E-Book, Englisch, 464 Seiten, ePub
Bauer / Kerschbaumer / Poisel Atlas of Spinal Operations
1. Auflage 1993
ISBN: 978-3-13-257935-4
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark
E-Book, Englisch, 464 Seiten, ePub
ISBN: 978-3-13-257935-4
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark
R. Bauer, F. Kerschbaumer, S. Poisel
Zielgruppe
Ärzte
Fachgebiete
Weitere Infos & Material
1 Approaches
2 Scoliosis
3 Kyphosis
4 Ankylosing Spondylitis
5 Fusion of the Cervical Spine
6 Fusion of the Lumbar Spine
7 Spondylolisthesis
8 Neurosurgical Operations
9 Rheumatoid Instability
10 Spondylitis
11 Tumors of the Spine
12 Tumors of the Chest Wall
13 Deformities of the Chest Wall
14 Torticollis
2 Scoliosis
R. Bauer
Halo Traction Techniques
Indication
As a general rule, a halo cast or halo vest may be used for stabilization, especially of the cervical spine. The halo technique can also be used in various ways (halo–gravity traction, halo–wheelchair traction, halo–pelvic traction) to correct spinal deformities. The effectiveness of halo traction in the preoperative correction of scoliosis is a matter of controversy. An important indication for these techniques is the correction of spinal deformities between operative sessions, e.g., after a mobilizing spinal osteotomy.
Operative Technique
Application of Halo
(Fig. 2.1)
The halo is applied either under local anesthesia or under general anesthesia (the latter particularly if surgery is to be performed afterwards). The patient is placed in a supine position, with the head extending over the edge of the table. The head is either held by an assistant, or the occiput is placed on a narrow metal support. Before application of the halo ring, the patient’s hair is shampooed for some time with disinfectant soap. When the pins are applied to the selected sites, the hair is merely retracted; shaving, even of small areas, is unnecessary.
Fig. 2.1 Halo ring with pins.
A halo ring of suitable size is chosen; the distance from the head should be approximately 1 cm, and not more than 2 cm (Fig. 2.2). The halo ring is positioned 1-2 cm above the ear or eyebrow. Appropriate holes in the ring are selected for positioning of the pins: the posterior pins should be placed at about the 5-o’clock and 7-o’clock positions, and the anterior pins over the lateral two-thirds of the eyebrows (Fig. 2.7). In this position, injury to the supraorbital nerve or penetration of the frontal sinus is avoided. The pins are applied under sterile conditions. It may be easier to apply them by using so-called positioning templates (one on the forehead and two posterolaterally, Fig. 2.2). The pins are then attached, using a torque screwdriver, without prior skin incision, either under local anesthesia following infiltration, or under general anesthesia. It is important that the ring should not be displaced during fixation of the pins. Two pins each are applied diagonally and are then slowly tightened simultaneously until the screw tip, after piercing the skin, penetrates the outer cortical substance. The pins are then alternately tightened until a torque of about 6 inch-pounds (ca. 0.7 newton meters) is reached. Finally, the pins are locked with a small screwplate. Additionally, pulleys are applied, as well as the extension set-up.
In the event of screw infection, local pin care and, possibly, the use of antibiotics based on antibiotic sensitivity testing are required. If the infection should not cease, the pin has to be reapplied at a different site.
Repeated tightening of the screws may lead to penetration of the internal table of the cranial bone. This is manifested by a sudden loss of pressure under the torque screwdriver. If this happens, the pin has to be removed and reapplied at a different site.
Fig. 2.2 The halo ring is temporarily stabilized with positioning plates; the pins are inserted into the tabula externa of the skull bone (see inset) with a torque screwdriver.
Fig. 2.3 Halo–femoral traction.
Halo–Femoral Traction
This involves a combination of halo traction with supracondylarly placed Steinmann nails (Fig. 2.3). This is a very effective method of traction for the correction of scoliosis and kyphosis. In this technique, continuous traction of between 20 and a maximum of 25 kg, depending on body weight, is performed, generally for a period of two to three weeks. To avoid skin complications, the patient is placed in a rotary bed and turned at least twice a day. Complete immobilization of the patient and marked loss of friction on the support are significant drawbacks.
