Halo traction

Halo vest traction is used infrequently in children. It is usually a planned event, and in children is fitted under a general anaesthetic.

It is used to stabilise the cervical spine, or to correct its alignment. (Rationale 1, Rationale 2)

Introduction

The implications of using the system should not be under-estimated - it is initially traumatic and stressful for both the child and family. (Rationale 3)

The child and family will require support, education and encouragement, both with daily living and in coping with the attitude of the public. (Rationale 4, Rationale 5)

Background

The Halo vest skeletal fixator provides the most rigid cervical immobilisation of all orthoses (Botte et al, 1999). It is used in an attempt to obtain ligamentous reconstruction and realignment by derotation, and may be used as first line management, or following surgery. 

The device consists of a halo vest with a sheepskin jacket underneath, support rods, a ring and skull pins. The system is made from carbon fibres and consequently compatible with Magnetic Resonance Imaging. To achieve the desired force, each skull pin is tightened individually and this will need to be undertaken regularly once the child is mobile.  

The child is mobilised as soon as clinically appropriate following fitting of the halo vest system. Once recovered from surgery, they will be discharged into the community. 

The halo apparatus is usually removed after three months, following radiological confirmation that the objective has been achieved. This is performed under general anaesthesia in children. A neck collar will be fitted at the same time for support as the neck muscles will initially be weakened and the head will feel heavy. The collar can be removed once the child feels more comfortable. 

Complications following halo traction in young children are common, including pin loosening and dislodgement and infection (Wong et al, 1994).  A thorough patient history and physical examination of the child should be undertaken, alongside computerised tomography to determine the safest pin placement (Papagelopoulos et al, 2001). 

Multiple pin placement in the young child, as opposed to the routine placement of four pins in the adult, has been shown to require significantly less torque to provide stability. This is highly significant in the infant where the skull might otherwise be considered too thin to withstand the required traction (Steinmetz et al, 2003). 

Despite regular pin tightening, some pin loosening and consequent reduction of traction will develop in patients (Fleming et al, 2000) and the frequency of pin tightening should be agreed on an individual basis.

Vertullo et al, 1997 conclude that pin tightening at 24 hours and at one week after application, is a safe and effective method to decrease pin site complications; his study however is based on the adult patient only. 

Superficially infected pins are managed with local pin care and occasionally oral antibiotics. More persistent or severe infections are rare, but will need pin replacement to a local site, and antibiotic therapy (May, 2001). 

Halo vest traction is used infrequently in children and will arouse curiosity from the public, and anxiety from the child and family. Good preparation in the form of both written and verbal information will help allay some of their concerns. 

Inform child and family

Explain the entire procedure to the family including the reason for the procedure. Provide an opportunity for the family to discuss any potential alternatives. 

Bearing in mind this is an unusual and often shocking procedure for the child, it may be advisable to talk to the parents prior to talking to the child. (Rationale 6)

Preparation

Various body measurements as specified by the manufacturers, will be necessary to ensure correct fitting of halo ring size and halo vest. (Rationale 7)

The appropriate use of play therapies and visual education should be utilised, to prepare the child psychologically for halo application. The parents and play specialist should be included. (Rationale 8, Rationale 9, Rationale 10, Rationale 11, Rationale 12)

A discussion will be undertaken between the surgeon and parents, outlining the aims of using the halo-vest apparatus. Potential complications will be discussed and a consent for the procedure taken. (Rationale 13, Rationale 14)

The child and family may be quite shocked by the halo vest system and diagrams and discussion may partially alleviate some of their anxieties. (Rationale 15)

Sensory problems: halo traction severely limits the visual field by restricting head movement. The child will be encouraged to turn around to see what is beside or behind them.

