The treatment of type-II traumatic spondylolisthesis of C2 remains controversial. We reviewed the outcome of 16 patients treated between 2001 and 2003. As classified by Levine and Edwards, 14 patients sustained type-II fractures and two type-I injuries. There were no type-III injuries. All except one patient, who was injured playing rugby, were injured in motor vehicle accidents (four drivers, 10 passengers and one pedestrian). Eight patients had associated injuries. Thirteen patients were managed by means of a halo body jacket within 2 weeks of presentation for 5 to 9 weeks. One patient with a type-II injury was treated in an ABCO brace and those with type-I injuries in a Philadelphia collar. All patients showed evidence of radiological union within 12 weeks (mean 7.5 weeks). Flexion/extension views revealed no instability. All patients regained full flexion and extension clinically, but five had some limitation of rotation. One patient removed the halo body jacket himself. There were no pin-tract or neurological complications. Mean follow-up time was 13.5 months (3 to 27). Four patients exhibited late disc space changes at C2/3 on radiographs. Early patient mobilisation in a halo body jacket is an effective and safe management option for type-II C2 traumatic spondylolisthesis

Introduction: A high incidence of pin loosening, infection and discomfort as well as pressure ulceration from the jacket were noted in a study performed in 1986. 1. we aimed to compare our figures with published literature. Methods: A retrospective case note review (1994–2004). One investigator reviewed the case notes and corroborated these with a spinal database, theatre database and microbiology results system. Results: 74 halos were applied in the 10-year period. A complete dataset was obtained for 37 patients (others had been destroyed either entirely or relevant volumes). Age range was 22–83 years (median 49), 20 males and 17 females. 28 were applied under local anaesthetic (LA), one with LA and sedation and 8 were applied under general anaesthetic (either for another trauma procedure or due to head injury). All halos applied were Bremer Halo Crown with Classic or Classic II vest (DePuy Spine, Warsaw, IN, USA). Indications for application included fractures (n=21), tumours (n=6) or subluxations (n=10). 8 patients required pin repositioning. This was due to poor position (n=2), pain (n=5) and pin loosening (n=1, 3%). Pin site infection was diagnosed using an accepted definition. 2. This occurred in 5 patients. 3 settled with antibiotics, one with debridement and one with repositioning. Overall infection rate was 13.5%, which compares favourably with published rates of 20–22%. Pin site infection dropped significantly after introduction of a pin care regimen introduced and published by our limb reconstruction team. 2. from three patients to one patient. Pin torque was also checked daily for seven days followed by weekly thereafter. The halo vest was a cause of significant morbidity in terms of pressure ulceration (3 patients) pneumonia (3 ventilated ITU patients of whom 2 died) and pain in one patient. Conclusion: Our pin loosening rate was significantly lower than published figures, which we ascribe to regular torque checking and use of a 0.90 Nm torque wrench. 3. Our pin site infection rate dropped significantly after use of our limb reconstruction teams pin care regimen. We now utilise this regimen in all halo patients with good effect. A prospective study is ongoing

Introduction: A high incidence of pin loosening, infection and discomfort as well as pressure ulceration from the jacket were noted in a study performed in 1986. 1. we aimed to compare our figures with published literature. Methods: A retrospective case note review (1994–2004). One investigator reviewed the casenotes and corroborated these with a spinal database, theatre database and microbiology results system. Results: 74 halos were applied in the 10-year period. A complete dataset was obtained for 37 patients (others had been destroyed either entirely or relevant volumes). Age range was 22–83 years (median 49), 20 males and 17 females. 28 were applied under local anaesthetic (LA), one with LA and sedation and 8 were applied under general anaesthetic (either for another trauma procedure or due to head injury). All halos applied were Bremer Halo Crown with Classic or Classic II vest (DePuy Spine, Warsaw, IN, USA). Indications for application included fractures (n=21), tumours (n=6) or subluxations (n=10). 8 patients required pin repositioning. This was due to poor position (n=2), pain (n=5) and pin loosening (n=1, 3%). Pin site infection was diagnosed using an accepted definition2. This occurred in 5 patients. 3 settled with antibiotics, one with debridement and one with repositioning. Overall infection rate was 13.5%, which compares favourably with published rates of 20–22%. Pin site infection dropped significantly after introduction of a pin care regimen introduced and published by our limb reconstruction team. 2. from three patients to one patient. Pin torque was also checked daily for seven days followed by weekly thereafter. The halo vest was a cause of significant morbidity in terms of pressure ulceration (3 patients) pneumonia (3 ventilated ITU patients of whom 2 died) and pain in one patient. Conclusion: Our pin loosening rate was significantly lower than published figures, which we ascribe to regular torque checking and use of a 0.90 Nm torque wrench. 3. . Our pin site infection rate dropped significantly after use of our limb reconstruction teams pin care regimen. We now utilise this regimen in all halo patients with good effect. A prospective study is ongoing

