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Simple cervical spine traction using a halo vest apparatus: technical note
Technique
Simple Cervical Spine Traction Using a Halo Vest Apparatus: Technical Note Kazuhiko Kyoshima, M.D., Yukinari Kakizawa, M.D., and Kazuo Tokushige, M.D. Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
Kyoshima K, Kakizawa Y, Tokushige K. Simple cervical spine traction using a halo vest apparatus: technical note. Surg Neurol 2003;59:518 –21. BACKGROUND
A halo vest apparatus, commonly used for external immobilization and protection of the cervical spine, offers several advantages. We present here a simple, accurate, easy, and safe cervical traction technique using a halo vest apparatus.
Description of Technique After application of the body jacket (vest) and halo crown (closed or open type) to the patient, the crown is fixed to the jacket with upright bars in accordance with the direction of traction, while
METHODS
The distinguishing feature of our technique is that, after application of a halo vest apparatus, the halo crown is distracted gradually and stepwise by turning the bilateral screw bolts that hold the halo crown over a period of one to several weeks. After each of these steps, care must be taken to check neurologic, radiologic, and skin conditions, as well as cranial pin tightening. CONCLUSSION
This distance control technique can provide a strong and accurate traction force by simply turning the bolts without the risk of overdistraction or the need for bed rest, and can be used in conjunction with radiologic examination and transportation of patients, even those unable to walk. The Sugita head fixation system constitutes a safe and easy way to facilitate surgical management after correction of cervical dislocation. © 2003 Elsevier Inc. All rights reserved. KEY WORDS
Cervical dislocation, cervical spine, halo vest, traction.
raction with suspended weights using skull tongs or a halo crown is the widespread use for cervical spine traction. However, this method has certain disadvantages mainly associated with control of the weights and the need for bed rest [7–10,13]. Application of a halo vest apparatus offers many advantages, [5,8] but there have been no previous reports of a halo vest system being used for cervical traction. We present here a simple, safe and accurate technique using a halo vest apparatus to enhance patient comfort.
T
Address reprint requests to: Dr. Kazuhiko Kyoshima, M.D., Department of Neurosurgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto 390-8621, Japan. Received July 10, 2002; accepted December 12, 2002. 0090-3019/03/$–see front matter doi:10.1016/S0090-3019(03)00035-1
Halo vest traction technique. After application of the halo vest apparatus, cervical traction is achieved gradually and stepwise by turning the bilateral screw bolts that hold the halo crown (arrows). Neurologic and radiologic conditions must be checked after each of these steps. When a Sugita head fixation system (see Figure 4) is used for subsequent surgery, it is necessary to create a space for insertion of a head-holding frame, so that a halo crown is attached in a position further above the external auditory meatus, and the upright bars that hold the halo crown is fixed with enough distance from the skull.
1
© 2003 Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010 –1710
Halo Vest Traction
Surg Neurol 519 2003;59:518 –21
Case 1. Lateral cervical X-ray film (left) and tomogram (middle) revealing locked atlantoaxial dislocation and odontoid upward shift in a rheumatoid arthritic woman presenting with neck pain and rightsided motor weakness. Lateral X-ray film (right) demonstrating reduction of the dislocation as a result of halo vest traction for 9 days, which also produced symptomatic improvement.
2
gentle manual traction is applied to the patient’s head by holding the crown. After 1-day observation of the patient’s condition to ensure that the jacket is properly applied without pressure sores, the crown is distracted gradually and stepwise by turning the screw bolts that hold the crown at both sides over a period of one to several weeks (halo vest traction) (Figure 1). After each of these steps, care must be taken to check neurologic and radiologic conditions, as well as cranial pin tightening, in addition to the skin condition under the jacket. Two adult and 1 pediatric patients with unstable craniovertebral junction were treated with this technique, resulting in satisfactory reduction (Figures 2 and 3) [12].