Clothing alterations need to be considered. (Rationale 16)

Training and education

All information and education should be provided in both written and verbal forms. The family should be educated regarding the following: (Rationale 17)

• Not to hold the child by handling the rigid bars from the halo to the vest system. (Rationale 18)
• To educate the child and family with how to get out of bed in a halo vest system. The child should get up by rolling onto their side, dropping their legs off the edge and pushing sideways, with their elbow and hand at the same time. (Rationale 19, Rationale 20)

Mobility

Slow elevation may be required if the child has been flat for several days. (Rationale 21)

The majority of young children however are quick to mobilise and the physiotherapist will assist, particularly with regard to negotiating stairs and kerbs. (Rationale 22)

Eating and drinking

The plastic jacket offers little room for expansion, so the patient may complain of difficulty breathing after eating. Small, frequent meals can help prevent this problem (Rosenburg et al, 2004) and constipation should be avoided. (Rationale 23)

Pin sites

Once the child becomes more active, the pin sites can become sore and encrusted. In extreme cases, individual pins may need to be repositioned under a short anaesthetic. (Rationale 24)

Hospital policy should be followed with regard to cleaning of pin sites and antibiotics prescribed as appropriate. Halo skull pin sites are not routinely cleaned at Great Ormond Street Hospital, but if they do require cleaning, normal saline and cotton wool balls are utilised. (Rationale 25, Rationale 26)

Sheepskin vest

To educate the child and family with care of the sheepskin vest. (Rationale 27)

Should this become wet or soiled, no attempt should be made to remove it except under medical supervision. Instead, the family should be advised when at home, to clean what they can with a damp sponge, and dry with a hairdryer. They should contact the ward if the jacket is heavily soiled. (Rationale 28, Rationale 29)

Once the surgeon has confirmed it is safe to do so, the hair can be washed with a shower, care being taken to keep the jacket system as dry as possible. (Rationale 30)

Procedure

The system is fitted under general anaesthesia in children. (Rationale 31, Rationale 32)

Particular attention to airway management post anaesthesia is essential, due to the diffuculty associated with intubating a child in halo-vest traction. (Rationale 33)

The parents should be reunited with the child at the earliest opportunity following anaesthesia. (Rationale 34)

Pillows can be placed around the frame to assist comfort. Putting a small towel between the head and back of the neck (without applying any pressure) or next to the cheek will assist with the feeling of normality. (Rationale 35)

Analgesia should be administered as required and a relaxant considered if the child is extremely frightened. (Rationale 36)

The child should be returned to the ward setting as soon as clinically stable. (Rationale 37)

Dysphagia can occasionally occur following placement of a halo. (Rationale 38)

Discharge care

Specific needs regarding discharge care should be given verbally to the family, and written information such as leaflets or pamphlets, supplied and discussed. (Rationale 39) 

Pin tightening should be arranged at the local hospital only if they are familiar with the process; it is more likely the family will need to return to the “host” hospital, or perhaps to an appropriate adult neurosurgical unit should that be nearer. 

A local contact should be given for the parents in case of emergency. The local hospital and community services should be made aware of the child’s discharge and any care needs. (Rationale 40, Rationale 41) 

The child can travel in a car wearing a seat belt, and on a train as long as they remain seated throughout the journey. (Rationale 42)

School:

• The child can return to school if adequate supervision can be provided, and playground activities omitted. (Rationale 43)
• Sports should be omitted throughout the time the child is wearing the halo vest system. (Rationale 44)

Pin site scarring can occur following removal of the halo and pins. Cortisone and Interferon are suggestions made by Hayes et al, 2005. (Rationale 45)  

Rationale

Rationale 1: Corrective cervical surgery is generally difficult in children due to immaturity of the bony elements, and therefore external support is required. A halo jacket is considered the optimum treatment for children (Marks et al, 1993).

Rationale 2: A halo vest apparatus is a simple, safe and effective means of external immobilisation and protection of the cervical spine (Kyoshima et al, 2003).

Rationale 3: Help the child and family face their fears and anxieties, by giving them the opportunity to voice and discuss them (Mitchell et al, 2004). These can then be addressed and partially alleviated.

Rationale 4: An educated child and family will be better equipped to cope with the attitude of a curious public.

Rationale 5: Professionals can bolster parental coping by stressing the potential benefits of surgery and encouraging parents to be actively involved in the child’s care and progress (Lamontagne et al, 2003).

Rationale 6: Well-informed parents are more likely to stay calm and will be in a better position to support their child (Melnyk et al, 2004).

Rationale 7: To ensure the orthosis will be comfortable, safe and effective.