Introduction. Halo traction, either on bed or with an accompanying vest is used commonly in Spine surgery, in a variety of clinical situations. The pins are inserted into the skull in safe anatomic zones, using wrenches that are either pre-torqued or exhibit a torque gauge to allow measurable torque application. A torque of 6 – 8 inch pounds is considered ideal for optimal pin tightening. Lesser torques may hypothetically lead to pin loosening and pin track infections, while, excessive torques could lead to pin penetration through the skull. Aim. To test the accuracy and consistency of different torque wrenches used for Halo pin insertion, using a standardised calibration device. Methodology. Three different types of torque wrenches were tested, using the MTS Systems 858 Mini Bionix II calibration device at the School of Engineering laboratory in Cardiff. Each type had four samples. Three more samples of one type, which were already in use at the Spine unit were also tested, making a total sample size of fifteen. The calibration device had a declared average error of 0.5 %. Each torque wrench was tested twenty five times to a pre set value of 6 inch pounds (0.67790897 N-m), resulting in 375 independent observations. Data was recorded electronically and was analysed for error, percentage of error and variability for each device. Results. All wrenches, regardless of model or make, failed to deliver accurate torque at the pre set value on repeated testing. There were both negative and positive errors. The average torque delivered by all wrenches together at a pre set value of 0.67790897 N-m was 0.721337 (+/- 0.116919) N-m. The average percent error for individual wrenches ranged from 4 % to 34 %. When grouped by model, the average percent error (model specific) ranged from 5 % to 29 %. When assessed for consistency, the wrenches revealed a range of values over a minimum of 0.053303 N-m to a maximum of 0.846512 N-m. The variability of all wrenches of one model type was however similar, though not identical. The best performing model had an average variation over 0.165531 N-m while the value for the worst was 0.685794 N-m. Conclusion. Torque wrenches used to tighten Halo pins appear to be neither accurate nor consistent. They deliver torques that are either less than or more than their pre set levels. Different wrenches of one model displayed a similar pattern of variability. While this study does not seek to relate this lack of accuracy and consistency to the development of specific complications like loosening or penetration, it does suggest that extreme care is advisable while using torque wrenches to minimise clinical mishaps

Background: Since high incidences of serious complications like death and pneumonia during halo vest immobilization (HVI) have been reported in recent literature, a tendency of restraint in using the halo vest is rising. Nevertheless, most of these studies were small-scale retrospective reports. The real incidence of complications in a highvolume center with sufficient experience is unknown. It was our objective to determine incidence and risk factors associated with complications during HVI prospectively. Methods: During a 5-year period a prospective cohort study was performed in a single level-I trauma and spinal disorders center. Data of all traumatic and non-traumatic patients who underwent HVI were prospectively collected. Every complication during follow-up, i.e. the period of HVI, was recorded. Primary outcome was presence or absence of complications. Statistical significance of relations between 30 covariates and primary outcome was determined with Chi-square analysis. Results: In 239 patients treated with HVI 26 major, 59 intermediate and 132 minor complications were observed. Fourteen patients (6%) died during the treatment, although only three were possibly related directly to the immobilization. Increasing age (p=0.005) was the only risk factor significantly related to mortality during HVI. Patients over the age of 70 were especially at risk (p=0.002). Twelve patients (5%) acquired pneumonia during HVI. Halo related complications ranged from 3 patients (1%) with incorrect initial assembly of the halo vest to 29 patients (12%) with pin site infections. Both pin site infection (p=0.003) and pin loosening (p=0.021) have been identified as significant risk factors in development of pin site penetration. Conclusions: Compared to previous retrospective reports, we found a lower percentage of mortality and pneumonia during HVI. Nevertheless, the numbers of minor complications remain substantial. This study confirms that awareness and responsiveness to minor complications can prevent subsequent development of serious morbidities and reduce mortality, while it is the first prospective report to identify risk factors for the development of complications during HVI

