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26 Cervical Tong Extension andtheHalo Fixator
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• Tighten the permanent screws by hand and subsequently
tighten them further using a torque screwdriver. Tighten
the diagonally opposing screws successively and simultaneously; this avoids pins from drifting and ensures greater
stability.
• Remove the positioning pins and apply the lock nuts.
These should be nger-tightened.
• Lastly, attach the halo ring to the vest or body cast,
or apply an extension device (see Figs. 26.7 and
26.8)[17].
26.4.3 Post-Operative Care
The following are part of the post-operative care
• Daily cleaning of screw sites.
• Regular clinical observation of the patient’s neurological
status.
• A slow increase in distraction at the adjustable brace
parts.
• A lateral radiograph of the cervical spine after application
of the halo xator, as well as during the treatment
process.
• Modifying items of clothing to accommodate the brace; a
larger clothing size may be required such that the neck
opening is large enough to t over the brace.
• Re-torqueing screws after 24h, 3–4days and then weekly
until the halo is removed. This is because screws will
loosen with time.
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Fig. 26.7 The complete Halo xator
26.4.4 Removal oftheHalo System
Patients must typically wear their halo for 12weeks depending on the treatment. Upon removal of the halo system,
patients are required to wear a collar for a period of weeks.
Removal of the system is accompanied by an adjustment and
balancing period, similar to when the halo was rst applied.
Since the neck has been held inactive for the treatment duration, patients may experience aching of the neck, back, and
shoulders.
26.4.5 Complications ofHalo Fixator
Complications are minor and include pin loosening, localized infections, periorbital oedema, supercial pressure
sores, and unsightly scars. Major complications may include
pin penetration, osteomyelitis, subdural abscesses, nerve
palsies, fracture overdistraction, and persistent instability.
However, complications can be well avoided by carefully
placing the pins during the procedure, as well as participat-
Fig. 26.8 Halo extension for the postoperative correction of a thoraco-
lumbar scoliosis in standing position
ing in thorough post-operative care at the pin sites. In elderly
patients, respiratory distress and other more life-threatening
complications have been reported at a more concerning rate
[5, 13, 19, 20].
188
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U. Vieweg et al.
References
1. Krag MH, Beynnon BD. A new halo-vest: rationale, design and
biomechanical comparison to standard halo-vest designs. Spine.
1988;13:228–35.
2. Gardner WJ. The principle of spring-loading points for cervical
traction: technical note. J Neurosurg. 1973;39:543–4.
3. Saleh H, Yohe N, Razi A, etal. Efcacy and complications of the
use of Gardner-Wells tongs: a systematic review. J Spine Surg.
2018;4:123–9.
4. Perry J, Nickel VL.Total cervical-spine fusion for neck paralysis. J
Bone Joint Surg Am. 1959;41:37–60.
5. Bono CM. The halo xateur. J Am Acad Orthop Surg.
2007;15:728–37.
6. Grundy DJ. Skull traction and its complications. Injury.
1983;15:173–7.
7. Lopes A, Andrade A, Silva I, etal. Brain abscess after halo xation
for cervical spine. World Neurosurg. 2017;104:1047.e7–11.
8. Majercik S, Tashijan RZ, Bif WL, etal. Halo vest immobilization
in the elderly: a death sentence? J Trauma. 2005;59:350–6.
9. Glaser JA, Whitehill R, Stamp WG, Jane JA.Complications associated with the halo-vest. A review of 245 cases. J Neurosurg.
1986;65:762–9.
10. Loeser JD.History of skeletal traction in the treatment of cervical
spine injuries. J Neurosurg. 1970;33:54–9.
11. Püschel K, Lignitz E, Saukko P, et al. Iatrogenic complications
of extension treatment of injuries of the cervical vertebrae using
Crutcheld tongs. Unfallchirurg. 1986;89:42–6. [In German].
12. Schulze W, Esenwein SA, Müller EJ, etal. Complications in the use
of the halo xator. Zentralbl Neurochir. 2001;62:2–9. [In German].
13. Anderson PA, Budorick TE, Easton KB, et al. Failure of halo
vest to prevent invivo motion with injured cervical spines. Spine.
1991;16:501–5.
14. Blauth M, Lange UF, Knop C, Bastian L.Spinal fractures in the
elderly and their treatment. Orthopade. 2000;29:302–17. [In
German].
