joaquim
- Universidade de São Paulo, Divisão de Neurocirurgia, São Paulo SP, Brasil.,Universidade Estadual de Campinas, Divisão de Neurocirurgia, Campinas SP, Brasil
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Esteves LA, Joaquim AF, Tedeschi H. Retrospective analysis of a case series of patients with traumatic injuries to the craniocervical junction. EINSTEIN-SAO PAULO 2017; 14:528-533. [PMID: 28076601 DOI: 10.1590/s1679-45082016ao3396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 10/20/2016] [Indexed: 11/22/2022] Open
Abstract
Objective To evaluate the correlation between the treatment, the characteristics of the lesions and the clinical outcome of patients with traumatic injuries to the craniocervical junction. Methods This was a retrospective study of patients treated conservatively or surgically between 2010 and 2013 with complete data sets. Results We analyzed 37 patients, 73% were men with mean age of 41.7 years. Of these, 32% were submitted to initial surgical treatment and 68% received conservative treatment. Seven (29%) underwent surgery subsequently. In the surgical group, there were seven cases of odontoid type II fractures, two cases of fracture of posterior elements of the axis, one case of C1-C2 dislocation with associated fractured C2, one case of occipitocervical dislocation, and one case of combined C1 and C2 fractures, and facet dislocation. Only one patient had neurological déficit that improved after treatment. Two surgical complications were seen: a liquoric fistula and one surgical wound infection (reaproached). In the group treated conservatively, odontoid fractures (eight cases) and fractures of the posterior elements of C2 (five cases) were more frequent. In two cases, in addition to the injuries of the craniocervical junction, there were fractures in other segments of the spine. None of the patients who underwent conservative treatment presented neurological deterioration. Conclusion Although injuries of craniocervical junction are relatively rare, they usually involve fractures of the odontoid and the posterior elements of the axis. Our results recommend early surgical treatment for type II odontoid fractures and ligament injuries, the conservative treatment for other injuries. Objetivo Avaliar a correlação entre o tratamento, as características das lesões e o resultado clínico em pacientes com lesões traumáticas na junção craniocervical. Métodos Estudo retrospectivo de pacientes maiores de 18 anos tratados de forma conservadora ou cirúrgica, entre 2010 e 2013. Resultados Foram analisados 37 pacientes, 73% eram do sexo masculino e a média de idade foi de 41,7 anos. Inicialmente 32% dos pacientes foram submetidos a tratamento cirúrgico, e 68% foram submetidos a tratamento conservador. Sete pacientes (29%) do grupo conservador foram submetidos posteriormente à cirurgia. No grupo cirúrgico, houve sete casos de fratura de odontóide tipo II, dois casos de fratura de elementos posteriores do áxis, um caso de luxação C1-C2, um caso de deslocamento occipito-cervical e um caso de fraturas de C1 e C2 e luxação facetária. Um paciente apresentava déficit neurológico, melhorando após o tratamento. Houve duas complicações pós-cirúrgicas, uma fístula liquórica e uma infecção de ferida operatória (reabordada). No grupo conservador, predominaram as fraturas do odontóide (oito) e dos elementos posteriores de C2 (cinco). Em dois casos, havia também fraturas em outros segmentos da coluna. Nenhum dos pacientes deste grupo apresentou deterioração neurológica. Conclusão As lesões da junção craniocervical são raras, sendo mais frequentes as fraturas do odontóide e dos elementos posteriores do áxis. Nossos resultados recomendam o tratamento cirúrgico precoce para os pacientes com fraturas do odontóide tipo II e lesões ligamentares, e tratamento conservador para os demais pacientes.