This study aims to evaluate the accuracy of sheer off self limiting screw drivers and to assess repeatability with age. It has been reported that overzealous tightening of halo pins is associated with co-morbidity. Our unit has recently received a tertiary referral where the patient over tightened a pin leading to intracranial haematoma, hence our interest in this subject. The torque produced by six new and nine old screw drivers was tested using an Avery Torque Gauge and a Picotech data recorder. These devices are designed to produce a torque of 0.68 Nm, any greater than this is potentially hazardous. Accepted error for each device was +/− 10%. The average torque produced by the new screw drivers was 0.56 Nm with a range of 0.35–0.64 Nm (SD 0.120). The older screw drivers produced an average torque of 0.67 Nm ranging from 0.52–0.85 Nm (SD 0.123). In conclusion, sheer off self limiting screw drivers are not accurate devices. The older devices are more likely to produce a torque exceeding a safe range and therefore we would recommend the use of new devices only. Ethics approval: none audit. Interest statement: none local grant

Aim. The localization of sequestrum in chronic osteomyelitis (COM) is crucial in preoperative planning. The identification of sequestrum on plain X-ray could be difficult. CT and MRI were reported to show the sequestrum. We aimed to analyze the sequestrum characteristics on 18F-FDG-PET-CT images. Methods. A prospective study included all patients diagnosed with long-bone chronic osteomyelitis. All patients had preoperative 18F-FDG-PET-CT. Images were analyzed using RadiAnt DICOM Viewer. Axial cuts were used to measure the Standard Uptake Ratio (SUV)max in the Region of Interest (ROI) in the sequestrum, the surrounding area, and the normal bone in the same cut. Surgical debridement was done as standard; samples were taken for microbiology and histopathology, and the intraoperative finding was documented. Results. Nineteen patients (17 males/2 females) were operated on in one center between October/2021 and Jan/2023 at a mean age of 32±18. There were 10 tibias, 7 femurs, one ulna, and one fibula. Ten had postoperative COM, six open fractures, and three hematogenous OM. They all showed sequestrum on PET-CT; the dead bone appeared void, surrounded by a halo of increased uptake. There was a trend of lower uptake in the sequestrum compared to the halo around. The mean SUVmax at the sequestrum was 4.18±3.16, compared to the surrounding halo, 7.08±5.81. The normal bone has a mean SUVmax of 1.61±1.42. Sequestrum was removed successfully in all cases. Conclusion. 18F-FDG-PET-CT can precisely localize the sequestrum preoperatively, it has a lower uptake than tissues around it. This would facilitate planning and improve the quality of debridement

Introduction and Objective. The treatment of severe deformities often requiring aggressive techniques such as vertebral resection and osteotomies with high comorbidity. To mitigate this risk, several methods have been used to achieve a partial reduction of stiff curves. The objective of this study was to evaluate and quantify the effectiveness of the Perioperative Halo-Gravity Traction (HGT) in the Treatment of Severe Spinal Deformity in Children. Materials and Methods. A historical cohort of consecutive childs with severe spinal deformity who underwent to a perioperative HGT as a part of the treatment protocol. Minimum follow-up of 2 years. Demographic, clinical and radiological data, including time duration of perioperative HGT and Cobb angle in the coronal and sagittal plane. The radiological variables were measured before the placement of the halo, after placement of the halo, at the end of the period of traction, after surgery and in the final follow-up. Results. Seventeen males (57%) and twenty females (43%) were included in the final analysis. The mean age was 6.5 years (SD 4.8). The most frequent etiology for the spinal deformity was syndromic (13 patients). The average preoperative Cobb angle was 88º (range, 12–135). HGT was used in 17 cases prior to a primary surgery and in 20 cases prior to a revision surgery. After the HGT, an average correction of 34% of the deformity was achieved (p <0.05). After the surgery this correction improved. At 2-year follow-up there was a correction loss of 20% (p <0.05). There were 3 complications (8.1%): 2 pin infections and cervical subluxation. Conclusions. The application of HGT in cases of severe rigid deformity is useful allowing a correction of the preoperative deformity of 34%, facilitating surgery. Preoperative HGT seems to be a safe and effective intervention in pediatric patients with high degree deformity

