Use of a Noninvasive Halo in Pediatric Spine Surgery (2003)

A halo vest with pins in the skull is the gold standard for providing maximum immobilization and control of the cervical spine. Inherent complications include infection, scarring, penetration of the cranial vault, and pin loosening. Other less invasive orthoses provide significantly less immobilization and control of the cervical spine. A pinless halo (Figures 1–4) has been developed with the goal of providing cervical spine immobilization and control approaching the standard halo in a less invasive fashion. This noninvasive halo holds the head with pads on the forehead and occiput connected through a universal joint to an adjustable vest. This study evaluates the use of this device in the management of a variety of pediatric cervical spine disorders.Figure 1: Anterior view rotated and laterally flexed.Figure 2: Posterior view.Figure 3: Oblique view.Figure 4: Anterior rotated view.MATERIALS AND METHODS Twelve patients with a variety of pediatric cervical spine disorders have been treated at our institution with the Lerman Noninvasive Halo since 1997. A retrospective chart review was performed to determine the effectiveness of the halo and its complications. The age of the patients, underlying conditions, surgical procedures, duration in the halo, and complications directly related to the halo were recorded. The use of the halo was considered a success if the patient tolerated its use for the duration of the planned therapy with the desired effect. RESULTS Twelve patients ages 2 to 16 years were treated with the noninvasive halo (Table 1). One patient initially failed treatment with a standard halo after pin site loosening and skin necrosis and was successfully transitioned to the noninvasive halo. There were compliance issues with this patient because the family removed the noninvasive halo vest without consequence. Complications directly related to the brace were seen in 3 of the 12 patients. Two patients experienced facial swelling and skin breakdown early in their course of treatment and were converted to a standard halo. Both of these patients were under 4 years of age. Another patient was immobilized postoperatively after anterior-posterior cervical fusion with anterior strut graft. The graft migrated anteriorly, which was thought to be the result of motion in the sagittal plane. The remaining 9 patients experienced no complications related to the halo. Treatment was considered a success in eight of these patients.Table 1: Patients placed in noninvasive haloDISCUSSION The noninvasive halo successfully controlled rotation and lateral bending of the cervical spine. It was quite successful in positioning the head and neck of patients with congenital muscular torticollis after sternocleidomastoid release, and in the gentle and safe reduction of C1–C2 rotatory subluxation. Use of the noninvasive halo for small children under 4 years of age led to facial soft tissue problems in 2 of 4 children. We do not recommend the noninvasive halo after structurally unstable cervical fusion, because an anterior strut graft migrated in one child. We suspect that the migration was secondary to flexion/extension motion greater than that permitted in a standard halo. The noninvasive halo has also been well tolerated after cervical spine fusion with stable constructs for a variety of conditions. INDICATIONS Positioning of structurally stable fusion. Salvage after complications of standard halo immobilization. Postoperative positioning following sternocleidomastoid release for congenital muscular torticollis. Reduction of C1–C2 rotatory subluxation. CONTRAINDICATIONS Immobilization of structurally unstable cervical spine.