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Affiliation(s)
- Luiz Adriano Esteves
- Universidade Estadual de Campinas, Campinas, SP, Brazil.,Núcleo do Hospital de Força Aérea de São Paulo, São Paulo, SP, Brazil
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Almeida TFDE, Charafeddine HT, Araújo FFDE, Cristante AF, Marcon RM, Letaif OB. TOMOGRAPHIC MORPHOLOGICAL STUDY OF THE CRANIUM AND ITS CORRELATION WITH CRANIAL HALO USE IN ADULTS. ACTA ORTOPEDICA BRASILEIRA 2017. [PMID: 28642643 PMCID: PMC5474395 DOI: 10.1590/1413-785220172501168033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objective: To evaluate using tomographic study the thickness of the cranial board at the insertions points of the cranial halo pins in adults Methods: This is a retrospective, cross-sectional, descriptive analysis of Computed Tomography (CT) scans of adult patients' crania. The study included adults between 20 and 50 years without cranial abnormalities. We excluded any exam with cranial abnormalities Results: We analyzed 50 CT scans, including 27 men and 23 women, at the original insertion points and alternative points (1 and 2 cm above the frontal and parietal bones). The average values were 7.4333 mm in the frontal bone and 6.0290 mm in the parietal bone Conclusion: There was no statistically significant difference between the classical and alternative points, making room for alternative fixings and safer introduction of the pins, if necessary.Level of Evidence II, Retrospective Study.
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Affiliation(s)
- Tiago Ferreira DE Almeida
- . Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Ortopedia e Traumatologia, São Paulo, SP, Brazil
| | - Homar Toledo Charafeddine
- . Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Ortopedia e Traumatologia, São Paulo, SP, Brazil
| | - Fernando Flores DE Araújo
- . Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Ortopedia e Traumatologia, São Paulo, SP, Brazil
| | - Alexandre Fogaça Cristante
- . Universidade de São Paulo, Faculdade de Medicina, Department of Orthopedics and Traumatology, São Paulo, SP, Brazil
| | - Raphael Martus Marcon
- . Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Ortopedia e Traumatologia, São Paulo, SP, Brazil
| | - Olavo Biraghi Letaif
- . Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Ortopedia e Traumatologia, São Paulo, SP, Brazil
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Abstract
Odontoid fractures are the most common cervical fracture type among the elderly population. Several treatment options exist for these patients, ranging from immobilization with a semirigid orthosis to surgical arthrodesis. This report reviews the key points in the management of odontoid fractures in the aged patient, including diagnosis, the various forms of conservative therapies, and the options for surgical intervention.
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Affiliation(s)
- Jian Guan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive East, Salt Lake City, UT 84132, USA
| | - Erica F Bisson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive East, Salt Lake City, UT 84132, USA.
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Sime D, Gabbe B, Liew S. Outcomes of halo immobilization in the management of subaxial cervical facet fractures. ANZ J Surg 2016; 87:159-164. [DOI: 10.1111/ans.13656] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 05/07/2016] [Accepted: 05/12/2016] [Indexed: 11/30/2022]
Affiliation(s)
- David Sime
- Department of Orthopaedic Surgery; Alfred Health; Melbourne Victoria Australia
| | - Belinda Gabbe
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Susan Liew
- Department of Orthopaedic Surgery; Alfred Health; Melbourne Victoria Australia
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Azimi K, Prescott IA, Marino RA, Winterborn A, Levy R. Low profile halo head fixation in non-human primates. J Neurosci Methods 2016; 268:23-30. [PMID: 27132241 DOI: 10.1016/j.jneumeth.2016.04.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 04/21/2016] [Accepted: 04/22/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND We present a new halo technique for head fixation of non-human primates during electrophysiological recording experiments. Our aim was to build on previous halo designs in order to create a simple low profile system that provided long-term stability. NEW METHOD Our design incorporates sharp skull pins that are directly threaded through a low set halo frame and are seated into implanted titanium foot plates on the skull. The inwardly directed skull pins provide an easily calibrated force against the skull. RESULTS This device allowed for head fixation within 1 week after implantation surgery. The low-profile design maximized the area of the skull available and potential implant orientations for electrophysiological experiments. It was easily maintained and was stable in 2 animals for the 6-8 months of testing. The quality of single unit neural recordings collected while using this device to head fix was indistinguishable from traditional head-post fixation. The foot plates used in this system did not result in significant MRI distortion in the location of deep brain targets (∼0.5mm) of a 3D printed phantom skull. COMPARISON WITH EXISTING METHOD(S) The low profile design of this halo design allows greater access to the majority of the frontal, parietal, and occipital skull. It has fewer parts and can hold larger animals than previous halo designs. CONCLUSIONS Given the stability, simplicity, immediate usability, and low profile of our head fixation device, we propose that it is a practical and useful means for performing electrophysiological recording experiments on non-human primates.
