|Year : 2016 | Volume
| Issue : 1 | Page : 13-19
Evaluation the efficiency of cervical orthoses on cervical fracture: A review of literature
Mohammad Taghi Karimi1, Mostafa Kamali1, Francis Fatoye2
1 Department of Orthotics and Prosthetics, Rehabilitation Faculty, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Health Professions, Manchester Metropolitan University, United Kingdom
|Date of Web Publication||17-Feb-2016|
Mohammad Taghi Karimi
Musculoskeletal Research Center, Isfahan University of Medical Sciences, Isfahan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Various methods have been used to stabilize the vertebra in cervical fractures, including the use of various orthoses and surgery. However, it is not cleared which type of orthosis is more suitable for the subjects with cervical fractures to best immobilize the vertebra and to decrease the associated side effects. Therefore, the aim of this study was to evaluate the efficiency of various orthoses based on the available literature. Materials and Methods: A search was done in some databases include PubMed, ISI Web of Knowledge, EBSCO, Embasco, and Google Scholar. The search was done with some key words such as: Cervical spine injuries; odontoid fractures; hangman's fractures; axis fracture; axis, atlas, cervical fractures; trauma; neck fracture; neck injury in combination with cervical orthoses. The quality of the studies was evaluated by use of Downs and Black assessment and Assessment of Multiple Systematic Reviews (AMSTAR) for original research and review articles, respectively. Results: Based on the aforementioned key words, 25 papers were selected. The quality of the studies varies 10-24. Most of the studies were on the use of the halo vest orthosis, its side effects and also on complications associated with various orthoses. Discussion: Halo orthoses provide a high degree of restriction and immobilization; however, there are some side effects associated with this orthosis, including swallowing, pin loosening, and infection. It should be emphasized that other types of orthoses fewer complications, with reasonable outputs on motion restrictions.
Keywords: Cervical, cervical fracture, fracture, motion restriction, orthosis, side effects
|How to cite this article:|
Karimi MT, Kamali M, Fatoye F. Evaluation the efficiency of cervical orthoses on cervical fracture: A review of literature. J Craniovert Jun Spine 2016;7:13-9
|How to cite this URL:|
Karimi MT, Kamali M, Fatoye F. Evaluation the efficiency of cervical orthoses on cervical fracture: A review of literature. J Craniovert Jun Spine [serial online] 2016 [cited 2018 Nov 19];7:13-9. Available from: http://www.jcvjs.com/text.asp?2016/7/1/13/176611
| Introduction|| |
The performance of the cervical spine is influenced by various diseases and also injuries.  There is no doubt that the motions and integrity of the cervical spine influence the performance of subjects.  Various treatment approaches have been used to manage the problems associated with cervical spine, including physical therapy, the use of various assistive devices, and surgery. ,,
Various kinds of assistive devices have been prescribed for the cervical spine to control the motions of unstable vertebra, and to decrease the loads on cervical spine including halo vest, cervical orthosis, Philadelphia collars, Minerva collars, Aspen, stiff-neck Miami collar, and NecLoc orthoses. ,,,,,, Some types of orthoses, such as halo vest collar and noninvasive collar, have been used especially for fractures of C1 and C2.  Although several studies support the effectiveness of these orthoses to immobilize the fracture sites, there are some side effects that influence the use of these orthoses including  pin loosening, infection of pin sites, penetrating skull bone, and uncosmetic of this device are some problems associated with the halo orthosis.  Other orthoses such as Minerva and Aspen collars have been designed and used to solve the problems associated with the use of halo vest collars.
However, the main question posed here is, is there any difference between the performance and compliance of Minerva and Aspen orthoses compared to the halo vest brace? Unfortunately, it is a matter of controversy which type of cervical orthosis is more suitable based on the type of injury, required immobilization, and associated side effects. Therefore, the aim of this review was to collect the evidences regarding the efficiency of various cervical orthoses based on the type of injury.
| Materials And Methods|| |
Two reviewers independently identified the studies published in English on some databases such as CINAHL, EBSCO, Medline, Google Scholar, PubMed, and ISI Web of Knowledge between 1960 and 2014. Some key words such as cervical spine injuries; odontoid fractures; hangman's fractures; axis fracture; axis, Atlas More Details, cervical fractures; trauma; neck fracture; neck injury have been used with cervical orthoses.
