Brain Abscess After Halo Fixation for the Cervical Spine

Accepted Manuscript Brain Abscess Following Halo Fixation for the Cervical Spine Arthur Lopes, M.D., Almir Andrade, Ph.D., Igor Silva, M.D., Wellingson Paiva, Ph.D., Roger Brock, M.D., Manoel Teixeira, Ph.D. PII:

S1878-8750(17)30721-0

DOI:

10.1016/j.wneu.2017.05.033

Reference:

WNEU 5727

To appear in:

World Neurosurgery

Received Date: 23 February 2017 Revised Date:

3 May 2017

Accepted Date: 4 May 2017

Please cite this article as: Lopes A, Andrade A, Silva I, Paiva W, Brock R, Teixeira M, Brain Abscess Following Halo Fixation for the Cervical Spine, World Neurosurgery (2017), doi: 10.1016/ j.wneu.2017.05.033. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT ABSTRACT Background: Halo fixation is one of the possible treatments for cervical spine fractures. However, improper use of these devices may lead to many complications, such

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as pin loosening, halo dislocation, pin site infection, and intradural penetration.

Case description:

We report a 43-year-old man who first presented with a seizure and an altered level of consciousness five months after halo-vest placement for an

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odontoid fracture. Brain imaging revealed a brain abscess, under the previous left parietal pin. He underwent abscess drainage and antibiotics were

mild strength impairments.

Conclusions:

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administered for 12 weeks. Upon hospital discharge, he only presented with

Misapplication of halo fixation devices may lead to serious complications, including intracranial pin penetration and brain abscesses. Proper use of the

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recommended technique may decrease the risk for complications related to the procedure.

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CASE REPORT

Introduction:

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A 43-year-old man was admitted to the emergency department after five tonic– clonic seizures. Five months before he was diagnosed, he developed an Anderson and D’Alonzo type 3 odontoid fracture after falling from a height (Fig.1). He underwent fracture reduction with cranial halo traction for ten days at another hospital department and then was discharged wearing a halo-vest, which was maintained for three months. Antibiotic prophylaxis was not used during that time. One month before admission, he presented with the first seizure and he was prescribed phenytoin, with no further investigation. Upon initial neurological assessment, the patient was given a Glasgow Coma Scale (GCS) score of 7 and right hemiparesis was observed (grade 2/5).

ACCEPTED MANUSCRIPT He underwent orotracheal intubation and a loading dose of phenytoin was administered. A brain CT scan showed frontal and parietal penetrations of the halo pins and a lesion suggestive of a brain abscess under the parietal fracture (Figs. 2 and 3). Due to neurological impairment and based on his brain CT findings, he promptly underwent decompressive craniectomy and abscess

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drainage. The administration of intravenous antibiotics was initiated with ceftriaxone, oxacillin, and metronidazole.

The patient evolved with improvements in the level of consciousness and motor strength (4/5). However, postoperative magnetic resonance imaging

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(MRI) showed an extensive residual abscess and reoperation was decided for lesion drainage (Figs. 4 and 5). Intraoperative cultures grew a methicillinsensitive Staphylococcus aureus (both surgeries). Intravenous antibiotics were

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administered for seven weeks and the patient was discharged while taking sulfamethoxazole-trimethoprim for five weeks. Discussion:

Odontoid fractures comprise approximately 10–20% of all cervical fractures and there are increasing incidences in the elderly population.7,9,11,20 Management of

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these fractures may be either surgical or nonoperative and the patient’s age, any neurological deficits, and the Anderson and D’Alonzo classification should be taken into account to define the treatment.11

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Halo immobilization is a non-surgical option for treating odontoid fractures. Perry and Nickel were the first to use these orthoses to treat cervical

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spine pathologies in 1959; however, skeletal traction has been used since 1933.13,25 Regarding odontoid fractures, the halo-vest is the best choice for type I and type III fractures, with a high union rate (99%).24 Despite the halo-vest providing adequate treatment to avoid the need of

surgery for stabilization and fusion, it is important to be aware of its associated complications. Tindall et al. reported three cases of intracranial abscesses related to skull traction by Crutchfield tongs in 1959, and Victor was the first to describe an intracranial abscess associated with halo traction in 1973.7,27 Later, Garfin analyzed 179 cases and all the complications related to the procedure. He noticed that pin site infection occurred in 20% and intradural penetration in

ACCEPTED MANUSCRIPT 1% of the patients.6 Recently, Lee reviewed studies reporting halo-vestassociated complications. In 795 patients, directly related to treatment, he found pin loosening (22%), pin site infection (15%), severe pin site scars (8%), injury to supraorbital/supratrochlear nerves (2%), halo ring dislocation (1%), dural penetration (1%), and death (0.1%).15

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Since the first publication by Tindall, there have been many papers that have reported brain abscesses secondary to skull fixation for skeletal traction. 3,5,7,8,10,12,13,17,19,21,23,25,26,27

related abscesses.