Introduction Cervical spine fractures and dislocations are uncommon injuries that can have serious neurological consequences. These injuries require adequate stabilisation to prevent further spinal cord injury during transfer between hospitals. Evacuation is often requires a combination of road ambulance, helicopter and fixed wing aircraft from military hospitals. This paper outlines the neck injuries sustained during Op Telic and discusses the need for Halo vests to be available at Role 3. Methodology The MND(SE) Hospital databases were used to identify all casualties admitted with either a “cervical” or “Neck” injury. The databases covered the period from March 2003 until February 2004. The diagnoses were categorised into minor and serious cervical spine injuries. We defined a serious cervical spine injury as either a fracture or dislocation. We looked at the discharge letters of all casualties evacuated to a Role 4 hospital to confirm whether the casualties had serious cervical spine injuries. Results 46 casualties were admitted and all were British except 2, who were Iraqi. 33 casualties were returned to their unit for duty or discharged at the airhead on return to the UK. Twelve casualties required hospital treatment. There were 3 serious cervical spine injuries over the study period which included one Hangman’s fracture of C2, one flexion compression injury of C5 and one unifacetal dislocation. All casualties were neurologically intact. Conclusions 3 casualties were treated at MND(SE) Hospital for serious injuries to the cervical spine. Two patients were transferred without Halo stabilisation after failing to obtain halos in Iraq. One casualty was kept until a halo was flown out from the UK. Recommendations All unstable cervical spine fractures should be stabilised with a halo vest prior to transfer from Role 3. Halo rings and vests should be available at Role 3 facilities

Purpose. The treatment of C2 fractures with collar, halo or surgery can all be justified depending on the patient. In our unit, primary treatment is with a halo: in a previous study presented at BASS we found an 85% fusion rate. In a follow on study, we wished to assess the outcome in those patients who underwent surgical treatment. Methods. The discharge logbook was examined retrospectively to identify patients who had posterior instrumentation for C2 fractures from 2008-2010 inclusive. Discharge summaries, clinic letters and radiology images/reports from PACS were analysed to obtain data regarding primary treatment, outcome, necessity for delayed treatment and radiological evidence of union. Results. Seven patients were identified who had surgery for C2 fracture. All 7 patients were treated with C1 and C2 lateral mass screws. In two of these patients additional lateral mass screws were inserted at C3. Due to patient preference, three of the seven patients underwent operative fixation without prior treatment in a halo. All three patients had evidence of bony union at the fracture site on subsequent radiological follow up. The remaining four patients were initially treated in a halo and had delayed surgery. After surgery two of these four patients had radiological evidence of bony union at the fracture site, one remained non-united and one patient has not yet been fully assessed. Conclusions. In this small series, operative fixation for C2 fracture lead to bony union at the fracture site in 5 out of 6 cases where full follow up was available. Interestingly, bony union at the fracture site may be an achievable objective even when surgery has been delayed or is not the primary treatment

