Halo Fixator and Halo Traction - Value for the Treatment of Spinal Disorders in Childhood. / Halofixateur und Halotraktion ­ Stellenwert bei Erkrankungen und Verletzungen der Wirbelsäule im Kindesalter.

The application of the Halo fixateur in case of spinal pathologies in childhood is a standardized technique. The halo fixateur may be used for treatment of injuries of the cervical spine, for additional stabilization following extended surgery at the cervical spine and their transitional regions as well as to achieve preoperative reduction in case of severe and rigid deformity. These indications are, referred to the early age, rare. However, the successful use of the Halo fixateur presumes a certain familiarity with the device and experiences regarding the underlying diseases to minimize related risks and to avoid possible complications. In this article the use and specific features regarding the application of the halo fixateur in childhood based on presented cases and the literature will be discussed.

Recommendations for the Diagnostic Testing and Therapy of Atlas Fractures. / Empfehlungen zur Diagnostik und Therapie oberer Halswirbelsäulenverletzungen: Atlasfrakturen.

In a consensus process with four sessions in 2017, the working group on "the upper cervical spine" of the German Society for Orthopaedic and Trauma Surgery (DGOU) formulated "Therapeutic Recommendations for the Diagnosis and Treatment of Fractures to the Upper Cervical Spine", incorporating their own experience and current literature. The following article describes the recommendations for the atlas vertebra. About 10% of all cervical spine injuries include the axis vertebra. The diagnostic process primarily aims to detect the injury and to determine joint incongruency and integrity of the atlas ring. For classification purposes, the Gehweiler classification and the Dickman classification are suitable. The Canadian c-spine rule is recommended for clinical screening for c-spine injuries. CT is the preferred imaging modality; MRI is needed to determine the integrity of the Lig. transversum atlantis in complete atlas ring fractures. Conservative treatment is appropriate in very many atlas fractures. Surgical treatment is recommended in existing or potential joint incongruity or instability, which are frequently seen in Gehweiler IIIB or Gehweiler IV fractures. Posterior atlanto-axial stabilisation and fusion using transarticular screws or an internal fixator are regarded as a gold standard in the majority of surgical cases. Especially in young patients, the possibility of isolated atlas osteosynthesis should be checked. A possible option for Gehweiler IV fractures is halo-fixation with mild distraction for ligamentotaxis. Secondary dislocation should be checked for frequently. Involvement of the occipito-atlantal joint complex requires stabilisation of the occiput as well.

Recommendations for Diagnosis and Treatment of Fractures of the Ring of Axis. / Empfehlungen zur Diagnostik und Therapie oberer Halswirbelsäulenverletzungen: Axisringfrakturen.

In a consensus process with four sessions in 2017, the working group "upper cervical spine" of the German Society for Orthopaedics and Trauma Surgery (DGOU) formulated "Therapeutic Recommendations for the Diagnosis and Treatment of Upper Cervical Fractures", taking their own experience and the current literature into consideration. The following article describes the recommendations for axis ring fractures (traumatic spondylolysis C2). About 19 to 49% of all cervical spine injuries include the axis vertebra. Traumatic spondylolysis of C2 may include potential discoligamentous instability C2/3. The primary aim of the diagnostic process is to detect the injury and to determine potential disco-ligamentous instability C2/3. For classification purposes, the Josten classification or the modified Effendi classification may be used. The Canadian C-spine rule is recommended for clinical screening for C-spine injuries. CT is the preferred imaging modality and an MRI is needed to determine the integrity of the discoligamentous complex C2/3. Conservative treatment is appropriate in case of stable fractures with intact C2/3 motion segment (Josten type 2 and 2). Patients should be closely monitored, in order to detect secondary dislocation as early as possible. Surgical treatment is recommended in cases of primary severe fracture dislocation or discoligamentous instability C2/3 (Josten 3 and 4) and/or secondary fracture dislocation. Anterior cervical decompression and fusion (ACDF) C2/3 is the treatment of choice. However, in case of facet joint luxation C2/3 with looked facet (Josten 4), a primary posterior approach may be necessary.

[Subaxial Cervical Spine Injuries: Treatment Recommendations of the German Orthopedic and Trauma Society]. / Therapieempfehlungen zur Versorgung von Verletzungen der subaxialen Halswirbelsäule.

In a consensus process during four sessions in 2016, the working group "lower cervical spine" of the German Society for Orthopedic and Trauma Surgery (DGOU), formulated "Therapeutic Recommendations for the Lower Cervical Spine", taking into consideration the current literature. Therapeutic goals are a permanently stable, painless cervical spine and the protection against secondary neurologic damage while retaining the greatest possible amount of motion and spinal profile. Due to its ease of use and its proven good reliability, the AOSpine classification for subaxial cervical injuries should be used. The Canadian C-Spine Rule is recommended as a clinical decision rule whether to perform imaging or not. If a structural or unstable injury is suspected by patient history or clinical findings, a spiral CT scan of the cervical spine is the favoured diagnostic modality. Conventional X-ray is reserved for patients in whom there is no "dangerous mechanism of injury". MR imaging is recommended in case of unexplained neurologic deficit, prior to closed reduction and open posterior surgery and to exclude disco-ligamentous injuries. Urgency of MR imaging depends on the specific findings. CT angiography is recommended in higher-grade facet joint injuries or in the presence of vertebra-basilar symptoms. Flexion-extension imaging is recommended only as a physician-guided dynamic fluoroscopy, when an unstable lesion is still suspected. The therapeutic strategy is mainly dependent on morphologic criteria, which are described using the AOSpine classification. A0-injuries are treated conservatively. A1- and A2-injuries are treated conservatively in the majority of cases, and in single cases a gross kyphotic deformity might indicate surgical stabilisation. A3-injuries do indicate a surgical therapy in the majority of cases, but certain cases might be treated conservatively. A4-fractures as well as B- and C-type injuries are to be treated surgically. Most injuries can be treated by anterior plate stabilisation with interbody support; when a complete burst fracture is present, corpectomy and vertebral body replacement is necessary. In certain cases, an additive posterior or pure posterior instrumentation might be possible or even mandatory. In most of these cases, lateral mass screws are sufficient; when pedicle screws are applied in C3 to C6, a 3D-navigation system is recommended. Injuries in an ankylosing spine (M3-modifier) should be treated preferably from posterior with long-segment instrumentation.