15. Barsoum WK, Mayerson J, Bell GR.Cranial nerve palsy as a complication of operative traction. Spine. 1999;24:585–6.
16. Fraunhoffer M.Transverse syndrome following extension of a dislocation of the cervical spine with a Crutcheld bracket. Aktuelle
Traumatol. 1986;16:164–6. [In German].
17. Schmolke S, Gosse F.The halo-xateur. Oper Orthop Traumatol.
2008;20:3–12. [In German].
18. Ballock RT, Lee TQ, Triggs KJ, et al. The effect of pin location on the rigidity of the halo pin bone interface. Neurosurgery.
1990;26:238–41.
19. Garn SR, Botte MJ, Waters RL, Nickel VL. Complications
in the use of the halo xation device. J Bone Joint Surg Am.
1989;68:320–5.
20. Hähnel H, Zippel H. Experiences with the external xation
of the cervical spine with the Halo-Yoke-System. Z Orthop.
1986;124:299–308. [In German].
Suggested Reading
Copley LA, Pepe MD, Tan V, et al. A comparison of various
angles of halo pin insertion in an immature skull model. Spine.
1999;24:1777–80.
Hayes VM, Silber JS, Siddiqi FM, etal. Complications of halo xation
of the cervical spine. Am J Orthop (Belle Mead NJ). 2005;34:271–6.
Nickel VL, etal. The halo. A spinal skeletal traction xation device. J
Bone Joint Surg Am. 1969;50:1400–9.
Papagelopoulos PJ, etal. Halo pin intracranial penetration and epidural
abscess in a patient with a previous cranioplasty: case report and
review of the literature. Spine. 2001;26:463–7.
Prothmann KH, etal. An interesting case: inammatory cerebral compli-
cations after Crutcheld-extension. Zentralbl Chir. 1989;114:1025–
30. [In German].
Rinella A, Lenke L, Whitaker C, et al. Perioperative halo-gravity
traction in the treatment of severe scoliosis and kyphosis. Spine.
2001;30:475–82.
Strohm PC, Muller CHA, Kostler W, et al. Halo xator vest—indi-
cations and complications. Zentralbl Chir. 2007;132:54–9. [In
German].
Vieweg U, Schultheiss R.A review of halo vest treatment of upper cer-
vical spine injuries. Arch Orthop Trauma Surg. 2001;121:50–5.
Voor MJ, Khalily C. Halo pin loosening: a biomechanical com-
parison of experimental and conventional designs. J Biomech.
1998;31:397–400.
Weigel K, Wilms H. Cranial complications in extension therapy of
cervical fractures. Riechert's modication of extension therapy.
Chirurg. 1978;49:374–6. [In German].
Part III
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Anterior Cervical Spine
Overview ofSurgical Techniques
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andImplants
TobiasPitzen, JörgDrumm, GregorOstrowski,
andMichaelRuf
27.1 Introduction and Core Message
This is a short overview on different techniques and
implants for anterior decompression and xation for
the cervical spine. Degenerative disc diseases, ossications of the posterior longitudinal ligament, vertebral
body tumours, spondylodiscitis, and vertebral body
compression fractures are amongst the most frequent
cervical spine pathologies a spine surgeon has to deal
with. All these are located within the anterior aspect of
the cervical spine—which are the vertebral bodies and
the discs. Thus, anterior cervical spine techniques as
anterior decompression, xation, and anterior possibilities of realignment are amongst the most popular
and necessary ones within the armamentarium of a
spine surgeon. Within this chapter, we will give a very
short overview on different techniques for anterior
decompression, xation, and realignment within the
cervical spine. Moreover, different anterior implants
for dynamic and permanent osseous xation, distributed by different companies are presented.
27
incision usually crosses the midline by 1cm and reaches the
medial edge of the sternocleidomastoid muscle. The incision
should be placed above the centre of the lesion. An oblique
incision is preferred by the authors, by careful subcutaneous/
subfascial spreading even three or more segments can be
reached. Once the supercial layer of the fascia has been split,
the approach is medial to the sternocleidomastoid muscle, cranial or caudal to the omohyoid muscle and medial to the
carotid artery to the anterior aspect of the spine that is reached
between the left and right longus colli muscle. Self- holding
sharp retractors are placed under the longus colli muscles,
blunt retractors are used to spread the wound in cranio-caudal
direction. A longitudinal incision is used, if the cervicothoracic junction has to be exposed. Now, the incision starts at the
medial aspect of the caudal part of the sternocleidomastoid
muscle and reaches the manubrium at its midline and is elongated 4–5cm to its caudal aspect. Using blunt dissection, the
soft tissue at the backside of the manubrium is detached and
the manubrium is split using a chisel or saw. If unfamiliar, ask
a thoracic surgeon for help. To the authors’ opinion and experience, percutaneous and endoscopic approaches do not have
any importance for anterior cervical spine surgery.