Rationale 8: To minimise the child’s distress.

Rationale 9: To promote involvement.

Rationale 10: To maximise compliance.

Rationale 11: The better informed the child, the able he will be in developing coping strategies (Thurgate, 2005).

Rationale 12: Parents and children have reported more satisfaction and less anxiety after having received specific information and preparation preoperatively (Hatava et al, 2000).

Rationale 13: To obtain legal written consent.

Rationale 14: To ensure parents have a thorough understanding of the procedure.

Rationale 15: Pre-operative psychological preparation has been shown to relieve anxiety and fear (Hatava et al, 2000).

Rationale 16: Clothes need to be adapted to fit under the vest and bars: the provision of a cotton vest which may need to be fitted next to the skin if sheepskin allergy occurs; clothes- including a coat, need to open at the front.

Rationale 17: Provision of both verbal and written information significantly increases knowledge and satisfaction scores (Reid, 1993).

Rationale 18: To reduce the likelihood of dislodging the halo pins or causing pain.

Rationale 19: To reduce the likelihood of falls from bed, or pain in attempting to get put of bed.

Rationale 20: By correct movement into an upright position, the stress to the front pins is reduced (Reid, 1993).

Rationale 21: To reduce the likelihood of postural hypotension.

Rationale 22: To achieve safe mobility.

Rationale 23: To alleviate feelings of discomfort and distress.

Rationale 24: To educate the child and family regarding pin site care.

Rationale 25: Bernardo (2001) states that prevention of pin site infection in children undergoing orthopaedic procedures consists of observation of the site for infection, cleaning and removing crusts and applying dressings. However, Gordon et al (2000) take a nihilistic approach and recommend showering without any other physical pin cleaning procedures in children undergoing external fixator procedures. There is no evidence-based practice for pin cleaning in children wearing halo vest jackets.

Rationale 26: Pin site scarring is possible, and is considered objectionable by the family (Dormans et al, 1995). Therefore all possible attempts at reducing the likelihood of this occurring, such as simple hygiene, should be encouraged.

Rationale 27: The sheepskin lining should not be removed except under medical supervision. Should it become dirty, the parent should sponge it clean and dry with a hairdryer.

Rationale 28: To maintain hygiene, whilst ensuring there is no disruption to the cervical spine alignment.

Rationale 29: Prevention of skin breakdown and pressure sores.

Rationale 30: To maintain scalp, hair and pin hygiene.

Rationale 31: To ensure good cervical alignment.

Rationale 32: To reduce anxiety.

Rationale 33: To ensure safety.

Rationale 34: To reduce anxiety and assist in reassuring the child.

Rationale 35: Placement of a halo vest system feels abnormal and uncomfortable and may result in initial difficulty with sleep and relaxation for the wearer.

Rationale 36: To reduce pain, and assist in reducing fear and anxiety.

Rationale 37: Placing the child back in a more familiar environment will help reduce anxiety and allow better access for the family to comfort them.

Rationale 38: Care should be taken when introducing diet and fluids; should dysphagia persist,any hyperextension of the cervical spine should be corrected by readjustment of the halo (Hayes et al, 2005).

Rationale 39: To ensure parents have a clear understanding and to promote confidence.

Rationale 40: To ensure the local health providers are sufficiently informed and educated in the needs of a child in halo vest system.

Rationale 41: To ensure the parents are aware of who to contact and when.

Rationale 42: To encourage a normal a life as possible whilst maintaining safety.

Rationale 43: Education should be re-instated as soon as practical.

Rationale 44: To minimise the likelihood of causing trauma to the child or the system.

Rationale 45: Early recognition and management of pin site scarring should be initiated to minimise this.

References

Reference 1:
Botte MJ, Byrne TP, Abrams RA, Garfin SR (1996) Halo Skeletal Fixation: Techniques of Application and Prevention of Complications. J Am Acad Orthop Surg 4 (1): 44-53.

Reference 2:
Wong WB, Haynes RJ (1994) Osteology of the pediatric skull. Considerations of halo pin placement. Spine 19 (13): 1451-4.