Discussion For reduction of cervical dislocations, traction with suspended weights using skull tongs or a halo crown is in widespread use. However, this method involves the risk of causing cervical overdistraction, which could lead to neurologic deterioration [7,9,13]. This risk is unavoidable because the determination of the optimal maximum traction weight depends on specific lesions and individuals. Other
disadvantages are the need for prolonged bed rest and unwieldiness during patient transportation and radiologic examination [8,10]. Kinnaird et al [10], constructed a portable traction device using constant-force springs, which use coiled stainlesssteel as the traction force, but their technique also needs bed rest. Graziano et al [6], used components of the Ilizarov apparatus, which connects a halo crown to a modified body cast for correction of cervical deformity. This technique allows the patient to sit and walk. We simply used an ordinary halo vest system to achieve cervical traction for the management of cervical spine dislocations. A halo vest apparatus is commonly used for external immobilization and protection of the cervical spine and offers many advantages [5,8]. The main complications involved in the use of a halo vest apparatus are cranial pin loosening, infection and pressure sores under the jacket [1–5,8]. Compared to the conventional weight suspension method, in which the traction weight is gradually increased, our halo vest traction technique, which controls the traction distance by the turning of screw bolts, can provide strong and accurate traction force without the risk of overdistraction or the need for bed rest.
Case 2. Lateral and coronal tomograms revealing upward shift of the odontoid process and the right C1 anterior arch (left and middle) because of destruction of the occipital condyle as a result of extensive surgery for clival chordoma in a 51-year-old patient presenting with neck pain and pharyngeal discomfort. Lateral tomogram (right) demonstrating reduction of the dislocation, which was accompanied with symptomatic improvement, as a result of 1-week halo vest traction with more extensive distraction on the right side than on the left. The white line indicates McGregor’s line (cited from reference 12).
3
520 Surg Neurol 2003;59:518 –21
Kyoshima et al
Application of the Sugita head fixation system to a patient with a halo vest apparatus. Surgical procedures after cervical reduction can be satisfactorily carried out while maintaining intraoperative cervical traction as well as stability. The halo vest apparatus can be removed and also reapplied postoperatively, if necessary. The arrow indicates the head-holding frame (figure on the left is cited from reference 11).
4
Subsequent surgical procedures after cervical reduction can be performed easily and safely by using a Sugita head fixation system (Figure 4) [14]. When surgery is carried out with the patient prone, a “freed” head-holding frame method, reported previously [11], is also useful. After fixation of the patient’s head it is possible to remove the halo vest if necessary. For use of this head fixation system, a space must be created to insert the head-holding frame when the halo vest apparatus is applied, so that the halo crown is attached in a position further above the external auditory meatus, and the upright bars are positioned laterally further from the skull than in standard applications (Figure 1).
Conclusions This technique provides accurate, simple, easy, and safe cervical traction as well as immobilization of the cervical spine, and facilitates radiologic examination and transportation of patients, even those unable to walk. A strong traction force can be obtained for gradual correction without the risk of overdistraction. Ambulatory patients do not need to stay in bed. However, this technique requires careful checking for cranial pin loosening and pressure sores under the vest. When subsequent surgical treatment is carried out, application of a Sugita head fixation system provides safe and easy positioning of the patient, even when prone, for facilitation of intraoperative maintenance of cervical traction and stability.
REFERENCES 1. Botte MJ, Byrne TP, Abrams RA, Garfin SR. Halo skeletal fixation: techniques of application and prevention of complications. J Am Acad Orthop Surg 1996; 4:44 –53. 2. Dormans JP, Criscitiello AA, Drummond DS, Davidson RS. Complications in children managed with immobilization in a halo vest. J Bone Joint Surg Am 1995;77: 1370 –3. 3. Fleming BC, Huston DR, Krag MH, Sugihara S. Pin force measurement in a halo-vest orthosis, in vivo. J Biomech 1998;31:647–51. 4. Fleming BC, Krag MH, Huston DR, Sugihara S. Pin loosening in a halo-vest orthosis: a biomechanical study. Spine 2000;25:1325–31. 5. Garfin SR, Botte MJ, Waters RL, Nickel VL. Complications in the use of the halo fixation device. J Bone Joint Surg Am 1986;68:320 –5. 6. Graziano GP, Herzenberg JE, Hensinger RN. The haloIlizarov distraction cast for correction of cervical deformity. Report of six cases. J Bone Joint Surg Am 1993;75:996 –1003. 