27.2 Approaches
The standard approach for anterior cervical spine C3–C7/T1
procedure is an antero-lateral approach as described by
Cloward. Description here is slightly modied according to
the authors experience and spreaders used. Take care, that the
T. Pitzen (*)
Center for Spine Surgery, Orthopedics, and Traumatology, SRH
Klinikum Karlsbad-Langensteinbach, Karlsbad, Germany
e-mail: tobias.pitzen@wkg.srh.de
J. Drumm · G. Ostrowski · M. Ruf
Center for Spine Surgery, SRH Klinikum KarlsbadLangensteinbach, Karlsbad, Germany
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_27
27.2.1 Tips andTricks
1. Preferred side of the approach—there has been a long
debate about this aspect. However, just two aspects dictate the side of the approach. (1) If there is a RLN palsy,
choose the side of the palsy for approach. (2) If surgery is
due to a tumour with extravertebral soft tissue mass,
chose this side for approach.
2. To prevent RLN palsy, ask the anaesthetist to reduce cuff
pressure after nal placing of your retractors. This will
reduce both dysphagia and incidence of RLN palsy.
3. If the patient had a surgical procedure at the anterior
aspect of the spine before, check for RLN palsy. This is
usually performed in the best way by laryngoscopy.
Hoarseness must not be clinically evident!
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27.3 Techniques forDecompression
27.3.1 Uncoforaminotomy
This is a technique that may be used for anterior lateral
decompression within the cervical spine for the indication of
soft disc prolapse or spondylosis that compress a root. The
main advantage is that the main parts of the disc are spared,
range of motion is probably not affected signicantly, no
implants are necessary. However, the technique is not very
easy to learn and take care of the vertebral artery that is
pretty close to your high speed drill.
27.3.2 Discectomy
The technique of cervical spine discectomy is the basic one
for anterior cervical spine decompression. No matter, if a one
or more level discectomy or a one or more level vertebral
body resection, you usually start by performing a cervical
spine discectomy via anterior approach. Following anterior
approach and placing of the retractor and spreading system,
the anterior longitudinal ligament must be incised and
removed with the disc by means of curettes and rongeurs.
The authors prefer to remove the lateral aspects of the disc
towards the uncus using a 4mm Kerrison (Take care: the vertebral artery is very close here!) and to remove the anterior
rim of the superior vertebra using a size 4 Kerrison. The bone
chips taken this way are used to ll a cage. A cylindrical burr
may be used to perform a rectangular shape of the disc space;
a round burr is used to remove posterior osteophytes in the
presence of an intact posterior ligament (Fig. 27.1).
Alternatively, these spurs may be removed after resection of
the posterior longitudinal ligament. Again, these bone chips
may or even should be taken to ll a cervical spine fusion
cage. When the disc is removed, you may try to recline the
head and thus the c-spine by changing the position of the
patient’s neck and head on the head–neck rest. This is an
important step for anterior realignment.
27.3.2.1 Tips andTricks
1. The dura should be exposed, where its encroachment is
less pronounced. This may reduce the risk of thecal sac
perforation and chord contusion. However, in the presence of a free disc fragment (sequester), remove this rst!
Usually, the dura is apparent after this manoeuver.
2. In case of far lateral osteophyte, compressing the root, an
uncoforaminotomy may be necessary. To do this, check
the course of the vessel before surgery starts. Start surgery as usual, decompress the root. Place a cottonoid
T. Pitzen et al.
Fig. 27.1 Lateral x-ray intraoperatively. A round burr is used to
remove posterior osteophtyes
upon the root, then remove the anterior wall of the
transverse foramen. Localize the vessel, place a peneld N 2 medial to the vessel to protect it. Then remove
the uncus using a small chisel, take the fragment out.
The cottonoid will protect the root during this manoeuver. Figure27.2 is an example of a coronal CAT scan
reconstruction following a left-sided uncoforaminotomy combined with cage insertion and anterior
plating.