Halo–Gravity Traction in a Wheelchair
(Fig. 2.4)
The patient is kept in traction against gravity in a wheelchair. In adults, traction is generally started with about 5 kg, and increased daily by 0.5–1 kg. The upper limit is 10–15 kg in adults, and correspondingly less in children.
This form of traction is particularly suitable for high thoracic curvatures. In the presence of more caudally situated curvatures, the effect is considerably diminished by an increase in the partial weight of the upper part of the body above the curvature. During the night, patients are maintained in traction in a tilted bed.
Fig. 2.4 Halo–gravity traction in a wheelchair.
Halo–Pelvic Traction
The equipment consists of the following parts:
– Cranial halo
– Pelvic ring
– Pelvic pins and anchors
– Threaded rods connecting the cranial halo to the pelvic ring
Fig. 2.5 Insertion of the pelvic rod with the aid of a drill jig.
Fig. 2.6 Correct position of pelvic rods in transverse section.
Adjustment of the Halo–Pelvic Apparatus
To begin with, the cranial halo is applied in the usual way. For application of the pelvic rods, the patient is placed in a semilateral position; the upper half of the pelvis is prepared for surgery and draped. To avoid misplacement, which might involve dangerous complications, a drill guide is supplied with the original instrumentation. It is advisable to use a hand drill. The following points are identified for orientation (Figs. 2.5, 2.6):
The anterior site, for insertion of the pelvic rod, is at the iliac crest in the region of the iliac tubercle, about 5 cm more proximal and posterior than the anterior superior iliac spine; the latter must never be used as the entry site for the nail, as dangerous complications may ensue. A stab incision is made at this point.
The exit site is the posterior superior iliac spine on the same side; here, too, a stab incision is made. The tips of the telescopically adjustable drill guide are introduced into the two incisions and anchored in the bone by compression. After this, the drill guide is locked in. While drilling, care should be taken to ensure that the pelvic pin does not slip down the inside of the iliac bone; further drilling would then cause the peritoneum to be wound around the drill, as shown by visible retraction of the abdominal wall. If there is any doubt, it is advisable to make a small incision above the iliac crest and to palpate the iliac fossa with the finger.
Once the pelvic pin has been fixed on one side, the patient is similarly placed in the contralateral position, and the second pin is inserted. The patient is then shifted to the supine position; the pelvic ring is pulled up over the legs and attached to the pelvic pins.
Fig. 2.7 Halo–pelvic apparatus after assembly.
The rods joining the skull ring to the pelvic part are put in place when the patient has recovered from the anesthesia and is able to sit again (Fig. 2.7).
Postoperative Treatment
In order to avert complications, or to detect them at an early stage, the following guidelines should be followed:
– Regular care of screw and pin entry sites
– Regular clinical observation of the patient
– Slow increase in distraction
– Lateral X-rays of the cervical spine
– Daily neurologic assessment with reference to a check list (Table 2.1).
In the event of neurologic deficits, the traction should be reduced at once. The chances for remission improve with prompt release of the traction.
Table 2.1 Checklist for skeletal traction
| Questions | Tests |
|---|
| Spine | – Weakness of legs? – Numbness of legs? – Urinary incontinence? | – Wiggling of toes – Ankleandkneeclonus |
| Cranial nerves (tests VI, IX, X, XII) | – Double images? – Difficulty swallowing? – Difficulty coughing? – Voice alterations? – Weakness of tongue? | – Eye movements (VI) – Palatal reflex (IX) – Vigorous coughing (X) – Ability to speak, nasal voice (IX or X) – Tongue extended to middle position (XII) |
| Upper extremities | – Difficulty with hand, shoulder or arm movements? – Numbness or weakness of hands? | – Abduction of shoulder joints (C5, C6) – Flexion of forearm (C5, C6) – Test hand pressure (C7–T1) – Sensibility test at finger tips (C6–C8) |
Pitfalls and Complications
Perforation by halo screws, brain abscess, pin infection, infection of pelvic pins, secondary degenerative changes in the cervical...
