Halo Placement
John B. Emans, MD
Indications
Unstable cervical spine injury
Postoperative immobilization for cervical spine injury treated surgically
Any age
Sterile Instruments/Equipment Table
Halo-crown vest system
Commercially available systems provide chest and torso measurements online for sizing the vest and halo. Online manufacturer videos are useful for understanding the attachment of the vest to the halo. Best to have a range of sizes available.
Halo-crown (3/4 circumference) is preferred, which is easier to apply than a full halo ring and does not interfere with posterior occipital fixation/surgery
Insertion set-up (Figure 16-1)
Prep swab/q-tips with betadine
Chloraprep contraindicated b/c eyes nearby
Local anesthetic infiltrate with epinephrine
#15 blade if making incision for pins
Figure 16-1 ▪ Set-up for application halo-crown.
Halo pins ranging from four (adolescent) to ten (infant/toddler)
both standard and long-length pins
Wrenches and torque-limiting driver
Halo-vest preparation
Vest size should be measured by measuring chest circumference at nipples and abdominal circumference at umbilicus; match to manufacturer’s recommendations.
Check vest visually to make sure the selected size really works for this patient.
If trach, chest-or G-tube is placed, make appropriate modifications to vest before application.
Patient Positioning
Supine on the operating table
Turn so that anesthesia and tubing could be applied in the position, giving maximum access to head.
Support tubing so that head is not pulled by anesthesia apparatus
Elevation of shoulder/body on blankets to allow occiput to recess posteriorly and avoid flexion (Figure 16-2).
Especially true for smaller children whose head is large relative to body and lying on a flat surface creates inadvertent cervical flexion
Posterior occiput elevated slightly off the bed to allow for halo-crown to protrude posteriorly without hitting the bed; place narrow cardboard or folded towel under occiput (Figure 16-3)
Head in neutral position and avoid inadvertent flexion
Eyes taped shut
Surgical Planning
Choosing the right-size crown
Halo-crown can be sized accordingly by measuring the circumference of the skull preoperatively and looking at manufacturer measurements/ring sizes
But there are many different shaped skulls with ages and individuals, and so size may need to be adjusted upward
If available, use trial templates to choose halo size (Figure 16-4)
Goal is minimum one fingerbreadth between skull and ring; closeness makes pin care challenging. If in doubt, larger halo and longer pins are a better choice (Figure 16-5)
Figure 16-2 ▪ Note that the position of shoulders elevated, so occiput can recess back and avoid flexion.
Figure 16-3 ▪ Towels placed under midline occiput to allow for ring to be centered.
Figure 16-4 ▪ Template showing appropriate size.
Figure 16-5 ▪ Centered position of template assuring space between crown and skull.
How many pins?
It depends on the bone quality
An adolescent with normal bone usually needs only four. Toddler or child with abnormally soft skull may need 10 pins.
How much torque for the pins?
It depends on the bone quality
The number of pins and lbs of torque depend on age and should range from:
toddler: 8 to 10 pins with finger-tightening pins
young child ages 4 to 8: 6 to 8 pins at 4 to 6 N/lbs
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