27.4 Vertebral Body Resection
Before a vertebral body resection is performed, all discs
adjacent to the vertebral body should be removed as
described above. The thecal sac should be exposed within
27 Overview ofSurgical Techniques andImplants
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Fig. 27.2 Coronal CAT scan reconstruction following a left-sided
uncoforaminotomy combined with cage insertion and anterior plating
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Fig. 27.3 Transverse CAT scan through a vertebral body with a VA
looped into the vertebral body
the segment where spinal encroachment is least. Vertebral
body resection starts using big size rongeurs. Again, the
bone is taken to ll a cage. 8mm of the vertebral body at
each side of the midline are removed for median resection
of a vertebral body—which is sufcient for placing a cage
for vertebral body replacement. Use sharp drills to remove
the posterior cortical shell down to the soft parts of the posterior longitudinal ligament. Resection of this may be performed nally using a size 2 Kerrison; the cuts are
performed at the most lateral parts of the ligament. Finally,
the ligament may be removed en bloc.
27.4.1 Tips andTricks
1. Bone from the vertebral body resection—except in
tumour and spondylitis cases—is ideal to ll into a VBR
cage. Do so, do not use iliac crest in such cases.
2. Severe bleedings from venous vessels during VBR procedures are best controlled using a 5–6mm diameter
diamond burr on a high speed drill. Do not irrigate (!)
until it gets dusty and dry. Bleeding has stopped usually, then ask for irrigation. This is better than the use
of bone wax, which will contaminate your local bone
graft.
3. Arterial bleeding from the midline (!) indicates that you
are close to the thecal sac, upon the cortical shell or
PLL.Take even more care now!
4. In some cases, the VA may be looped into the vertebral
body. Figure27.3 shows such a rare case. Be sure, before
VBR, that this is not the case!
27.5 Spondylectomy
The term Spondylectomy is derived from the greek words
“Spondylos—vertebra” and “tomi—cut” and therefore means
a complete removal of the vertebra. This is usually indicated
in case of primary bone tumours or single metastasis. Usually,
spondylectomy rst requires a complete removal of the posterior structures. Via anterior approach, the discs are excised
and lateral circumferential dissection is performed until the
vertebra can be removed “en bloc”. Due to the relationship of
both VA to the cervical spine, a classic en bloc removal as
known from the thoracic or lumbar spine is not possible at the
cervical level. If, however, radical removal is necessary
between C1 and C6, it must be planned using VA occlusion
tests, VA unilateral resection, or bypass procedures. Ask radiologists, vascular surgeons, and even more experienced spine
surgeons for help. At the level of C7/T1, the VA are usually
outside the spine (Fig.27.4). Thus, a spondylectomy may be
performed here in a two stage procedure: rst remove the
posterior parts, then the vertebral body en bloc. Figure27.5 is
an example of this. Figure27.6 shows the sagittal MRI of the
lesion before surgery, Fig. 27.7 the lateral x-ray after
surgery.
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Fig. 27.4 Coronal CAT scan
reconstruction of a patient
with a C7 metastasis of a
tonsillar carcinoma. At the
level of C7, the VA are
usually outside the spine
T. Pitzen et al.
Fig. 27.5 Vertebral body C7—case from Fig.27.4—removed en bloc
27.6 Techniques forInterbody Fixation
27.6.1 Cages
Cages are amongst the most successful implants within
spine surgery and especially within cervical spine surgery
within the last years. Obviously, these implants helped to
solve and eliminate the problem of graft site morbidity,
which was mainly not only a problem of long lasting donor
site pain. Cages usually consist of titanium, PEEK, or car-
bon bre composite or the later ones with titanium spray
covering to promote bony ingrowth. They usually have one
or more perforations to allow bony ingrowth for long term
stability and teeth/ns or similar for secure xation after
insertion until bony ingrowth is completed. It is believed
that cages made from titanium have a greater tendency for
settling, but the main disadvantage of these is that bony
fusion is difcult to judge via x-ray or CAT scan and visualisation of soft tissue (tumour cases) is difcult if not
impossible via MRI.Cages can be used to replace one single
or more discs or to replace one or even more vertebral bodies. The function of cages may be described as follows: (1)
Disc replacement, (2) Restoration of normal disc height, (3)
Induction of bony fusion, (4). Stabilisation of the segment.
This function is even more pronounced in cages, combined
with anterior screws to be xed within the vertebral bodies.
There is a huge variety of cages available; Table27.1 gives
a short overview on cervical cages for disc replacement.
Although the authors do not recommend (too expensive, too
technical), they would like to mention cages for vertebral
body replacement that include mechanisms to distract.
There are some cages available with inclined endplates, thus
giving the possibility to create some lordosis to the
surgeon.