The main criteria to select the papers were those published in English and focused on the use of orthoses. The first selection of the papers was based on their titles and abstracts. If the title and abstract addressed the research questions of interest, the paper was selected for final analysis.
All articles related to the topic were selected and their bibliographies were searched for further references in this context. The second selection of the papers was done based on the inclusion of orthosis and/or cervical orthosis. This means that all papers related to the use of other rehabilitation methods (exercise, physical therapy) and surgery were removed.
The quality of the original research articles was evaluated by use of the Downs and Black questionnaire, which evaluates the internal validity, external validity, and bias of various research studies. The reliability and validity of the Downs and Black tool in evaluation of quality of research papers have been proved.  The quality of review article was evaluated by the Assessment of Multiple Systematic Reviews (AMSTAR) tool, which is a reliable tool to assess the quality of review articles. It consists of 11 questions. 
Some information, such as the method of evaluation, number of studies, type of studies, number of subjects, follow-up period, type of orthosis used, and brief review of outcomes, were provided in tables [Table 1], [Table 2], [Table 3], [Table 4], [Table 5] and [Table 6].
|Table 2: The complications associated with the use of various cervical orthoses|
Click here to view
|Table 3: The complications associated with the use of various cervical orthoses|
Click here to view
|Table 4: Comparisons of various methods of cervical spine fracture treatment|
Click here to view
|Table 5: The results of the reviews done on efficiency of cervical orthoses in treatment of cervical fractures|
Click here to view
| Results|| |
Based on the key words mentioned above, 1800 papers were found. After screening the papers based on titles and abstracts, 25 were selected for final analysis. The quality of original studies varied 10-24. Nearly 7 studies were found on comparison between the efficiency of various orthoses with quality varied 16-20. Fifteen studies focused on complications of orthosis. Three papers also focused on outputs of treatment by orthoses based on type of fractures.
| Discussion|| |
The performance of the cervical spine is influenced by various musculoskeletal disorders and injury. Various treatment methods have been recommended for the treatment of cervical spine including surgery, rehabilitation, and the use of cervical orthoses. Cervical orthoses are being used for the immobilization of the spine following injuries. Although various orthoses have been used for fracture of the cervical spine, it is controversial which orthosis is more suitable to be used depends on the type of injury. Moreover, it was not cleared which orthoses have more ability to restrict the motions and have fewer complications. Therefore, the aim of this study was to compare the efficiency of various cervical orthoses depending on the type of injury.
Efficiency of cervical orthosis
There were only five studies on the efficiency of the cervical orthosis for the treatment of cervical injuries which most of them focus on cervical fracture. In the research done by Vieweg et al. with 70 patients with upper cervical injury (with ligament injury, C1, C2, C1, and C2 fractures) it was shown that the use of halo orthosis is a good choice with no complications.  Moreover, the use of halo orthosis decreases hospital time and stabilizes the injured spines successfully.  The outputs of the study done by Sewers et al. also showed that the noninvasive halo (NIH) orthosis successfully immobilized the fractured sites with acceptable alignment and with no additional loss of neurological dysfunction.  As can be seen from the studies mentioned above, most of the studies focused on the use of the halo orthosis for immobilization of the fractured cervical spine. It can be concluded that the halo orthosis is a good alternative to surgery to stabilize the fractures of the cervical spine.
Comparison between orthoses
There were five studies comparing the efficiency of orthoses. It should be noted that the efficiency of an orthosis is determined based on restricted motions, which mostly was evaluated by the x-ray in extremes of flexion and extension.  In the research done by Horodyski et al. on the comparison of two different orthoses (one-piece extraction collar and two-piece), it was shown that although using a cervical collar is better than no immobilization, the mentioned collars do not efficiently reduce the motion in unstable vertebra at C5/C6.  The efficiency of the soft collar, Minerva brace, and Miami collar for fracture of the odontoid process (type 2) was evaluated by Richter et al.  Based on the results of this study, halo resists the motions of C1-C2-, C2-C3 more than other, mentioned orthoses. Thus, it would be the first choice for conservative treatment of unstable injuries of the upper cervical spine. 