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Affiliation(s)
- Kousha Azimi
- School of Medicine, Queen's University, Kingston, Ontario K7L 3N6, Canada.
| | - Ian A Prescott
- Centre for Neuroscience Studies, Queen's University, Kingston, Ontario K7L 3N6, Canada; Department of Surgery, Kingston General Hospital, Kingston, Ontario K7L 2V7, Canada.
| | - Robert A Marino
- Centre for Neuroscience Studies, Queen's University, Kingston, Ontario K7L 3N6, Canada; Department of Surgery, Kingston General Hospital, Kingston, Ontario K7L 2V7, Canada.
| | - Andrew Winterborn
- Animal Care Services, Queen's University, Kingston, Ontario K7L 3N6, Canada.
| | - Ron Levy
- Centre for Neuroscience Studies, Queen's University, Kingston, Ontario K7L 3N6, Canada; Department of Surgery, Kingston General Hospital, Kingston, Ontario K7L 2V7, Canada.
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Esteves LA, Joaquim AF, Tedeschi H. Retrospective analysis of a case series of patients with traumatic injuries to the craniocervical junction. EINSTEIN-SAO PAULO 2016; 14. [PMID: 28076601 PMCID: PMC5221380 DOI: 10.1590/s1679-45082016ao3396\] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To evaluate the correlation between the treatment, the characteristics of the lesions and the clinical outcome of patients with traumatic injuries to the craniocervical junction. METHODS This was a retrospective study of patients treated conservatively or surgically between 2010 and 2013 with complete data sets. RESULTS We analyzed 37 patients, 73% were men with mean age of 41.7 years. Of these, 32% were submitted to initial surgical treatment and 68% received conservative treatment. Seven (29%) underwent surgery subsequently. In the surgical group, there were seven cases of odontoid type II fractures, two cases of fracture of posterior elements of the axis, one case of C1-C2 dislocation with associated fractured C2, one case of occipitocervical dislocation, and one case of combined C1 and C2 fractures, and facet dislocation. Only one patient had neurological déficit that improved after treatment. Two surgical complications were seen: a liquoric fistula and one surgical wound infection (reaproached). In the group treated conservatively, odontoid fractures (eight cases) and fractures of the posterior elements of C2 (five cases) were more frequent. In two cases, in addition to the injuries of the craniocervical junction, there were fractures in other segments of the spine. None of the patients who underwent conservative treatment presented neurological deterioration. CONCLUSION Although injuries of craniocervical junction are relatively rare, they usually involve fractures of the odontoid and the posterior elements of the axis. Our results recommend early surgical treatment for type II odontoid fractures and ligament injuries, the conservative treatment for other injuries. OBJETIVO Avaliar a correlação entre o tratamento, as características das lesões e o resultado clínico em pacientes com lesões traumáticas na junção craniocervical. MÉTODOS Estudo retrospectivo de pacientes maiores de 18 anos tratados de forma conservadora ou cirúrgica, entre 2010 e 2013. RESULTADOS Foram analisados 37 pacientes, 73% eram do sexo masculino e a média de idade foi de 41,7 anos. Inicialmente 32% dos pacientes foram submetidos a tratamento cirúrgico, e 68% foram submetidos a tratamento conservador. Sete pacientes (29%) do grupo conservador foram submetidos posteriormente à cirurgia. No grupo cirúrgico, houve sete casos de fratura de odontóide tipo II, dois casos de fratura de elementos posteriores do áxis, um caso de luxação C1-C2, um caso de deslocamento occipito-cervical e um caso de fraturas de C1 e C2 e luxação facetária. Um paciente apresentava déficit neurológico, melhorando após o tratamento. Houve duas complicações pós-cirúrgicas, uma fístula liquórica e uma infecção de ferida operatória (reabordada). No grupo conservador, predominaram as fraturas do odontóide (oito) e dos elementos posteriores de C2 (cinco). Em dois casos, havia também fraturas em outros segmentos da coluna. Nenhum dos pacientes deste grupo apresentou deterioração neurológica. CONCLUSÃO As lesões da junção craniocervical são raras, sendo mais frequentes as fraturas do odontóide e dos elementos posteriores do áxis. Nossos resultados recomendam o tratamento cirúrgico precoce para os pacientes com fraturas do odontóide tipo II e lesões ligamentares, e tratamento conservador para os demais pacientes.
