[Complications in the use of the halo fixator]

Conservative treatment of upper cervical spine injuries with the halo vest: an appropriate option for all patients independent of their age?

Object

Most upper cervical spine injuries are able to heal conservatively by halo vest application. The acceptance of the halo is different among patients due to the weight of the apparatus and the limited mobility it causes. Additionally, the fracture healing rate in older patients seems to be inferior to that in younger patients, which would make an operative stabilization procedure more appropriate for the elderly. Furthermore, the risk of complications is assumed to be higher in older people. The purpose of this retrospective study was to find out if there are differences in the clinical and radiological results and in complication rates between 2 patient groups with upper cervical spine injuries and halo vest treatment with special interest of their age group.

Methods

A total of 29 patients with upper cervical spine injuries were treated by halo vest application. The clinical and radiological results and the complication and revision surgery rates were identified. Patients were divided into 2 groups (18 patients were < 65 years and 11 were > 65 years), and the results were evaluated to examine whether there were any differences.

Results

The clinical and radiological results and the complication rate were not statistically significantly different between the 2 patient groups; however, there was a tendency for a longer time interval for fracture healing and more complications in the elderly people.

Conclusions

If the conditions for conservative treatment of upper cervical spine injuries with halo fixation are right, the clinical and radiological results are good and almost similar in patients regardless of their age, although there is a tendency for more complications in older people.

Incidence of and risk factors for complications associated with halo-vest immobilization: a prospective, descriptive cohort study of 239 patients

BACKGROUND

Since high rates of serious complications, such as death and pneumonia, during halo-vest immobilization have been reported, there has been a tendency of restraint with regard to the use of the halo vest. However, the rate of complications in a high-volume center with sufficient experience is unknown. Our objective was to determine the incidence of and risk factors associated with complications during halo-vest immobilization.

METHODS

During a five-year period, a prospective cohort study was performed in a single, level-I trauma center that was also a tertiary referral center for spinal disorders. Data from all patients undergoing halo-vest immobilization were collected prospectively, and every complication was recorded. The primary outcome was the presence or absence of complications. Univariate regression analysis and regression modeling were used to analyze the results.

RESULTS

In 239 patients treated with halo-vest immobilization, twenty-six major, seventy-two intermediate, and 121 minor complications were observed. Fourteen patients (6%) died during the treatment, although only one death was related directly to the immobilization and three were possibly related directly to the immobilization. Twelve patients (5%) acquired pneumonia during halo-vest immobilization. Patients older than sixty-five years did not have an increased risk of pneumonia (p = 0.543) or halo vest-related mortality (p = 0.467). Halo vest-related complications ranged from three patients (1%) with incorrect initial placement of the halo vest to twenty-nine patients (12%) with a pin-site infection. Pin-site infection was significantly related to pin penetration through the outer table of the skull (odds ratio, 4.34; 95% confidence interval, 1.22 to 15.51; p = 0.024). In 164 trauma patients treated only with halo-vest immobilization, cervical fractures with facet joint involvement or dislocations were significantly related to radiographic loss of alignment during follow-up (odds ratio, 2.81; 95% confidence interval, 1.06 to 7.44; p = 0.031).

CONCLUSIONS

There are relatively low rates of mortality and pneumonia during halo-vest immobilization, and elderly patients do not have an increased risk of pneumonia or death related to halo-vest immobilization. Nevertheless, the total number of minor complications is substantial. This study confirms that awareness of and responsiveness to minor complications can prevent subsequent development of serious morbidities and perhaps reduce mortality.

Zur Problematik des Halofixateurs beim alten Patienten

INTRODUCTION

The treatment of unstable cervical spine injuries with the halo vest represents an established procedure. So far no data reflecting the quality of life of patients following a halo vest treatment are available. Elderly people make up a large part of the inpatients in our hospital. Therefore special attention is payed to this group of patients in this study.

METHODS

In this study 41 patients (average age of 51.8 +/- 23.5 years) with an unstable injury of the upper cervical spine were investigated. All of them underwent a halo vest therapy in our hospital during 1988-2003. The health-related quality of life was assessed in the mean 8.0 years after the trauma by using the SF-36 Health Survey. Additionally, the incidence of complications and the union rate over time were observed.

RESULTS

The evaluation of the data obtained from the SF-36 revealed a reduced quality of life in the patient group in comparison to the reference population. This was particularly apparent in patients older than 60 years. The fracture healing under halo vest treatment was comparably slow. In 17% of the cases no fracture union was obtained after 12 weeks. This was only seen for patients older than 60 years. The complication rate associated to the halo vest amounted to 43% and was independent of age.

CONCLUSION

The treatment of unstable fractures of the upper cervical spine with a halo vest results in a prolongated fracture healing for elderly people. Furthermore a halo vest therapy reduces the health related quality of life. Therefore, even for elderly patients an internal osteosynthetic stabilization of an unstable injury of the upper cervical spine should be considered if indicated.