In another research done on normal subjects, the efficiency of the NecLoc cervical orthosis on motion restriction was evaluated. It has been shown that this orthosis was superior in controlling flexion/extension, rotation, and lateral rotation to the Philadelphia and Aspen collars. 
The results of other studies showed that Newport/Aspen controlled flexion/extension/rotation and lateral bending in daily activities but had no ability to control snaking.  The efficiency of cervical orthosis to control the upper and lower parts was also evaluated. It was found that the cervicothoracic orthosis (CTO) produced more motion control (gross and intervertebral) compared to Miami and Aspen collars. ,[ 17]
There are also some studies that compared Minerva and halo and other cervical orthoses. ,,,, In the research done by Benzel et al., the intervertebral motions were evaluated on 18 patients. They showed that the unstable fractures in the upper part of cervical vertebra should be treated with a halo orthosis. In contrast, the injuries between the mid- and low cervical vertebra can be treated with a Minerva orthosis.  The intervertebral motions of 20 healthy subjects were also evaluated by Maiman et al. The results of their research confirmed that the immobilization provided by the Minerva orthosis was the same as that of halo. However, it seems that the Minerva provided more immobilization at C3-C4 and C6-C7.  Most of these studies were done on normal subjects or cadavers. Based on these studies, the Minerva orthosis was as effective as the halo in controlling the cervical motions, especially in the lower part of the cervical spine.
Based on the studies mentioned above, it can be concluded that the use of the cervical orthosis is a good and effective alternative to surgery to stabilize the injured spine. It seems that the efficiency of the halo orthosis is more than other available orthoses, especially to immobilize the upper cervical spine.
Complication of cervical orthoses
Regarding the complication of available orthoses, 15 papers were found. ,,,,,,,, The quality of the papers varies 10-16. The main complications associated with the use of cervical orthoses include: Pin losing, pin site infection, misalignment, local neck symptoms, pressure sores from plastic vests, nerve injury, dual penetration, pain, change in swallowing function, stiffness of facial muscles, change in bolus flow, and occipital ulceration. However, most of the problems mentioned are related to the use of the halo cervical orthosis.
In the research done by Shin et al. on 23 patients with upper cervical injuries (C1 fracture, C2 dens fracture, C2 hangman's fracture), 34.8% and 17.4% of the subjects had complications from pin loosening and pin site infection, respectively.  In contrast, Morishima et al. (CNM et al.) showed that of 179 subjects treated with halo-external device, 36 had complications from pin loosening, 20% from pin site infection, 11% pressure sores from pelvic vest, 2% from nerve injury, 1% from dural penetration, 2% from dysphasia, 9% from scar, and 18% from severe pain/discomfort.
Swallowing was the other complication mentioned following the use of cervical orthoses. ,, In the review article published by Branco, it was concluded that cervical orthoses change swallowing functions. Bradley et al. also showed that 66% of the subjects had dysphasia and aspiration  and this was counter to the finding of Bagley et al., which showed a low percentage of dysphasia. 
From the studies mentioned above, it can be concluded that many complications mentioned with regard to cervical orthoses relate to the use of alo vest orthosis. There is not enough evidence regarding the complications associated with other types of cervical orthoses. However, the interesting point is that the complications vary across different studies, which may be due to methods of use of orthoses, types of orthoses, available facilities to control infections, etc. Based on the results of the study done by Ho et al., most of the complications, such as infection and pin loss following the use of halo orthosis, are related to the reuse of titanium skull pins.  They concluded that reuse of titanium skull pins should be avoided. Regarding swallowing, it can be concluded that most total-contact orthoses restrict the normal swallowing performance of subjects.