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Affiliation(s)
- Luiz Adriano Esteves
- Universidade Estadual de Campinas, Campinas, SP, Brazil.,Núcleo do Hospital de Força Aérea de São Paulo, São Paulo, SP, Brazil
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Abstract
BACKGROUND The use of the conventional halo is accompanied by the possibility of serious complications, especially in the pediatric population. Complications could include penetration of pin into the skull, pin loosening, pin tract infection, cranial nerve palsies, and vest-related pressure sores. The noninvasive "pinless" halo was introduced in an attempt to mitigate these problems while retaining the effectiveness of the conventional halo. The purpose of this study is to determine the indications and complications related to pinless halo application. METHODS We retrospectively reviewed 61 patients, whose treatment included the use of a pinless halo device, presenting to our institution between 2004 and 2012. RESULTS There were 35 male and 26 female patients with an average age of 6.04 years. Indications of pinless halo application included postoperative immobilization for congenital muscular torticollis in 38 cases, conservative management of atlantoaxial rotatory subluxation in 11 cases, postoperative immobilization following cervical fusion in 10 cases, and immobilization for occipital condyle fracture in 2 cases. The average duration of the pinless halo application was 32.68 days. Thirteen patients had complications, among which major complications were seen in 2 patients, each of whom developed a pressure sore; one on the scalp and the other on the chest. Both the pressure sores responded to local treatment; however, 1 resulted in permanent alopecia. CONCLUSIONS The use of the noninvasive pinless halo was found to be safe with few complications in our study. The complications were infrequent and patients were compliant to treatment, indicating that this modality is patient-friendly. Effectiveness of this treatment in comparison with invasive halos and other cervical orthoses was not determined and is a limitation of this study. LEVEL OF EVIDENCE Level IV-Case series.
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Menon KV, Al Rawi AE, Taif S, Al Ghafri K, Mollahalli KK. Orbital roof fracture and orbital cellulitis secondary to halo pin penetration: case report. Global Spine J 2015; 5:63-8. [PMID: 25648519 PMCID: PMC4303484 DOI: 10.1055/s-0034-1384818] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 05/24/2014] [Indexed: 01/08/2023] Open
Abstract
Study Design Case report. Objective To report and discuss a rare complication after a patient was treated conservatively with a halo vest. Methods A 51-year-old man sustained a hangman's injury of the C2 vertebra following a motor vehicle collision. He was treated conservatively in a halo vest appliance and following mobilization was discharged from the hospital. Two weeks after discharge, the patient presented to the emergency department complaining of proptosis, ptosis, diplopia, and pin loosening. He was readmitted to the hospital, the halo vest was removed, and urgent imaging studies including computed tomography scan and magnetic resonance imaging were performed. They revealed that one of the halo pins had penetrated the orbital roof with active infection of the extraocular soft tissues. In consultation with the ophthalmologist, he was treated conservatively with antibiotics for 10 days. Results His ophthalmologic complaints resolved gradually and his eye returned to normal appearance and function. In the meantime, he was immobilized in a sterno-occipital mandibular immobilizer brace. Conclusion Though rare, penetrating injuries after cranial pin insertion can occur. Halo devices must be applied by, or under close supervision of, experienced personnel to avoid such complications, and halo vests should be reviewed frequently to detect such incidents early.