Reference 3:
Papagelopoulos PJ, Sapkas GS, Kateros KT, Papadakis SA, Vlamis J, Falagas ME (2001) Halo pin intracranial penetration and epidural abscess in a patient with a previous cranioplasty: case report and review of the literature. Spine 26(19): E463-7.

Reference 4:
Steinmetz M, Roseanna M, Anderson J (2003) Atlantooccipital dislocation children: presentation, diagnosis and management. Neurosurgical Focus 14(2): 1-6.

Reference 5:
Fleming BC, Krag MH, Huston DR, Sugihara S (2000) Pin loosening in a halo-vest orthosis: a biomechanical study. Spine 25 (11): 1325-31.

Reference 6:
Vertullo CJ, Duke PF, Askin GN (1997) Pin-site complications of the halo thoracic brace with routine pin re-tightening. Spine 22 (21): 2514-6.

Reference 7:
May L (2001) Spinal Surgery May L. Paediatric Neurosurgery. London, Whurr Publications

Reference 8:
Marks DS, Roberts P, Wilton PJ, Burns LA, Thompson AG (1993) A halo jacket for stabilisation of the paediatric cervical spine. Arch Orthop Trauma Surg 112 (3): 134-5.

Reference 9:
Kyoshima K, Kakizawa Y, Tokushige K (2003) Simple cervical spine traction using a halo vest apparatus: technical note. Surg Neurol 59 (6): 518-21; discussion 521.

Reference 10:
Mitchell M, Johnston L, Keppell M (2004) Preparing children and their families for hospitalization. Neonatal, Paediatric Child Health Nursing 7(2): 5-15.

Reference 11:
Lamontagne LL, Hepworth JT, Salisbury MH, Riley LP (2003) Optimism, anxiety, and coping in parents of children in hospital for spinal surgery. Applied Nursing Research 16(4): 228-35.

Reference 12:
Melnyk BM, Alpert-Gillis L, Feinstein NF, Crean HF, Johnson J, Fairbanks E, Small L, Rubenstein J, Slota M, Corbo-Richett B (2004) Creating opportunities for parent empowerment. Pediatrics 113(6): 597-607.

Reference 13:
Thurgate C, Heppell S (2005) Needle phobia - changing venopuncture practice in ambulatory care. Paediatric Nursing 17(9): 15-8.

Reference 14:
Hatava P, Olsson G, Lagerkranser M (2000) Preoperative psychological preparation for children undergoing ENT operations. Paediatric Anaesthesia 10(5): 477-86.

Reference 15:
Johnson A, Sandford J, Tyndall J (2003) Cochrane Database System Review. 2003(4) CD003716. Flinders University of South Australia, Department of Public Health

Reference 16:
Reid, B (1993) Your guide to wearing your halo-vest. Jacksonville, Fla., Bremer Medical Inc

Reference 17:
Rosenburg S, Seger L, Tran L (2004) Halo device preliminary report. BME 401- Senior Design, Washington University in Saint Louis. userfs.cec.wustl.edu/~spr2/media/halo_prelim.pdf. Viewed on: 29/06/2009

Reference 18:
Bernardo LM (2001) Evidence-based practice for pin site care in injured children. Orthopaedic Nursing 20(5): 29-34.

Reference 19:
Gordon JE, Kelly-Hahn J, Carpenter CJ, Schoenecker PL (2000) Pin site care during external fixation in children: results of a nihilistic approach. J Pediatr Orthop 20 (2): 163-5.

Reference 20:
Dormans JP, Crisitiello AA, Drummond DS, Davidson RS (1995) Complications in children managed with immobilisation in a vest. Journal of Bone Joint Surgery 77(9): 1370-3.

Reference 21:
Hayes VM, Jeff S, Silber M, Siddiqi FN, Kondrachov D, Lipetz JS, Lonner B (2005) Complications of Halo Fixation of the Cervical Spine. American Journal of Orthopedics 34(6): 271-6.

Reference 22:
Wilson CJ (1999) Parental preparation of children for routine physical examinations. Journal of Pediatric Nursing 14(5): 329-35.

Document control information

Lead author(s)
Lindy May, Nurse Consultant, Paediatric Neurosurgery