From the reviewed studies, it can be determined that most studies were done on halo vest orthoses and in subjects with cervical fractures. The use of the halo orthosis has a high healing rate but also has some complications. Halo orthosis may be more effective in the immobilization of injuries above C2 but the Minerva is safer, more comfortable, has more patient compliance, and more reliable. ,,
There is no doubt that the immobilization provided by the halo orthosis is greater than that provided by other available orthoses and this is the main reason to use this orthosis. However, the mentioned complications restrict the usability of this orthosis. Therefore, new orthoses should be designed to decrease the complications of the halo vest orthosis but maintain the same performance. The Wilson orthosis is one of the orthoses designed especially to overcome the problems mentioned above.  This new orthosis was tested on 20 patients with unstable cervical spines. The results confirmed that this orthosis can control appropriate motions properly and can be used successfully for the immobilization of the cervical spine.
| Conclusion|| |
The results of this review study showed that most studies done on the efficiency of cervical orthoses were based on halo vest orthoses. Although the halo orthosis provides a high degree of restriction and immobilization, it has lots of complications. Swallowing problems and pin loosening infections are the most important complications associated with the use of the halo. There is not enough evidence regarding the efficiency of other types of cervical orthoses. Therefore, it is recommended that available cervical orthoses be studied regarding motion restriction and complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Fredø HL, Rizvi SA, Lied B, Rønning P, Helseth E. The epidemiology of traumatic cervical spine fractures: A prospective population study from Norway. Scand J Trauma Resusc Emerg Med 2012;20:85.
Lewkonia P, Dipaola C, Schouten R, Noonan V, Dvorak M, Fisher C. An evidence-based medicine process to determine outcomes after cervical spine trauma: What surgeons should be telling their patients. Spine (Phila Pa 1976) 2012;37:E1140-7.
Lauweryns P. Role of conservative treatment of cervical spine injuries. Eur Spine J 2010;19(Suppl 1):S23-6.
Longo UG, Denaro L, Campi S, Maffulli N, Denaro V. Upper cervical spine injuries: Indications and limits of the conservative management in Halo vest. A systematic review of efficacy and safety. Injury 2010;41:1127-35.
Sawers A, DiPaola CP, Rechtine GR 2 nd
. Suitability of the noninvasive halo for cervical spine injuries: A retrospective analysis of outcomes. Spine J 2009;9:216-20.
Stambolis V, Brady S, Klos D, Wesling M, Fatianov T, Hildner C. The effects of cervical bracing upon swallowing in young, normal, healthy volunteers. Dysphagia 2003;18:39-45.
Rusanen M, Karaharju E, Korkala O. The halo brace in unstable fractures of the cervical spine: A review of 14 cases. Injury 1985;16:318-20.
Horodyski M, DiPaola CP, Conrad BP, Rechtine GR 2 nd
. Cervical collars are insufficient for immobilizing an unstable cervical spine injury. J Emerg Med 2011;41:513-9.
Bell KM, Frazier EC, Shively CM, Hartman RA, Ulibarri JC, Lee JY, et al
. Assessing range of motion to evaluate the adverse effects of ill-fitting cervical orthoses. Spine J 2009;9:225-31.
Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52:377-84.
Seo HJ, Kim KU. Quality assessment of systematic reviews or meta-analyses of nursing interventions conducted by Korean reviewers. BMC Med Res Methodol 2012;12:129.
Vieweg U, Meyer B, Schramm J. Differential treatment in acute upper cervical spine injuries: A critical review of a single-institution series. Surg Neurol 2000;54:203-11.
Sharpe KP, Rao S, Ziogas A. Evaluation of the effectiveness of the Minerva cervicothoracic orthosis. Spine (Phila Pa 1976) 1995;20:1475-9.
Richter D, Latta LL, Milne EL, Varkarakis GM, Biedermann L, Ekkernkamp A, et al
. The stabilizing effects of different orthoses in the intact and unstable upper cervical spine: A cadaver study. J Trauma 2001;50:848-54.
Askins V, Eismont FJ. Efficacy of five cervical orthoses in restricting cervical motion. A comparison study. Spine (Phila Pa 1976) 1997;22:1193-8.
Hughes SJ. How effective is the Newport/Aspen collar? A prospective radiographic evaluation in healthy adult volunteers. J Trauma 1998;45:374-8.