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Affiliation(s)
- K. Venugopal Menon
- Department of Orthopaedics, Khoula Hospital, Mina al Fahal, Muscat, Sultanate of Oman,Address for correspondence K. Venugopal Menon, MS (Orth), MCh (Orth), MSc (Orth Engg) Senior Consultant, Orthopaedics, Khoula HospitalMina al Fahal, MuscatSultanate of Oman
| | - Asif Esam Al Rawi
- Department of Orthopaedics, Khoula Hospital, Mina al Fahal, Muscat, Sultanate of Oman
| | - Sawsan Taif
- Department of Radiology, Khoula Hospital, Mina al Fahal, Muscat, Sultanate of Oman
| | - Khalifa Al Ghafri
- Department of Orthopaedics, Khoula Hospital, Mina al Fahal, Muscat, Sultanate of Oman
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Reduction of halo pin site morbidity with a new pin care regimen. Asian Spine J 2013; 7:91-5. [PMID: 23741545 PMCID: PMC3669708 DOI: 10.4184/asj.2013.7.2.91] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 07/16/2012] [Accepted: 08/04/2012] [Indexed: 12/28/2022] Open
Abstract
Study Design A retrospective analysis of halo device associated morbidity over a 4-year period. Purpose To assess the impact of a new pin care regimen on halo pin site related morbidity. Overview of Literature Halo orthosis treatment still has a role in cervical spine pathology, despite increasing possibilities of open surgical treatment. Published figures for pin site infection range from 12% to 22% with pin loosening from 7% to 50%. Methods We assessed the outcome of a new pin care regimen on morbidity associated with halo spinal orthoses, using a retrospective cohort study from 2001 to 2004. In the last two years, our pin care regimen was changed. This involved pin site care using chlorhexidene & regular torque checking as part of a standard protocol. Previously, povidone iodine was used as skin preparation in theatre, followed by regular sterile saline cleansing when pin sites became encrusted with blood. Results There were 37 patients in the series, the median age was 49 (range, 22-83) and 20 patients were male. The overall infection rate prior to the new pin care protocol was 30% (n=6) and after the introduction, it dropped to 5.9% (n=1). This difference was statistically significant (p<0.05). Pin loosening occurred in one patient in the group prior to the formal pin care protocol (3%) and none thereafter. Conclusions Reduced morbidity from halo use can be achieved with a modified pin cleansing and tightening regimen.