7. Gruenberg MF, Rechtine GR, Chrin AM, Sola CA, Ortolan EG. Overdistraction of cervical spine injuries with the use of skull traction: a report of two cases. J Trauma 1997;42:1152–6. 8. Heary RF, Hunt CD, Krieger AJ, Antonio C, Livingston DH. Acute stabilization of the cervical spine by halo/ vest application facilitates evaluation and treatment of multiple trauma patients. J Trauma 1992;33:445–51. 9. Jeanneret B, Magerl F, Ward JC. Overdistraction: a hazard of skull traction in the management of acute injuries of the cervical spine. Arch Orthop Trauma Surg 1991;110:242–5. 10. Kinnaird RH, Jelsma RK. A portable traction device for cervical fractures. Technical note. J Neurosurg 1992;76:544 –5. 11. Kyoshima K, Kobayashi S, Sugita K. Fixation system
Halo Vest Traction
Surg Neurol 521 2003;59:518 –21
for cervical spinal operation: application of the head fixation system and multipurpose cervical frame. Neurosurgery 1987;21:591–4. 12. Kyoshima K, Kobayashi S, Tanaka Y, Muraoka S, Sugita K. Fixation by means of bone graft and plating of atlanto-occipital instability as a consequence of extensive surgery of a clivus chordoma. Case report. Neuro-Orthopedics (Springer-Verlag) 1989;7:101–5. 13. Star AM, Jones AA, Cotler JM, Balderston RA, Sinha R. Immediate closed reduction of cervical spine dislocations using traction. Spine 1990;15:1068 –72. 14. Sugita K, Hirota T, Mizutani T, Mutsuga N, Shibuya M, Tsugane R. A newly designed multipurpose microneurosurgical head frame. Technical note. J Neurosurg 1978;48:656 –7. COMMENTARY
The authors have provided a valuable service reminding us of the effectiveness of utilization of a halo, ring, and vest for reduction of deformity prior to spinal surgery. Particularly in patients with deformity such as old fractures, myelopathy, etc., gradual traction will be extremely helpful in
“
simplifying the surgical procedure and in improving ultimate alignment. Most patients will easily tolerate the use of such a halo for several weeks prior to surgery. However, there are some cautions: significant surveillance is necessary, as indicated by the authors, to make sure that over distraction does not occur, and that the alignment is gradual. Thus, repeated imaging is necessary. Needless to say there are complications associated with the pin sites as well. In spite of those concerns, we regulary employ halo vest traction for reduction of deformities in disorders as diverse as ankylosing spondylitis to chronic fracture deformity. The new halo vest described seems to be ideal for this purpose, and we look forward to employing it in the future. Dennis J. Maiman, M.D., Ph.D. Neurosurgeon Milwaukee, Wisconsin
e conquers who endures.”
H
—Persius
Simple Cervical Spine Traction Using a Halo Vest Apparatus: Technical Note Kazuhiko Kyoshima, M.D., Yukinari Kakizawa, M.D., and Kazuo Tokushige, M.D. Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
Kyoshima K, Kakizawa Y, Tokushige K. Simple cervical spine traction using a halo vest apparatus: technical note. Surg Neurol 2003;59:518 –21. BACKGROUND
A halo vest apparatus, commonly used for external immobilization and protection of the cervical spine, offers several advantages. We present here a simple, accurate, easy, and safe cervical traction technique using a halo vest apparatus.
Description of Technique After application of the body jacket (vest) and halo crown (closed or open type) to the patient, the crown is fixed to the jacket with upright bars in accordance with the direction of traction, while
METHODS
The distinguishing feature of our technique is that, after application of a halo vest apparatus, the halo crown is distracted gradually and stepwise by turning the bilateral screw bolts that hold the halo crown over a period of one to several weeks. After each of these steps, care must be taken to check neurologic, radiologic, and skin conditions, as well as cranial pin tightening. CONCLUSSION
This distance control technique can provide a strong and accurate traction force by simply turning the bolts without the risk of overdistraction or the need for bed rest, and can be used in conjunction with radiologic examination and transportation of patients, even those unable to walk. The Sugita head fixation system constitutes a safe and easy way to facilitate surgical management after correction of cervical dislocation. © 2003 Elsevier Inc. All rights reserved. KEY WORDS
Cervical dislocation, cervical spine, halo vest, traction.
raction with suspended weights using skull tongs or a halo crown is the widespread use for cervical spine traction. However, this method has certain disadvantages mainly associated with control of the weights and the need for bed rest [7–10,13]. Application of a halo vest apparatus offers many advantages, [5,8] but there have been no previous reports of a halo vest system being used for cervical traction. We present here a simple, safe and accurate technique using a halo vest apparatus to enhance patient comfort.