27.6.2 Disc Prostheses
Disc prostheses have been introduced into surgical treatment
of the degenerative disc disease of the lumbar spine as early
27 Overview ofSurgical Techniques andImplants
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195
Fig. 27.6 Sagittal MRI of the lesion—case from Figs.27.4 and 27.5—
before surgery
as in 1960s, but disappeared from the market due to major
problems until they had a second peak in the early 2000.
Within the cervical spine, they became more popular when
Hilibrand in 1999 reported that more than 25.6% of all
patients having received an ACDF will receive an adjacent
level disease within 10years. Today, these values are known
to be probably overestimated, but meanwhile cervical disc
prostheses became a popular—and efcient—tool to deal
with the problem of degenerative disc disease within the cervical spine. Initially, the clinical results are good and there
has been some evidence that segmental motility may be preserved at least for a certain time. If, however, disc prosthesis
will reduce the problem of ALD or if this is a natural history
is still unclear. There are more and more data that genetics
are the key point for ALD.Moreover, we face another problem in cervical spine disc replacement using prosthesis, that
is heterotopic ossication. The problem of revision surgery,
Fig. 27.7 Lateral x-ray after surgery, case from Figs.27.4, 27.5, and
27.6
however, is not as pronounced as it is (no big vessels) within
the lumbar spine.
Twenty years after initial insertions of cTDR, it must be
noted that there is currently no evidence that these implants
produce a better outcome than ACDF or signicantly reduce
ALD.
Table 27.2 gives an overview of current implants designed
and distributed by several companies.
27.6.3 Anterior Cervical Plating
Anterior cervical plating has been introduced into routine
cervical spine surgery by Caspar in the 1980s to reduce graftrelated complications. In fact, there is some evidence that
anterior cervical plating may reduce complications such as
graft compression fracture, graft dislocation, or pseudarthrosis healing. Every anterior cervical plate will add stability to
a cervical spine segment in exion—extension, axial rotation and lateral bending. However, complications such as
screw loosening or even plate loosening as a consequence of
screw loosening occurred in the presence of this plate. Thus,
more recently, plating concepts in which the screws are connected to the plate—thus secured against screw back-out—
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Table 27.1 Cages for cervical disc replacement distributed by different companies
Solis Cage (Stryker) Cervios (Synthes)
PEEK
Syncage-C (Synthes) Afnity (Medtronic)
Titanium
Cornerstone (Medtronic) Bengal (Depuy)
Other
Table 27.2 Cervical disc prosthesis distributed by different companies
activ C (Aesculap) Prodisc C (Synthes) Discover (DePuy) Neo Disc e (NuVasiv)
T. Pitzen et al.
• Ball and socket • Ball and socket Ball and socket Elastomer core
• Fixed post.COR • Fixed central COR
• Motion limitation • Forced translation
have been developed. Amongst these, rigid plate designs and
dynamic plate designs will be discussed a little more in detail
here: Rigid Plates do not allow any screw motility within the
plate. Thus, they are believed to give more stability, especially in trauma cases. There is, however, some evidence that
this is not the case. Loading of the interbody cage or graft is
less pronounced when compared to dynamic plates. Dynamic
plates allow some screw motility within the plate, with the
consequence of graft or cage loading, thus resulting in higher
speed of fusion and lower incidence of implant complications. Semiconstrained or semirigid or semidynamic plates
are located—concerning the implant mechanics—some-
where in between the mechanism of these two poles. There
seems to be some evidence that dynamic plates reduce the
rate of implant complications and have a tendency to a more
rapid fusion when compared to rigid plates. On the other
hand, rigid plates reduce the loss of height and lordosis after
surgery when compared to dynamic ones. Clinical results are
comparable or equal. Usually, plates are prebend to give
some lordosis to the segments treated. In some models, the
bending may be reduced or increased to adapt to the individual lordosis.
Table 27.3 gives a short overview on different implants,
supplied by different companies.
27 Overview ofSurgical Techniques andImplants
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Table 27.3 Different implants for anterior cervical plates distributed by different companies
Aesculap Synthes Medtronic DePuy
Dynamic
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Semi- constrained
Constrained
Hybrid
ABC
Caspar
Vectra T
CSLP variable angle
CSLP
Vectra
ACCS
Premier
Swift
Eagle Slim Loc Uniplate
Venture/Zephir
Atlantis
Skyline
Atlantis
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enhances arthrodesis following discectomy and fusion with cortical
allograft. Neurosurgery. 2002;50(2):229–36.
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