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Predictors of treatment outcomes in geriatric patients with odontoid fractures: AOSpine North America multi-centre prospective GOF study. Spine (Phila Pa 1976) 2013; 38:881-6. [PMID: 23459135 PMCID: PMC3678886 DOI: 10.1097/brs.0b013e31828314ee] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Multicenter prospective cohort study. OBJECTIVE To identify patient and treatment characteristics associated with treatment success or failure in the management of odontoid fractures. SUMMARY OF BACKGROUND DATA Odontoid fractures are the most common cervical spine fractures in the elderly and represent a significant management challenge with widely divergent views regarding operative versus nonoperative management. METHODS A total of 159 patients 65 years and older with radiographically confirmed type II odontoid fractures were enrolled at 10 sites in the United States and 1 site in Canada between January 2006 and May 2009. Subjects were followed at 6 and 12 months post-initial treatment with Neck Disability Index and SF-36v2 scores. Final treatment outcome was classified as failure or success. Treatment failure was defined as death by any cause, decline in Neck Disability Index by more than 9.5 absolute points, or occurrence of a major treatment-related complication. Baseline characteristics between the groups were compared using t test for the continuous variables and χ2 test for the categorical variables. Baseline characteristics associated with treatment outcomes were identified by multiple logistic stepwise regression analysis. RESULTS A total of 101 (63.5%) patients were treated surgically and 58 (36.5%) conservatively. Forty-four (27.7%) patients had a successful outcome and 86 (54.1%) had a treatment failure; for 29 patients (18.2%), treatment status could not be determined (3 withdrew; 26 were lost to follow-up). Twenty-nine (18.2%) patients expired before the 12-month follow-up. Follow-up information was available for 103 of 127 surviving (81.1%) patients. Twelve-month SF-36v2 scores were worse in the failure group. The characteristics associated with treatment failure were older age (odds ratio [OR] = 1.08 for each year of age); initial nonsurgical treatment (OR = 3.09); male sex (OR = 4.33), and baseline neurological system comorbidity (OR = 4.13). CONCLUSION Older age, initial nonsurgical treatment, and male sex are associated with failure of treatment in patients with geriatric odontoid fractures.
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Medhkour A, Massie L, Horn M. Acute subdural hematoma following halo pin tightening in a patient with bilateral vertebral artery dissection. Neurochirurgie 2012; 58:386-90. [PMID: 22989701 DOI: 10.1016/j.neuchi.2012.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 06/13/2012] [Indexed: 01/07/2023]
Abstract
We report the first case of acute subdural hematoma (SDH) developing after tightening the halo of an osteoporotic 61-year-old woman on warfarin therapy for bilateral traumatic vertebral artery dissection. We discuss literature relevant to this case with an emphasis on identifying warning signs, including recurrent pin loosening, especially in patients with compromised bone structure and high risk of bleeding. Our 61-year-old patient presented to neurosurgery clinic for a 2-month follow-up of a type-III odontoid fracture sustained in a motor vehicle accident. The patient had repeatedly loosened halo pins, and shortly after the pins were tightened, the patient had a syncopal event and struck her head. An emergent computed tomography scan revealed acute SDH requiring emergent craniotomy and evacuation. SDH following pin penetration in a patient with bilateral vertebral artery dissection, osteoporosis, and anticoagulation has not been reported as a complication of the use of the halo vest for stabilization of the cervical spine. The risk of this serious complication can be minimized by giving special consideration to patients with comorbidities and by repositioning problematic pins. This case demonstrates the importance of special attention to bone strength, bleeding risk, and recurrent minor complaints with use of the halo vest.
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Affiliation(s)
- A Medhkour
- The University of Toledo College of Medicine, 3000 Arlington Avenue, Toledo, OH 43614, USA.
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Walker J. Pressure ulcers in cervical spine immobilisation: a retrospective analysis. J Wound Care 2012; 21:323-6. [DOI: 10.12968/jowc.2012.21.7.323] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- J. Walker
- Division of Orthopaedic and Accident Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, UK
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Abstract
STUDY DESIGN A retrospective chart review. OBJECTIVE To describe the presentation and the rationale for management of pathological odontoid fracture and complete odontoid destruction in craniovertebral junction tuberculosis (CVJ TB). SUMMARY OF BACKGROUND DATA Presentation of CVJ TB ranges from minor osteomyelitic changes to severe structural damage leading to instability. Structural damage to the odontoid process is poorly characterized in the literature. Inadequate knowledge about the radiological presentations has led to controversy in the management of CVJ TB. METHODS The cohort consisted of 15 consecutive patients with CVJ TB, with structural damage to the odontoid process in the form of either odontoid fracture (n = 7) or complete odontoid destruction (n = 8). These patients presented with pain, neurological deficit, torticollis, dysphagia, or respiratory distress. The cause of neurological deficit was craniocervical instability characterized as anterioposterior (n = 15), rotatory (n = 4), and vertical (n = 6). Displacement reduced anatomically in 13 patients. Apart from antibiotics, all patients were treated surgically by either C1-C2 fusion (n = 7) or occipitocervical fusion (n = 8). RESULTS Average duration of follow-up was 3.6 years (range, 1.5-8 yr). All patients achieved normal neurological status. No complications were noted, except for 1 case, who had a loss of reduction after the use of Hartshill rectangle for occipitocervical fusion. Postoperative computed tomographic scan showed nonunion of odontoid fracture in 2 of 4 patients. No patient of odontoid destruction, of the 5 investigated, revealed structural reformation of the dens. CONCLUSION CVJ TB can severely damage the odontoid process, resulting in atlantoaxial dislocation. In these patients, surgery restores and maintains the craniocervical alignment and has a predictable outcome compared with conservative therapy. Pathological odontoid fractures have the potential to go into nonunion. Odontoid process once destroyed completely is rarely restored after antibiotic therapy.