Gavin TM, Carandang G, Havey R, Flanagan P, Ghanayem A, Patwardhan AG. Biomechanical analysis of cervical orthoses in flexion and extension: A comparison of cervical collars and cervical thoracic orthoses. J Rehabil Res Dev 2003;40:527-37.
Millington PJ, Ellingsen JM, Hauswirth BE, Fabian PJ. Thermoplastic Minerva body jacket - A practical alternative to current methods of cervical spine stabilization. A clinical report. Phys Ther 1987;67:223-5.
Maiman D, Millington P, Novak S, Kerk J, Ellingsen J, Wenninger W. The effect of the thermoplastic Minerva body jacket on cervical spine motion. Neurosurgery 1989;25:363-8.
Benzel EC, Larson SJ, Kerk JJ, Millington PJ, Novak SM, Falkner RH, et al
. The thermoplastic Minerva body jacket: A clinical comparison with other cervical spine splinting techniques. J Spinal Disord 1992;5:311-9.
Shin JJ, Kim SJ, Kim TH, Shin HS, Hwang YS, Park SK. Optimal use of the halo-vest orthosis for upper cervical spine injuries. Yonsei Med J 2010;51:648-52.
Ho CH, Li KK, Chin RP, Lee HW, Kwong WY, Kwan HH. Monitoring the use of halo fixation device through an assessment form. J Orthop Surg (Hong Kong) 2011;19:322-5.
Lind B, Sihlbom H, Nordwall A. Halo-vest treatment of unstable traumatic cervical spine injuries. Spine (Phila Pa 1976) 1988;13:425-32.
Anderson PA, Budorick TE, Easton KB, Henley MB, Salciccioli GG. Failure of halo vest to prevent in vivo
motion in patients with injured cervical spines. Spine (Phila Pa 1976) 1991;16(Suppl):S501-5.
Bradley JF 3 rd
, Jones MA, Farmer EA, Fann SA, Bynoe R. Swallowing dysfunction in trauma patients with cervical spine fractures treated with halo-vest fixation. J Trauma 2011;70:46-50.
Bagley CA, Witham TF, Pindrik JA, Davis RF, Bydon A, Gokaslan ZL, et al
. Assuring optimal physiologic craniocervical alignment and avoidance of swallowing-related complications after occipitocervical fusion by preoperative halo vest placement. J Spinal Disord Tech 2009;22:170-6.
Morishima N, Ohota K, Miura Y. The influences of Halo-vest fixation and cervical hyperextension on swallowing in healthy volunteers. Spine (Phila Pa 1976) 2005;30:E179-82.
Odderson IR, Lietzow D. Dysphagia complications of the Minerva brace. Arch Phys Med Rehabil 1997;78:1386-8.
Vieweg U, Schultheiss R. A review of halo vest treatment of upper cervical spine injuries. Arch Orthop Trauma Surg 2001;121:50-5.
Pringle RG. Halo versus Minerva - Which orthosis? Paraplegia 1990;28:281-4.
Wilson C, Hadjipavlou A, Berretta G. A new non-invasive halo orthosis for immobilization of the cervical spine. Prosthet Orthot Int 1978;32:16-9.
Johnson RM, Hart DL, Owen JR, Lerner E, Chapin W, Zeleznik R. The yale cervical orthosis: An evaluation of its effectiveness in restricting cervical motion in normal subjects and a comparison with other cervical orthoses. Phys Ther 1978;58:865-71.
Robert MC, Lillian AT, Joseph CM. A new cervical-thoracic orthosis: Clinical report of seven cases. J Prosthet Orthot 1998;10:33-6.
Garfin SR, Botte MJ, Waters RL, Nickel VL. Complications in the use of the halo fixation device. J Bone Joint Surg Am 1986;68:320-5.
Zhang S, Wortley M, Clowers K, Krusenklaus JH. Evaluation of efficacy and 3D kinematic characteristics of cervical orthoses. Clin Biomech (Bristol, Avon) 2005;20:264-9.
Hughes S. Efficacy of five cervical orthoses in restricting cervical motion: A comparison study. Spine (Phila Pa 1976) 1998;23:744.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]