What Is Halo Vest?

A halo is a ring that is encircles the head and is fixed to it by means of pins that are inserted in the head. It is also known as “halo ring” or “halo crown,”.
This device is used in management of cervical spine diseases where spine needs external stabilization. Halo ring can be used to put traction on the cervical spine or to provide external support and immobilization. In the latter case the ring is attached to a brace that encircles patient’s torso and the whole assembly is termed as halo vest. Read more

Surgery In Upper Cervical Spine Injury

Surgery in cervical spine injuries consist of following procedurtes either alone or in combination.

• Decompression
• Osteosynthesis of a fracture and arthrodesis of vertebral motion segments.

The choice of procedure is dependent on the nature of injury and the profile of the patient.

Decompression

Decompression of neural elements in upper cervical spine fractures is rarely necessary. Decompression should be performed only if indirect fracture reduction maneuvers fail and if compression of neural elements from bony elements remains.

The approach to dempression  can be anterior or posterior depending upon the offending structure.

Osteosynthesis

Repair of the fracture fragments using internal fixation is indicated in very few cases in upper cervical spine. These injuries are type II odontoid fractures and type II  traumatic spondylolisthesis of the axis.

Arthrodesis

Arthrodesis is fusion of the vertebrae and along with instrumentation, it is most common surgery employed in cervical spine injuries.

The most common upper cervical fusion procedure involves an atlantoaxial  fusion followed by an occipitocervical fusion. Very rarely is a C1–3 fusion indicated.

Non Operative Treatment Of Upper Cervical Spine Injury

Many cervical spine injuries do not require surgical treatment or cannot be taken for surgical treatment because of one reason or other. These cervical spine injuries are managed by non operative means of treatment.

The basic nonoperative options consist of bracing, skeletal traction in recumbent position and halo vest. These treatment modalities can be used either separately or in conjunction with one another.

The treatment needs to be monitored at regular intervals by radiographs.

The duration of application of an external immobilization device usually ranges from 2 to 4 months, and depends on the type of injury and the age of the patient.

External immobilization is also used for the adjuvant postoperative management of patients having undergone surgical stabilization of the cervical spine. Read more

Biomechanics of Upper cervical Spine

The three bony components of the upper cervical spine are

• Skull base
• Atlas
• Axis

these three components form a functional unit. There are five joints in the upper cervical spine which are stabilized by  ligamentous check rein and muscular control.

Together these contribute to the movements in the neck substantially. This enables us for a rapid response and  large-scale head excursion.

Upper cervical spine is thought to contribute approximately 60% of rotation, 40% of flexion-extension, and 45% of overall neck motion.

The normal axial plane C1–2 rotational excursion amounts to 80 to 88 degrees from left to right. Read more

Rotrary Subluxation of C1 Vertebra On C2 Vertebra

This is an uncommon injury in adults. Rotary C1-C2 subluxation is more common in children and that behaves differently from the injury in adults.

Cause

In adults, the injury is caused by motor vehicle accidents and often may be missed in initial evaluation of the patient.

Presentation

Following an injury , the patient complains of torticollis and restricted neck motion. Read more

Upper Cervical Injury – Rupture of Transverse Ligament

This is a pure ligamentous injury of upper cervical spine and behaves differently from other injuries of C1-C2 region.

Most common cause of this injury is blow on the back of the head following a fall.

How Does Transverse ligament Rupture?

The ligament may either be avulsed with a bony fragment from the lateral mass on either side or it may rupture in its substance.

Diagnosis

The presentation would be like other injuries of upper cervical spine. The xrays may reveal anterior subluxation of ring of C1 on lateral views in flexion.

The instability can be reduced on extension.

These flexion and extension views should be made under supervision of a physician.

Presence of retropharyngeal hematoma suggests an acute injury.

A small fleck of the bone may suggest avulsion of the ligament.

Anterior widening of atlanto-dens interval of more than 5 mm in lateral view in flexion suggests that transverse ligament is incompetent.

Treatment

Rupture of the transverse liagment is a ligamentous injury and non operative treatment is not effective in this type of injury.

Therefore surgery is almost always needed.

Initial treatment of this injuryis by stablization of the spine using traction.

Definitive treatment involves fusion of C1-C2 vertebrae.

An Overview of Atlantoaxial Injuries

In normal conditions, the articulation of the odontoid process of C2 (axis) with the anterior arch of C1 (atlas) allows for 50% of cervical lateral rotation.

The liagments responsible for stability are transverse and alar ligaments. They  maintain joint integrity and limit posterior motion of the odontoid process relative to the C1 anterior arch.

An acute injury to this area can cause cord compression and could be fatal.

Acute trauma, usually cervical hyperflexion, hyperextension, or a direct axial load on the head or cervical spine causes atlanto axial injuries. Certain conditions  congenital odontoid anomalies, such as odontoid aplasia, odontoid hypoplasia, and a separate odontoid process or  os odontoideum and inflammatory processes predispose an individual to these injuries.

Most of these injuries are the result of significant trauma to the head, although they may occur in older patients with a simple fall and striking of the occiput.

The individuals suffering from these injuries present with general symptoms of neck pain, limited range of motion, and torticollis. However, worsening of  symptoms like headache, fatigue, transient upper-extremity paresthesias could be an indicator of this injury. Read more

Dynamic Radiography of Cervical Spine – Flexion Extension Xrays

Dynamic motion studies of the neck are helpful in eliciting less than obvious instability of the cervical spine and assessing the healing results of the cervical spine following trauma and other pathologies.

What Is Dynamic Radiography?

In this xrays are taken in different positions of neck for example flexion and extension. The xrays are then studied for relations of vertebral bodies and the preservation or loss of anatomical alignment which may be indicated by

• Development of deformity in particular position
• Inability to maintain normal relationships of vertebrae on change of position.
• More than desired motion of a vertebral segment on movement.

Any of the above indicates an imbalance of ligamentous structure. Read more

Fracture of C1 Vertebra or Atlas

Atlas fractures can be  stable or unstable injuries.  This fracture has very high association with  injuries to other areas of the spine.

A fracture of atlas vertebra should cause enough alert to search for injuries in other region of the spine.

Almost 43%  of all C-1 fractures are found to be associated with a C-2 fracture.

Atlas fractures have been divided into following 5 types. Read more

Occipital Condyle Fractures and Occipitocervical Dissociation

Occipital condyle fractures have previously been viewed as relatively uncommon injuries; but with the increased utilization of CT scanning with reconstructions in the evaluation of suspected spine trauma patients, an increased incidence has been noted. It has been reported to occur in 3-15% of trauma patients. Presence of these fractures indicate high injury trauma.

Occipital condyle fractures may be stable or represent the bony component of occipitocervical dissociation.

Montesano classified these fractures into three categories. Read more

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