Purpose: Odontoid fractures are the most common cervical spine injuries in the elderly. Although octogenarians are the fastest growing age group, limited data exists on the natural history after they sustain odontoid fractures. Published mortality rates vary greatly, but are high enough to elicit comparisons to post-hip fracture mortality. It has also been suggested that halo-vest immobilization independently predicts mortality. Method: All traumatic odontoid fractures (type II or III) seen at our institution between 1996 and 2008 were identified and only patients who were ≥ 80 years of age were selected. A retrospective chart review was performed for injury characteristics, comorbidities, hospitalization details, treatment regimen and documented complications. Patients were stratified using the Charlson comorbidities index. The primary outcome was mortality at one year and was identified using a provincial database. Results: 72 cases were identified. Median age was 86 years (range 80 to 102). Patient treatment regimens included rigid neck collar, Halo vest orthosis, surgery or a combination thereof. 31% percent of the cohort (22 patients) was treated by Halo vest immobilization. Overall 1-year mortality rate was 15% (n=11) with only 1 Halo vest patient dying during this period. The majority of deaths (9 / 11) occurred in first 2 weeks following the injury. Conclusion: Mortality rate in the octogenarian population sustaining an odontoid fracture is high and approaches the 1-year hip fracture mortality rate. The utilization of a Halo vest was not associated with increased mortality rate in our study. Optimal treatment regimens, and strategies to minimize morbidity, particularly in the early post-injury phase, necessitate further study

The management of type two odontoid peg fractures remains controversial. The policy in our unit is to initially manage all of these injuries non-operatively. Patients with displaced fractures (0.2mm translation, > 15° angulation) are placed in halo vests followed by fracture reduction under radiological control. Undisplaced or minimally displaced fractures are treated in either custom-made minerva orthoses or halo vests. We report the results of 42 consecutive cases of type two odontoid peg fractures. There were 24 males and 18 females with a mean age of 53 (range 18–89) years. Twenty-one (50%) of patients were > 65 years of age. In 29 cases the fracture was undisplaced or minimally displaced and in the remaining 13 cases it was displaced (> 2mm translation, > 15° angulation) either posteriorly (extension-type)(6) or anteriorly (flexion type) (7). All displaced cases were treated in halo vests while the remainder were treated in minervas (14) or halo vests (15). Loss of reduction occurred in nine cases necessitating adjustment in five and C1/2 posterior fusion in four. Of these cases five were displaced extension type-fractures, two required fusion. Pin site infection necessitated early removal of halo vest and conversion to minerva in three cases. In all of these cases fracture union was achieved. Overall, union was achieved in 37 patients giving a non-union rate of 12%. The mean age of the five non-unions was 42 years with only one patient over 65 years of age. Four of these patients had C1/2 posterior fusions and the remaining patient refused surgery. Of the 29 patients with displaced or minimally displaced fractures five (17%) required surgery for either non-union (3) or displacement (2), whereas three (23%) of the displaced group required surgery for non-union (1) or displacement (2). All of these were extension type fractures. We conclude that a policy of non-operative management of these fractures resulted in union in a high proportion of patients of all age groups except for those with extension type fractures. This fracture pattern may warrant primary surgical intervention

