Halo-Vesting in Preschool Aged Children with Synchondrosis Fracture: A Case Series which Explores the Current Techniques Associated with this Procedure

Abstract

Upper cervical spine injuries are the most common form of spinal cord trauma that occur in preschool children. Among such injuries, odontoid synchondrosis fractures are the most frequently observed, though relatively few cases have been reported in the medical literature. The most appropriate approach to describe such cases is physeal injuries of the basilar synchondrosis plate between the odontoid process and the body of the axis. Acute odontoid synchondrosis fractures are further classified into 3 subtypes based on the amount of dense displacement and the degree of fracture angulation. Type Ic, the most severe subtype, will require a posterior atlantoaxial fixation for an associated atlantoaxial subluxation. The majority of Type Ia and type Ib odontoid synchondrosis fractures that display only mild to moderate dense displacement and angulation, can be adequately addressed through proper fusion. Complete fusion may be achieved through external immobilization after careful alignment is reached by either Minerva Orthosis or the use of a Halo-vest. Regardless of the technique applied, prior to immobilization, acute synchondrosis fractures should be brought together through either neck hyperextension or by using the skull traction procedure. While Minerva orthosis has been effective in the treatment for two case series and a few case reports, the use of Halo-vesting in young children presents challenges due to decreased skull thickness and the presence of a certain amount of soft osseous tissue. For these reasons, a certain level of controversy exists in the medical literature as to whether the use of such a device is warranted. According to the opponents of this practice, Halo-vesting is often a frustrating and anxiety-provoking experience for young patients. They likewise draw attention to the concerns and hospitality anticipated from the caregivers of such children who have been vested. Furthermore, these authors document that Halo orthosis is associated with a higher percentage of complications such as pin site infections, pin loosening or dislodgement, the breakdown of skin, dysphagia, dural tears and even brain abscesses. Conversely, proponents believe that Halo-vesting is a well-tolerated procedure in a majority of children as well as in toddlers. In accordance with this belief, existing evidence demonstrates that with a modification in the pin number, pin design, location of insertion, and insertion torque, the incidence of pin dislodgement and pin loosening may be reduced. Moreover, pin-site infections can be prevented through periodic medical supervision of the child patient as well as educating caregivers on how to properly clean and monitor pin sites. Overall, the number of the children with odontoid synchondrosis fractures, who have been treated with Halo-vesting accounts for roughly 40 cases with a mean percentage of complication rate recorded at 40%. Herein, 3 young children with acute odontoid synchondrosis fractures are reported in whom solid fusion at the synchondrosis plate was achieved t...

Septic cavernous sinus thrombosis secondary to halo vest pin site infection

“…Simultaneously, the involved pin should be promptly removed, but prior to removal, new pin should be inserted in a new anchoring site [9,11]. If pin site infection is neglected, rare complications such as osteomyelitis of the cranium, the epidural, subdural or brain abscesses may occur [12][13][14][15][16][17][18].…”

“…Pin site infection is regarded as a frequent complication of halo crown vest orthosis [9] , [10] , [11] . This complication can be reduced by means of proper pin site daily care.…”

“…Cleaning should be started with normal saline and then with Chlorhexidine solution. Finally, the pin site should be wrapped with normal-saline-soaked gauze for 10 to15 min and wiped dry following the removal of the gauze [9 , 11] . Training for the care givers should be a necessary addendum in the undertaking of the Halo procedure in order to ensure the best overall outcome for the patient.…”

“…With appearance of pus drainage at the pin site, an oral antibiotic should be administered blindly after a culture is taken, but it should be later switched to the most appropriate antibiotic. Simultaneously, the involved pin should be promptly removed, but prior to removal, new pin should be inserted in a new anchoring site [9 , 11] . If pin site infection is neglected, rare complications such as osteomyelitis of the cranium, the epidural, subdural or brain abscesses may occur [12] , [13] , [14] , [15] , [16] , [17] , [18] .…”

“…One of the most common complications of halo vest orthosis is a pin site infection [9] , [10] , [11] . Herein, we describe a case of septic CST that is secondary to a halo pin site infection which eventually had a favorable outcome.…”