Early mortality in elderly patients with isolated C2 odontoid fracture treated by halo-vest immobilization, anterior spinal fixation, or posterior spinal fixation: A generalized propensity score-based analysis using a nationwide database

Purpose To compare in-hospital mortality of three procedures in the treatment of elderly patients with isolated C2 odontoid fracture: halo-vest immobilization, anterior spinal fixation (ASF), and posterior spinal fixation (PSF). Methods We extracted data for elderly patients who were admitted with C2 odontoid fracture and treated with at least one of the three procedures (halo-vest immobilization, ASF, or PSF) during hospitalization. We conducted a generalized propensity score-based matching weight analysis to compare in-hospital mortality among the three procedures. We further investigated independent risk factors for in-hospital death. Results The study involved 891 patients (halo-vest, n = 463; ASF, n = 74; and PSF, n = 354) with a mean age of 78 years. In-hospital death occurred in 45 (5.1%) patients. Treatment type was not significantly associated with in-hospital mortality. Male sex (odds ratio, 2.98; 95% confidence interval, 1.32–6.73; p = 0.009) and a Charlson comorbidity index of ≥ 3 (odds ratio, 9.18; 95% confidence interval, 3.25–25.92; p < 0.001) were independent risk factors for in-hospital mortality. Conclusions Treatment type (halo-vest immobilization, ASF, or PSF) was not significantly associated with in-hospital mortality in elderly patients with isolated C2 odontoid fracture. Halo-vest immobilization can help to avoid adverse events in patients with C2 odontoid fracture who are considered less suitable for surgical treatment.

Evaluation of using the Anderson-Montesano and the Tuli classifications in pediatric patients with occipital condyle fractures

Background Occipital condyle fractures (OCFs) in patients before 18 years of age are rare. Classifications of OCF are based on the CT images of the cranio-cervical junction (CCJ) and MRI. The Anderson-Montesano and Tuli classifications are the types which are most commonly used in these cases. Classification of OCFs allows the implementation of OCF treatment. The aim of this study was to evaluate the effectiveness of using the OCF classification in pediatric patients based on the analysis of our own cases. Methods During the years 2013–2020, 6 pediatric patients with OCFs, aged 14–18, have been treated. Two patients with unstable fracture III according to Anderson-Montesano and IIB according to Tuli were treated with the halo-vest. Additionally, one patient presenting neurological symptoms and with an associated C1 fracture was qualified for the halo-vest stabilization as well. The other patients were treated with a Minerva collar. We evaluated the results 6 months after completing the OCF treatment using the Neck Disability Index (NDI) and SF-36 questionnaires. Confidence intervals for the mean values were verified using the MeanCI function (from the R library DescTools) for both classical and bootstrap methods. Results Based on NDI results, we have obtained in our patients an average of 4.33/45 points (2–11) and 9.62% (4.4–24.4). Based on the SF-36 questionnaire, we obtained an average of 88.62% (47.41–99.44). Conclusion The Anderson-Montesano and Tuli’s classifications of OCF can be used to assess the stability of OCF in adolescents, but both classifications should be used simultaneously. CT and MR imaging should be used in diagnosing OCFs, whereas CT allows assessing therapeutic outcomes in OCF.

Complications of Halo Vest Orthosis: A Narrative Study

Background and Aim: Perry and Nickel introduced the halo vest in 1959. It is the most common immobilization device for the unstable cervical spine. In the literature review, most articles review the beneficial effects of the halo vest, and a few report its complications. This study aims to evaluate the complications associated with halo orthosis. Methods and Materials/Patients: This is a narrative study about halo vest complications. To provide up-to-date information, we reviewed the articles written about halo complications. All relevant articles were retrieved from Google Scholar, Medline, PubMed, etc., using the keywords of “halo vest orthosis”, “unstable cervical spine fracture”, “halo vest complications”, “halo vest immobilization”, “pin-site-related complications”, and “vest-related complications”. Afterward, we reviewed and critically analyzed the articles. Results: At first, the halo vest was used for postoperative paralyzed poliomyelitis patients, and later, it was also used for traumatic injury of the cervical spine or postoperatively in cervical spine reconstructive surgery. Compared to other orthoses, the halo vest provides a more effective external fixation and maintains normal anatomic alignment of the cervical spine without impacting jaw motion and resulting in eating problems. However, it has many temporary complications. To prevent halo vest complications, experienced people should apply it, and the patients should be regularly followed up for early detection and treatment of complications. Conclusion: Our review is the starting point for the evaluation and investigation of halo vest complications. Because of the high incidence of pin loosening and infection, it is better to evaluate the design and application of halo pin. Since the initial design of the halo vest, only its superstructure has been redesigned without any significant change in other parts of it.