Injuries of the cervical spine can be classified into six categories according to a mechanistic system describing the biomechanical deficiencies incurred in a cervical spine injury. However high velocity flexion compression loads cause multiple contiguous and noncontiguous fractures due to multiple force vectors. A universal classification system cannot be applied. Instability exists if there is greater than 3.5 mm of translation or greater than 11 degrees of angulation as compared to other segments. The degree of ligamentous injury on MRI correlates with instability in patients with lateral mass facet fractures, with rupture of multiple ligaments including the anterior longitudinal, posterior longitudinal, interspinous, or facet capsule. Patients with less than 13 mm of narrowing of the sagittal canal are predisposed to neurologic injury. Vertical compression injuries cause canal occlusion and vertebral column shortening. The timing of surgery in cases of spinal cord injury is controversial. There is no difference in outcome between early (< 72 hours) and late (> 5 days) surgery. However, there remains at least a theoretical benefit to early surgery. Compression-flexion injuries result in loss of the anterior column by compression followed by the posterior column in distraction. The injury is considered unstable if there is a vertical cleavage fracture of the vertebral body or displacement. Treatment includes a cervical orthosis or halo for minor injuries, depending on the degree of kyphosis. Major injuries with displacement should be treated surgically by anterior corpectomy and plate or an anterior/posterior fusion, depending on the degree of posterior instability. The most common level of vertical-compression injuries is at the C6 or C7 level. Minimally displaced injuries can be treated with a collar or halo. Fragmentation and peripheral displacement of the bony fragments needs a halo followed by surgery and this may include an anterior corpectomy and plating. Distraction-flexion injuries may result in facet sub-luxation with less than 25% displacement, or dislocation of one (UFD) or both (BFD) facet joints. When there is 3 mm of translation (25%), the canal is occluded 20–25%. With 6mm of translation (50%), there is 40–50% canal occlusion. MRI can help analyse the soft tissue and ligamentous injuries. In UFD, all posterior ligamentous structures including joint capsule, and half the disc annulus are disrupted. Disruption of ALL and PLL is not necessary to create a UFD. In addition to the posterior structures, the ALL, the PLL and disc are disrupted in BFD. Rupture of the intervertebral disc may include posterior herniation or circumferential disruption. All distraction flexion injuries should be reduced closed. The necessity of a preoperative MRI is undetermined. Preoperative MRI is recommended if there is an unreliable exam due to the patient being uncooperative, if there is neurological worsening with, or failure of closed reduction. If the patient is neurologically intact and closed reduction successful, a posterior cervical fusion is advocated if there is no evidence of an extruded disc on the post reduction MRI. If the closed reduction failed, or MRI indicated, and there is no evidence of a herniated disc, an open posterior reduction followed by fusion is performed. Anterior discectomy with reduction, a graft and a plate is performed for a herniated disc. Compression-extension injuries fail by compression of the posterior elements followed by distraction of the anterior elements. There are unilateral or bilateral fractures of the laminae/neural arch with degrees of displacement. Undisplaced neural arch fractures can be treated with a cervical orthosis or halo. Displaced neural arch fractures are treated with a posterior cervical fusion. There are two stages in the distraction-extension injury group. The anterior longitudinal ligament is disrupted with possibly a transverse fracture of the body. With more major injuries, there is a significant displacement injuring the posterior column. Stage 1 injuries can be treated with a halo and Stage 2 with an anterior decompression and fusion with a plating device. There are two stages to lateral flexion injuries. Minor injuries include asymmetric centrum fracture and a unilateral arch fracture. In addition, there is displacement of the body with contralateral ligamentous failure in major injuries. The treatment for Stage 1 is usually a collar while treatment for Stage 2 is usually a posterior cervical fusion. Posterior stabilization procedures may be performed with wires and cables with or without rods. Posterior clamps usually are not recommended; while plates and screws are preferred. The plates and screws are biomechanically superior to wiring and avoid canal penetration. They are ideal when there is loss of the posterior elements. Pedicle fixation should be considered when operating on the C2 or C7 level. One in five patients may have complete disruption of vertebral artery blood flow. This occurs most commonly with flexion-distraction or flexion-compression injuries. Vertebral artery evaluation is recommended in patients with flexion injuries and symptoms consistent with vertebral artery insufficiency. It is important to understand the mechanism of injury; to understand which elements are compromised. We have to get the appropriate imaging studies, we have to be cognizant of the fact that the vertebral artery may be injured, or there may be an associated herniated disc. We have to understand the degree of instability, which dictates the appropriate treatment and we have to understand the risk benefit of the specific internal fixation systems that we use

The aim of this study was to assess the use of early ambulatory halo-thoracic immobilisation in paediatric patients with spinal instability. The case notes, radiographs and clinical findings at follow-up of 12 patients treated this way were reviewed. The mean age was 8.6 years (4 to 16). The aetiology was trauma in six, os odontoidium in one, tuberculosis in three, and Morquios syndrome and chronic granulomatous osteitis in one each. The instabilities were atlanto-axial rotatory subluxation in one patient, transverse ligament rupture in six, dens anomalies in two, anterior destruction by tuberculosis in two, and a dens fracture. The halo jackets were applied under general anaesthetic. In addition, posterior C1/2 fusions were performed in seven patients, posterior occipitocervical decompression and fusions in two, and posterolateral thoracotomies in two. No surgery was done on the patient with the dens fracture. Autograft was used in all cases except one posterior C1/2 fusion. This patient, who was HIV-positive, was the only one in whom union did not occur. There was one case of minor pin-tract sepsis. All patients mobilised in the halo jacket and, where possible, were managed as outpatients. Despite radiological nonunion in one patient, spinal stability was achieved in all. Early ambulatory halo jacket immobilisation is a useful, safe and well-tolerated technique in the paediatric patient group

