Use of halo fixation therapy for traumatic cranio-cervical instability in children: a systematic review

Table 1 shows summary data from all included studies.

We found two studies about HF therapy for AOD. Vachata et al. [48] reported that “two patients were in severe neurological states, with lesions of the upper cervical spinal cord and medulla oblongata on MRI, these patients were treated with external HF and died within 3 days of the trauma” [48]. In contrast, Able et al. recently reported that treatment with HF was a safe, viable, and definitive treatment option for selected children with AOD [1]. Although several factors biased their results, Able et al. reported good outcomes in eight out of ten patients with AOD (aged between newborn and 17) whose only therapy was external fixation with HF. The treatment lasted 3 months and only a pin-site complication was the only reported complication was pin-site complication [1].

We identified seven publications presenting conservative treatment with HF in patients with traumatic AARS. The results and success rates are presented in Table 2 [6, 11, 17, 29, 35, 44, 50].

Bakhshi et al. used primary pinless HF in 11 patients with an average age of 6.04 years. They reported success in every case [6].

Tauchi el al. treated seven children with HF. Six of these demonstrated remodeling of the deformed vertebra. Only one patient showed greater deformity and needed surgical C1-2 fixation [44]. Powel et al. [35] retrospectively describe a higher rate of traction in nine patients treated with HF (mean age 7.7 years). Two of these received secondary surgical fusion due to HF failure. Glotzbecker et al. reported on three patients with chronic traumatic AARS (average age of 7.2 years) who received primary conservative HF and another child who received secondary HF [17]. The only complication was mild neck pain and reduction of the cervical range of motion. Verhofste et al. reported that three out of seven patients successfully received primary HF and the other four received it in addition to surgery. Their mean age was 11.3 ± 5.58 years [50]. Chechik et al. successfully treated one girl, aged 7 [11]. Mifsud et al. reported on successful HF therapy for AARS [29].

Two patients with OCF were successfully treated with HF [6]. Mean therapy duration was 51 days. Skin irritation was the only reported complication. The average age was 12.61 years.

We identified eight studies, five of them favoring primary therapy with HF [37, 39, 42, 46, 47]. Takahashi et al. [43] used HF prior to surgery and other authors used it after surgery [18, 30]. The principal purpose of HF therapy for traumatic C2 fracture with instability is fusion or bone healing [39, 42, 46, 47].

A hangman’s fracture is a hyperextension C2 injury, which is almost exclusively seen in children under 2 years of age. The incidence increases again from the age of 16, and then has the same characteristics as C2 fractures in adults [38, 42]. The recommended treatment for a hangman’s fracture varies according to the type and severity of the fracture instability. Types I and II are suitable for conservative treatment with HF, whereas patients with type IIA and III should undergo surgical instrumentation. However, internal fixation has a higher probability of secondary deformities and limitation in growth potential. HF seems to be beneficial not only in preserving movement capacity, but also in avoiding late consequences of surgery [31].

AOD is a devastating injury with high mortality, usually caused by high energy trauma [5, 40, 48]. Traction should be avoided because of the risk of deterioration [45]. The definitive treatment of traumatic AOD remains controversial, but a widely held view is that all patients with AOD should be treated with early surgical fusion (internal dorsal fixation and arthrodesis) [5, 45, 48]. In contrast to this opinion, external immobilization with HF on a small group of eight patients was found to be viable, safe and effective [1].

AARS is one of the more common cervical injuries which, due to their ligament elasticity, is found almost exclusively in children [35]. The decision of this study to prefer surgery to HF was based on the time from symptom onset, although very good outcomes have been described for delayed HF therapy in combination with traction [6, 11, 17, 24, 29, 35, 44, 50] or for delayed therapy with pinless HF [6]. The decision to prefer surgery to HF was based on the time from symptom onset. Although very good outcomes have been described after delayed therapy with HF [19, 29, 52], chronic pain lasting more than 6 weeks or acute neurological deficits are the most common indications for primary surgical therapy.

The main recommendation in the literature for this injury type is HF therapy.

OCF is a rare cervical spine injury after blunt trauma with a prevalence of 1.4–4.4% [3]. Generally, non-surgical management is recommended [6]. The Anderson–Montesano classification divides OCF into 3 types and non-surgical management with cervical orthosis is recommended for types 1 and 2 [3, 4]. External fixation with HF is recommended as a therapy of choice for OCT type 3 [37]. The possible complications, such as nerve palsies, are explained by pannus creation, which is not primarily associated with HF. Good healing chances are associated with immobilization for 1–3 months [3, 4]. Surgical fusion is indicated only in the case of severe brainstem compression or compression of the upper cervical spinal cord’[22].

C2 is the most frequently injured cervical vertebra in children [27]. Successful conservative therapy avoids the limitations on movement reported after surgical fusion [39, 46]. Fulkerson et al. treated two patients with internal fixation and also reviewed similar cases in the literature. They recommended HF as the therapy of choice to prevent possible movement restrictions [16]. They also recommended considering early surgical intervention in cases of odontoid angulation (> 30°), significant displacement, and symptoms of spinal cord injury, due to the higher probability of ligament disruption and the greater instability of the fracture. In line to above opinion recommended Rusin et al. his therapy management [37].

A hangman’s fracture is a hyperextension C2 injury with upper cervical spine fracture, which is almost exclusively seen in children under the age of two. The incidence increases again from the age of 16, where it has the same characteristics as C2 fractures in adults [18, 30, 38, 42]. The recommended treatment for a hangman’s fracture varies according to the type and severity of the fracture instability [2]. Unstable fractures should undergo surgical instrumentation [24, 30, 43]. The main recommendation for traumatic C2 injuries is primary treatment with HF. Cases with angulation or fracture displacement should be treated surgically with internal fixation.

Generally, HF was associated with only minor complications including pin loosening, pin tract infection, cranial nerve palsies, and vest-related pressure sores [1, 6, 29, 50]. An anatomical guide for safe pin placement, with recommended pin sizes for different age groups, has been produced by Domenech-Fernandez et al. [13] and Chavasiri et al. [10].

The pinless halo was introduced to reduce the complications associated with HF pins [6]. Only one minor complication (skin irritation) was described in the literature we reviewed [6]. Because of the lack of data in this particular area, more studies are needed to evaluate the use of pinless HF in traumatic instabilities.