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Intradural penetration is the main risk factor for halo-

Nonetheless, there have been some cases in which

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penetration of the internal calvaria was identified, but the dura mater was intact and Humbyrd reported one case without any inner table perforation.3,10 Most

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cases were observed in men, since cervical traumatic fractures are the main indication for halo-vest immobilization.25

The most common clinical findings are headaches and inflammation at the point of pin insertion. In some cases, purulent drainage from the pin sites is observed.12 Fever is present in up to 25% of patients. Seizures and an altered

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level of consciousness are also uncommon.2,5,18,25 Brain imaging is essential to diagnosis and management. Usually, the first image examination performed is a head CT, which may only reveal a localized hypoattenuation in the early cerebritis phase or the classical finding of a ring-enhancing lesion.18 Brain MRI,

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associated with diffusion-weighted images and spectroscopy, has high sensitivity (96%) and specificity (96%) for differentiating brain abscesses from

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other diagnoses.2

Brain abscess cultures may be negative in up to 30% of patients,

depending on the time of antibiotic administration prior to drainage. The isolated organisms vary according to etiology (e.g., hematogenous spread; traumatic brain injury; contiguous paranasal, otogenic, or dental infection) and the host immune status (fungi account for the majority of cases in solid organtransplanted patients).2,18 S. aureus is the most common organism identified in halo-vest-associated abscesses. S. epidermidis, streptococci, and peptococci have already been reported.3,25

ACCEPTED MANUSCRIPT Avoiding brain abscess secondary to halo-vest immobilization involves two main components: proper skin care and adequate pin application. Kazi proposed a new regimen for reducing pin site infection. The pins were inserted using a sterile technique and debris was removed with saline. In this technique, they dressed the pins with gauze soaked in clorhexidine or an alcoholic solution,

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which was followed by daily cleaning with 70% alcohol for three days. Gauze dressing was reapplied. This technique was repeated every 7–10 days and it was recommended to patients to wash using 4% chlorhexidene. Infection rates fell from 30% to 5% after implementing this method.14

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Some steps must be followed to avoid intracranial pin penetration. Usually, four pins are placed in adults. Temporal insertion should be averted

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since temporal bone is thin and lesions of the temporalis muscle may cause pain mastication.15 Safe zones where the bone density is greater are described (these areas correspond to 12 and 4 o’clock anteriorly and 6 and 8 o’clock posteriorly). Nevertheless, we recommend a personalized application based on head CT. This approach allows for the recognition of anatomical variations, such

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as enlarged frontal sinuses, and thus avoids complications.15,19 Rizzolo et al. studied the adequate torque to prevent complications. Although not statistically significant, they found that a 6 in-lb torque would be more appropriate, with a decreased risk of intracranial penetration and

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infection.22 However, more recent studies in human cadavers showed intracranial penetration only at 16 in-lbs.15 Most hospitals use 8 in-lbs as the

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standard application.4

Halo-vest placement is also a treatment option for cervical spinal cord

diseases in children of any age, although a higher complication rate than adults has been reported. However properly following some principles can reduce the chance of intracranial penetration in this age group: use of head CT to plan pin insertion; eight-pin fixation instead of the standard four-pin technique; use of wide flanged and short-tipped pins; and perpendicular pin insertion.1

Conclusion: Halo-vest immobilization is an option with a high union rate for treating

ACCEPTED MANUSCRIPT some cervical fractures. As with any medical treatment, there are some complications related to the procedure, such as failure of fracture ossification, pin loosening, pin site infection, nerve head injuries, dural penetration, intracranial abscesses, and even death. In this paper, we reported the case of a patient with a brain abscess following halo pin insertion. As in previous reports,

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the patient did not die; however, brain abscesses may lead to severe neurological impairments. Careful observation of head imaging before halo insertion, proper skin care, and adequate torque application may avoid this

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cumbersome complication.

REFERENCES

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ACCEPTED MANUSCRIPT HIGHLIGHTS: - Missapplication use of halo fixation devices may lead to serious complications - There are literature reports of cranial fractures and abscesso related to cervical halo fixation

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- Properly use of the recommended technique may decrease risk for complications related to the procedure

ACCEPTED MANUSCRIPT Abbreviations list:

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- GCS: Glasgow Coma Scale - CT: Computed tomography - MRI: Magnetic resonance imaging