Atlanto-axial rotatory fixation is a rare abnormality of the atlanto-axial joint characterised by a fixed rotated atlanto-axial joint. Duration of symptoms is the best predictor of those cases that ultimately require surgical fixation. We report 6 cases of atlanto-axial rotatory fixation that were treated at the Royal National Orthopaedic Hospital between 1998 and 2005. Diagnosis was confirmed by CT scan in all cases. The mean duration of symptoms was 8 weeks. 4 cases were reduced with halo traction, for between 7–28 days (mean 15 days), and 2 cases were reduced under anaesthesia. This was followed by application of a halo jacket in all 6 cases for between 6–12 weeks (mean 7.2 weeks). There was no significant recurrence with a mean duration of follow up 24 months. This rare series demonstrates late presenters of AARF responding favourably to non surgical intervention

Evaluating the effectiveness of conservative treatment of odontoid fractures, from 1997 to 1999 we reviewed 22 cases. All were treated first in halo traction and subsequently by halo thoracic brace immobilisation. We used Anderson and D’Alonzo’s classification of types I to III. The mean follow-up time was seven months. Initial displacement was measured radiologically and union was evaluated. In type-II fractures, the incidence of pseudarthrosis was 40%. Fractures with more than 5 mm of initial displacement and more than 10° angulation all went on to nonunion, suggesting that type-II fractures should be treated by internal fixation

Radiographic follow-up of traumatic spondylolisthesis of the axis is well documented in the literature. However, there is a paucity of studies regarding the long-term functional outcome of this type of injury. To study the population, treatment and outcome following traumatic spondylolisthesis of the axis, we reviewed 36 consecutive patients presenting to our institution, a tertiary referral spinal trauma centre, over a 6-year period. We assessed: (a) the mechanism of injury, (b) the mode of treatment, (c) the radiographic classification using the Levine and Edwards system and (d) functional outcome using the Cervical Spine Outcomes Questionnaire (CSOQ) by BenDebba. Of the 36 patients presenting there were 24 males and 12 females with a mean age of 46 (range18-82) years. The commonest mechanism of injury was road traffic accidents. There were 14 Type-I, 11 Type-II and 1 Type-IIA fractures. Twenty-seven patients were treated with halo vest immobilisation and nine were immobilised in a Minerva jacket. Four patients were converted from halo to Minerva because of pin failure. The mean duration of hospital stay was 10 (range 3-30) days. All fractures demonstrated radiographic union at a mean of 12 (range 10-16) weeks. There were no neurological complications. Upon review, all patients, whether Type-I or Type-II demonstrated low CSOQ scores approaching their pre-morbid status. However, Type-II fractures scored higher in 3 functional outcome categories when compared to Type-I fractures. This unique study of an uncommon fracture shows for the first time a difference in the functional outcome scores of Type-II fractures of the axis when compared to Type-I fractures at a mean follow-up of 3 years and 10 months