Upper Cervical Spine Fracture-Dislocation in Patients With Ankylosing Spondylitis: Application of Halo Vest Before and During Posterior Surgery

Background It is a challenge to reduce and immobilize the broken “bamboo spine”, especially for the upper cervical spine, in patients with ankylosing spondylitis (AS) before and during posterior surgery. Methods We retrospectively analyzed the case histories, operations, neurologic outcomes, follow-up data, and imaging records of 17 patients with AS and upper cervical spine fracture-dislocation who underwent surgical treatment in three clinical spine center from 2010 to 2019. A halo vest was used to reduce and immobilize fractured spinal column ends. The neurological injury was evaluated using the American Spinal Injury Association (ASIA) impairment scale score and Japanese Orthopaedic Association (JOA) score before and after operation. Complications and time of bone fusion were recorded. Results Fourteen patients achieved closed anatomical reduction after halo vest application. No displacement in fracture ends and loss of reduction occurred after prone position. No patient presented with secondary neurological deterioration. All patients was performed posterior surgery. The surgery improved the ASIA grade in all patients (P < 0.001). The mean JOA score also increased significantly at last follow-up compared to preoperation (14.5 ± 2.3 vs. 9.2 ± 2.4, P < 0.01). No severe complication and death occurred. All patients reached solid bony fusion at 12-month follow-up. Conclusions Use of a halo vest before and during the operation is safe and effective in patients with AS who develop upper cervical spine fracture-dislocation. This technique makes positioning, awake nasoendotracheal intubation, nursing, and the operation more convenient. It can also provide satisfactory reduction and rigid immobilization and prevent secondary neurologic deterioration. .

Treatment of Unstable Occipital Condylar Fractures in Children—A STROBE-Compliant Investigation

Background and objectives: Occipital condyle fractures (OCF) occur rarely in children. The choice of treatment is based on the Anderson–Montesano and Tuli classification systems. We evaluated the outcome of unstable OCF in children and adolescents after halo-vest therapy. Materials and Methods: We treated 6 pediatric patients for OCF, including 3 patients (2 girls, 1 boy) with unstable OCF. Among the 3 patients with unstable OCF, 2 patients presented with an Anderson–Montesano type III and Tuli type IIB injury, while 1 patient had an Anderson–Montesano type I fracture (Tuli type IIB) accompanied by a C1 fracture. On admission, the children underwent computed tomography (CT) of the head and cervical spine as well as magnetic resonance imaging (MRI) of the cervical spine. We treated the children diagnosed with unstable OCF with halo-vest immobilization. Before removing the halo vest at the end of therapy, we applied the CT and MRI to confirm OCF consolidation. At follow-up, we rated functionality of the craniocervical junction (CCJ) based on the Neck Disability Index (NDI) and Questionnaire Short Form 36 Health Survey (SF-36). Results: All children achieved OCF consolidation after halo-vest therapy for a median of 13.0 weeks (range: 12.5–14.0 weeks). CT and MRI at the end of halo-vest therapy showed no signs of C0/C1 subluxation and confirmed the correct consolidation of OCF. The only complication associated with halo-vest therapy was a superficial infection caused by a halo-vest pin. At follow-up, all children exhibited favorable functionality of the CCJ as documented by the NDI score (median: 3 points; range: 3–11 points) and SF-36 score (median: 91 points; range: 64–96 points). Conclusions: In our small case series, halo-vest therapy resulted in good mid-term outcome in terms of OCF consolidation and CCJ functionality. In pediatric patients with suspected cervical spine injuries, we recommend CT and MRI of the CCJ to establish the diagnosis of OCF and confirm stable fracture consolidation before removing the halo vest.

Transoral approach using a tubular retractor system in the treatment of atlantoaxial Pott’s disease: a novel method of surgical decompression

The use of tubular retractors in minimally invasive spine surgery has been described extensively in the literature. However, there are only select reports discussing their use specifically in a transoral approach for upper cervical pathologies such as an epidural abscess and a dystrophic os odontoideum.We report the first use of a transtubular transoral approach in a rare case of an adult presenting with severe neck pain with progressing neurologic signs secondary to atlantoaxial Pott’s disease. Debridement and partial odontoidectomy performed using this approach allowed less trauma to surrounding soft tissues without sacrificing an excellent visualisation of the operative field. A halo vest was applied to provide temporary stability. The patient transitioned out of his halo vest after 6 months while completing medical therapy after a year without need for further intervention. The transtubular transoral approach is a suitable alternative to the conventional approach in patients with atlantoaxial Pott’s disease.