T
Address reprint requests to: Dr. Kazuhiko Kyoshima, M.D., Department of Neurosurgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto 390-8621, Japan. Received July 10, 2002; accepted December 12, 2002. 0090-3019/03/$–see front matter doi:10.1016/S0090-3019(03)00035-1
Halo vest traction technique. After application of the halo vest apparatus, cervical traction is achieved gradually and stepwise by turning the bilateral screw bolts that hold the halo crown (arrows). Neurologic and radiologic conditions must be checked after each of these steps. When a Sugita head fixation system (see Figure 4) is used for subsequent surgery, it is necessary to create a space for insertion of a head-holding frame, so that a halo crown is attached in a position further above the external auditory meatus, and the upright bars that hold the halo crown is fixed with enough distance from the skull.
1
© 2003 Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010 –1710
Halo Vest Traction
Surg Neurol 519 2003;59:518 –21
Case 1. Lateral cervical X-ray film (left) and tomogram (middle) revealing locked atlantoaxial dislocation and odontoid upward shift in a rheumatoid arthritic woman presenting with neck pain and rightsided motor weakness. Lateral X-ray film (right) demonstrating reduction of the dislocation as a result of halo vest traction for 9 days, which also produced symptomatic improvement.
2
gentle manual traction is applied to the patient’s head by holding the crown. After 1-day observation of the patient’s condition to ensure that the jacket is properly applied without pressure sores, the crown is distracted gradually and stepwise by turning the screw bolts that hold the crown at both sides over a period of one to several weeks (halo vest traction) (Figure 1). After each of these steps, care must be taken to check neurologic and radiologic conditions, as well as cranial pin tightening, in addition to the skin condition under the jacket. Two adult and 1 pediatric patients with unstable craniovertebral junction were treated with this technique, resulting in satisfactory reduction (Figures 2 and 3) [12].
Discussion For reduction of cervical dislocations, traction with suspended weights using skull tongs or a halo crown is in widespread use. However, this method involves the risk of causing cervical overdistraction, which could lead to neurologic deterioration [7,9,13]. This risk is unavoidable because the determination of the optimal maximum traction weight depends on specific lesions and individuals. Other
disadvantages are the need for prolonged bed rest and unwieldiness during patient transportation and radiologic examination [8,10]. Kinnaird et al [10], constructed a portable traction device using constant-force springs, which use coiled stainlesssteel as the traction force, but their technique also needs bed rest. Graziano et al [6], used components of the Ilizarov apparatus, which connects a halo crown to a modified body cast for correction of cervical deformity. This technique allows the patient to sit and walk. We simply used an ordinary halo vest system to achieve cervical traction for the management of cervical spine dislocations. A halo vest apparatus is commonly used for external immobilization and protection of the cervical spine and offers many advantages [5,8]. The main complications involved in the use of a halo vest apparatus are cranial pin loosening, infection and pressure sores under the jacket [1–5,8]. Compared to the conventional weight suspension method, in which the traction weight is gradually increased, our halo vest traction technique, which controls the traction distance by the turning of screw bolts, can provide strong and accurate traction force without the risk of overdistraction or the need for bed rest.
Case 2. Lateral and coronal tomograms revealing upward shift of the odontoid process and the right C1 anterior arch (left and middle) because of destruction of the occipital condyle as a result of extensive surgery for clival chordoma in a 51-year-old patient presenting with neck pain and pharyngeal discomfort. Lateral tomogram (right) demonstrating reduction of the dislocation, which was accompanied with symptomatic improvement, as a result of 1-week halo vest traction with more extensive distraction on the right side than on the left. The white line indicates McGregor’s line (cited from reference 12).
3
520 Surg Neurol 2003;59:518 –21
Kyoshima et al
Application of the Sugita head fixation system to a patient with a halo vest apparatus. Surgical procedures after cervical reduction can be satisfactorily carried out while maintaining intraoperative cervical traction as well as stability. The halo vest apparatus can be removed and also reapplied postoperatively, if necessary. The arrow indicates the head-holding frame (figure on the left is cited from reference 11).
4
Subsequent surgical procedures after cervical reduction can be performed easily and safely by using a Sugita head fixation system (Figure 4) [14]. When surgery is carried out with the patient prone, a “freed” head-holding frame method, reported previously [11], is also useful. After fixation of the patient’s head it is possible to remove the halo vest if necessary. For use of this head fixation system, a space must be created to insert the head-holding frame when the halo vest apparatus is applied, so that the halo crown is attached in a position further above the external auditory meatus, and the upright bars are positioned laterally further from the skull than in standard applications (Figure 1).