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van Middendorp JJ, Barbagallo G, Schuetz M, Hosman AJF. Design and rationale of a Prospective, Observational European Multicenter study on the efficacy of acute surgical decompression after traumatic Spinal Cord Injury: the SCI-POEM study. Spinal Cord 2012; 50:686-94. [DOI: 10.1038/sc.2012.34] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Carter KJ, Dunham CM, Castro F, Erickson B. Comparative analysis of cervical spine management in a subset of severe traumatic brain injury cases using computer simulation. PLoS One 2011; 6:e19177. [PMID: 21544239 PMCID: PMC3081343 DOI: 10.1371/journal.pone.0019177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 03/29/2011] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND No randomized control trial to date has studied the use of cervical spine management strategies in cases of severe traumatic brain injury (TBI) at risk for cervical spine instability solely due to damaged ligaments. A computer algorithm is used to decide between four cervical spine management strategies. A model assumption is that the emergency room evaluation shows no spinal deficit and a computerized tomogram of the cervical spine excludes the possibility of fracture of cervical vertebrae. The study's goal is to determine cervical spine management strategies that maximize brain injury functional survival while minimizing quadriplegia. METHODS/FINDINGS The severity of TBI is categorized as unstable, high risk and stable based on intracranial hypertension, hypoxemia, hypotension, early ventilator associated pneumonia, admission Glasgow Coma Scale (GCS) and age. Complications resulting from cervical spine management are simulated using three decision trees. Each case starts with an amount of primary and secondary brain injury and ends as a functional survivor, severely brain injured, quadriplegic or dead. Cervical spine instability is studied with one-way and two-way sensitivity analyses providing rankings of cervical spine management strategies for probabilities of management complications based on QALYs. Early collar removal received more QALYs than the alternative strategies in most arrangements of these comparisons. A limitation of the model is the absence of testing against an independent data set. CONCLUSIONS When clinical logic and components of cervical spine management are systematically altered, changes that improve health outcomes are identified. In the absence of controlled clinical studies, the results of this comparative computer assessment show that early collar removal is preferred over a wide range of realistic inputs for this subset of traumatic brain injury. Future research is needed on identifying factors in projecting awakening from coma and the role of delirium in these cases.
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Affiliation(s)
- Kimbroe J Carter
- Medical Decision Making Society of Youngstown Ohio, St. Elizabeth Health Center, Youngstown, Ohio, United States of America.
