The halo skeletal fixator: current concepts of application and maintenance

The halo device provides the most rigid cervical immobilization of all cervical orthoses. Despite its established efficacy, reported complications include pin loosening (36% to 60%), pin-site infection (20% to 22%), severe pin discomfort (18%), ring migration (13%), pressure sores (4% to 11%), unacceptable scars (9% to 30%), nerve injury (2%), dysphagia (2%), prolonged bleeding at pin sites (1%), and dural puncture (1%). Appreciation of skull anatomy and established application guidelines can help minimize these complications. A relative "safe zone" for anterior pin placement is located 1 cm above the orbital rim, superior to the lateral two thirds of the orbit. This position avoids injury to the nearby frontal sinus (medially), temporalis fossa (laterally), and sensory nerves (supraorbital and supratrochlear nerves medially, and zygomaticotemporal nerve laterally). Posterior pin positions are less critical, located roughly diagonal to the contralateral anterior pins. Pins should enter the skull perpendicular to the cortex, with the ring or crown sitting below the equator of the skull, passing about 1 cm above the helix of the ear. Pins are inserted at 8 in-lbs and re-tightened once at 48 hours. A loose pin can be re-tightened to 8 in-lbs if resistance is met; otherwise, a loose pin requires replacement in a nearby site. Superficially infected pins are managed with oral antibiotics and local pin care. Refractory infections require pin removal, parenteral antibiotics, and incision and drainage as indicated. Dysphagia (difficulty in swallowing), produced by exaggerated cervical extension, may necessitate repositioning of the C-spine. Dural pin puncture is managed with hospitalization, antibiotics, and elevation of the head of the bed to decrease cerebrospinal fluid pressure and allow dural healing.(ABSTRACT TRUNCATED AT 250 WORDS)