Conclusions This technique provides accurate, simple, easy, and safe cervical traction as well as immobilization of the cervical spine, and facilitates radiologic examination and transportation of patients, even those unable to walk. A strong traction force can be obtained for gradual correction without the risk of overdistraction. Ambulatory patients do not need to stay in bed. However, this technique requires careful checking for cranial pin loosening and pressure sores under the vest. When subsequent surgical treatment is carried out, application of a Sugita head fixation system provides safe and easy positioning of the patient, even when prone, for facilitation of intraoperative maintenance of cervical traction and stability.
REFERENCES 1. Botte MJ, Byrne TP, Abrams RA, Garfin SR. Halo skeletal fixation: techniques of application and prevention of complications. J Am Acad Orthop Surg 1996; 4:44 –53. 2. Dormans JP, Criscitiello AA, Drummond DS, Davidson RS. Complications in children managed with immobilization in a halo vest. J Bone Joint Surg Am 1995;77: 1370 –3. 3. Fleming BC, Huston DR, Krag MH, Sugihara S. Pin force measurement in a halo-vest orthosis, in vivo. J Biomech 1998;31:647–51. 4. Fleming BC, Krag MH, Huston DR, Sugihara S. Pin loosening in a halo-vest orthosis: a biomechanical study. Spine 2000;25:1325–31. 5. Garfin SR, Botte MJ, Waters RL, Nickel VL. Complications in the use of the halo fixation device. J Bone Joint Surg Am 1986;68:320 –5. 6. Graziano GP, Herzenberg JE, Hensinger RN. The haloIlizarov distraction cast for correction of cervical deformity. Report of six cases. J Bone Joint Surg Am 1993;75:996 –1003. 7. Gruenberg MF, Rechtine GR, Chrin AM, Sola CA, Ortolan EG. Overdistraction of cervical spine injuries with the use of skull traction: a report of two cases. J Trauma 1997;42:1152–6. 8. Heary RF, Hunt CD, Krieger AJ, Antonio C, Livingston DH. Acute stabilization of the cervical spine by halo/ vest application facilitates evaluation and treatment of multiple trauma patients. J Trauma 1992;33:445–51. 9. Jeanneret B, Magerl F, Ward JC. Overdistraction: a hazard of skull traction in the management of acute injuries of the cervical spine. Arch Orthop Trauma Surg 1991;110:242–5. 10. Kinnaird RH, Jelsma RK. A portable traction device for cervical fractures. Technical note. J Neurosurg 1992;76:544 –5. 11. Kyoshima K, Kobayashi S, Sugita K. Fixation system
Halo Vest Traction
Surg Neurol 521 2003;59:518 –21
for cervical spinal operation: application of the head fixation system and multipurpose cervical frame. Neurosurgery 1987;21:591–4. 12. Kyoshima K, Kobayashi S, Tanaka Y, Muraoka S, Sugita K. Fixation by means of bone graft and plating of atlanto-occipital instability as a consequence of extensive surgery of a clivus chordoma. Case report. Neuro-Orthopedics (Springer-Verlag) 1989;7:101–5. 13. Star AM, Jones AA, Cotler JM, Balderston RA, Sinha R. Immediate closed reduction of cervical spine dislocations using traction. Spine 1990;15:1068 –72. 14. Sugita K, Hirota T, Mizutani T, Mutsuga N, Shibuya M, Tsugane R. A newly designed multipurpose microneurosurgical head frame. Technical note. J Neurosurg 1978;48:656 –7. COMMENTARY
The authors have provided a valuable service reminding us of the effectiveness of utilization of a halo, ring, and vest for reduction of deformity prior to spinal surgery. Particularly in patients with deformity such as old fractures, myelopathy, etc., gradual traction will be extremely helpful in
“
simplifying the surgical procedure and in improving ultimate alignment. Most patients will easily tolerate the use of such a halo for several weeks prior to surgery. However, there are some cautions: significant surveillance is necessary, as indicated by the authors, to make sure that over distraction does not occur, and that the alignment is gradual. Thus, repeated imaging is necessary. Needless to say there are complications associated with the pin sites as well. In spite of those concerns, we regulary employ halo vest traction for reduction of deformities in disorders as diverse as ankylosing spondylitis to chronic fracture deformity. The new halo vest described seems to be ideal for this purpose, and we look forward to employing it in the future. Dennis J. Maiman, M.D., Ph.D. Neurosurgeon Milwaukee, Wisconsin
e conquers who endures.”
H
—Persius