Purpose. Patients with ankylosing spondylitis (AS) are vulnerable to cervical spine injury following relatively minor trauma. The authors present a retrospective review to determine the characteristics, treatment and outcome following cervical spine injury in these patients. Methods. Retrospective analysis of case notes and images of patients with AS admitted to the Spinal Injury Unit over a 10-year period. Results. Thirty-nine patients were identified. Records were available for 31 patients at the time of this analysis. The median age was 62 years (range 37-84). The male:female ratio was 7:1. Mechanisms of injury included falls (72%) and RTAs (7%), while 14% were unable to recall an injury. Alcohol was involved in 20% of the cases. Fracture through an ankylosed disc in the mid to low cervical spine was the commonest injury. Concomitant non-contiguous bony injury was seen in 2 patients. More than half (55%) were Grade E on ASIA impairment scale (AIS), while 14% were Grade A and 31% Grade D. Two patients required skull traction. Most patients were successfully treated by external immobilisation. Halo crown and jacket was the most common orthosis used. Twelve patients underwent surgical stabilisation. The mean duration of external immobilisation in the non-surgical group was 13 weeks (range 10-32), whereas following surgery it was 6 weeks (range 2-8). Adequate radiological evidence of fusion was seen in all 22 patients for whom this information was available at a median of 22 weeks (range 12-32). Patients with AIS Grade A and E were unchanged at discharge, while 4 patients in AIS Grade D improved to E. Conclusion. External immobilisation with halo in an effective first-line therapy in achieving fusion and stability. Surgical stabilisation can be reserved as a second-line treatment

Purpose. Patients with ankylosing spondylitis (AS) are vulnerable to cervical spine injury following relatively minor trauma. The authors present a retrospective review to determine the characteristics, treatment and outcome following cervical spine injury in these patients. Methods. Retrospective analysis of case notes and images of patients with AS admitted to the Spinal Injury Unit over a 10-year period. Results. Thirty-nine patients were identified. Records were available for 31 patients at the time of this analysis. The median age was 62 years (range 37-84). The male:female ratio was 7:1. Mechanisms of injury included falls (72%) and RTAs (7%), while 14% were unable to recall an injury. Alcohol was involved in 20% of the cases. Fracture through an ankylosed disc in the mid to low cervical spine was the commonest injury. Concomitant non-contiguous bony injury was seen in 2 patients. More than half (55%) were Grade E on ASIA impairment scale (AIS), while 14% were Grade A and 31% Grade D. Two patients required skull traction. Most patients were successfully treated by external immobilisation. Halo crown and jacket was the most common orthosis used. Twelve patients underwent surgical stabilisation. The mean duration of external immobilisation in the non-surgical group was 13 weeks (range 10-32), whereas following surgery it was 6 weeks (range 2-8). Adequate radiological evidence of fusion was seen in all 22 patients for whom this information was available at a median of 22 weeks (range 12-32). Patients with AIS Grade A and E were unchanged at discharge, while 4 patients in AIS Grade D improved to E. Conclusion. External immobilisation with halo in an effective first-line therapy in achieving fusion and stability. Surgical stabilisation can be reserved as a second-line treatment

Introduction: The management atlanto-axial fractures, particularly those of the odontoid peg, remains controversial. We managed patients with C1/C2 fractures non-operatively in rigid immobilization until CT-scanning confirmed bony union, rather than for the standard 3-month period. We examined whether this improved outcomes and reduced the need for surgery. Method: All patients admitted to our unit with atlanto-axial fractures between 2001–2007 were retrospectively analyzed. All fractures had the ‘intention-to-treat’ conservatively in either halothoracic vest (85%) or Aspen collar (15%). Rigid immobilization was maintained until CT-scanning demonstrated bony fusion. Functional stability was subsequently assessed with flexion-extension radiographs after removal of rigid immobilization. Results: Twenty-seven patients were studied. Nineteen had odontoid peg fractures (10 type II; 9 type III). The remainder consisted of 3 Hangman’s, 3 lateral mass and 2 atlas ring fractures. 83% of patients progressed to union at an average of 13.2 weeks (range 5–22). Six complications related to halo immobilization were observed (three skull perforations/pin-site infections). All of these patients progressed to union non-operatively. Failure of non-operative management was deemed as non-union or poor patient tolerance of halo, and occurred in 4 patients (17%). All four had type II odontoid peg fractures, and had transarticular screw fixation. One postoperative complication of screw fracture was recorded. Conclusion: Non-union rates of conservatively managed atlanto-axial fractures with standard 3-month rigid immobilization have been reported as high as 35%. In our series, CT-imaging to confirm bony union prior to removal of the rigid immobilization (prolonging immobilization where necessary) significantly lowered the rate of non-union and therefore the need for subsequent surgery. Ethics approval: None Audit. Interest Statement: None