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Pal D, Sell P, Grevitt M. Type II odontoid fractures in the elderly: an evidence-based narrative review of management. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2010; 20:195-204. [PMID: 20835875 DOI: 10.1007/s00586-010-1507-6] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2009] [Revised: 06/18/2010] [Accepted: 06/27/2010] [Indexed: 02/07/2023]
Abstract
Considerable controversy exists regarding the optimal management of elderly patients with type II odontoid fractures. There is uncertainty regarding the consequences of non-union. The best treatment remains unclear because of the morbidity associated with prolonged cervical immobilisation versus the risks of surgical intervention. The objective of the study was to evaluate the published literature and determine the current evidence for the management of type II odontoid fractures in elderly. A search of the English language literature from January 1970 to date was performed using Medline and the following keywords: odontoid, fractures, cervical spine and elderly. The search was supplemented by cross-referencing between articles. Case reports and review articles were excluded although some were referred to in the discussion. Studies in patients aged 65 years with a minimum follow-up of 12 months were selected. One-hundred twenty-six articles were reviewed. No class I study was identified. There were two class II studies and the remaining were class III. Significant variability was found in the literature regarding mortality and morbidity rates in patients treated with and without halo vest immobilisation. In recent years several authors have claimed satisfactory results with anterior odontoid screw fixation while others have argued that this may lead to increased complications in this age group. Lately, the posterior cervical (Goel-Harms) construct has also gained popularity amongst surgeons. There is insufficient evidence to establish a standard or guideline for odontoid fracture management in elderly. While most authors agree that cervical immobilisation yields satisfactory results for type I and III fractures in the elderly, the optimal management for type II fractures remain unsolved. A prospective randomised controlled trial is recommended.
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Affiliation(s)
- D Pal
- Department of Spinal Studies and Surgery, Queen's Medical Centre, Nottingham, NG7 2UH, UK
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Isolated transverse process fractures of the subaxial cervical spine: a clinically insignificant injury or not?: a prospective, longitudinal analysis in a consecutive high-energy blunt trauma population. Spine (Phila Pa 1976) 2010; 35:E965-70. [PMID: 20479701 DOI: 10.1097/brs.0b013e3181c9464e] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective single cohort study. OBJECTIVE To analyze the incidence, associated injuries, treatment outcomes and associated adverse events of isolated transverse process fractures (TPFs) of the subaxial cervical spine in a high-energy blunt trauma population. SUMMARY OF BACKGROUND DATA Currently, TPFs of the subaxial cervical spine are considered to be clinically insignificant. However, this hypothesis is based on clinical experience and has never been supported by research previously. METHODS During a 32-month period, routine computed tomography scans of the spine were obtained in high-energy blunt trauma patients. Patients with isolated TPFs of the subaxial cervical spine were prospectively identified. For each enrolled patient, gender, age, mechanism of injury, trauma severity, neurologic deficit, injury levels, affected structures, treatment, radiographic follow-up, functional outcome (Cybex goniometer, neck disability index), and patient satisfaction (10 point visual analog scale) were recorded. RESULTS Of 865 enrolled patients, 21 patients (2.4%) had 25 isolated TPFs of the subaxial cervical spine. The seventh vertebra was involved predominantly (76%). The initial treatment regimen was unrestricted movement in all patients. No associated adverse events were observed. A follow-up of 13 to 39 months was available in 14 patients. Follow-up showed a stable and intact subaxial cervical spine in all patients' radiographs, a patient satisfaction of 9.3 (SD 1.48), a Cybex measured range of motion in the sagittal plane of 109 degrees (SD 12.5, 95-129), the frontal plane of 70 (SD 17.8, 37-100) and the transverse plane of 144 (SD 12.5, 116-164), and a mean neck disability index score of 3.93 (SD 8.24). CONCLUSION The incidence of isolated TPFs of the subaxial cervical spine was 2.4%. Unrestricted movement resulted in satisfying functional, anatomic, and neurologic outcomes without associated adverse events. This study confirms that isolated TPFs of the subaxial cervical spine can be considered as clinically insignificant and do not require treatment.
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Developing a Standard of Care for Halo Vest and Pin Site Care Including Patient and Family Education. J Neurosci Nurs 2010; 42:169-73; quiz 174-5. [DOI: 10.1097/jnn.0b013e3181d4a3be] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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