Brain abscess from halo pin penetration

doi:10.4236/crcm.2013.29132

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Vol.2, No.9, 505-507 (2013) Case Reports in Clinical Medicine

http://dx.doi.org/10.4236/crcm.2013.29132

Brain abscess from halo pin penetration

Rohit Patel, Bobby K. Desai*, T. James Gallagher

Department of Emergency Medicine, College of Medicine, University of Florida, Gainesville, USA;

*Corresponding Author: [email protected]

Received 9 October 2013; revised 7 November 2013; accepted 6 December 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In accor-

ABSTRACT

Halo fixation devices are often employed for

critically ill or trauma patients with unstable cer-

vical pathologies. These include fractures, spi-

nal decompression and reconstruction proce-

dures. However, the critical care literature has

surprisingly little information in regard to asso-

ciated complications. Perry and Nickel pio-

neered the initial halo device in 1959 and soon

afterward recognized complications associated

with its use [1]. They developed a detailed regi-

men to prevent abnormal pin placement and

infections. The details include pin placement in

“safe” zones, specific degrees of torque, and

techniques to minimize infection risk. Despite a

low death rate, a cerebral brain abscess often

leads to prolonged neurological morbidity [2].

Seizures and pneumocranium have also been

ascribed to intracranial penetration of halo pins

[3,4]. The following describes a patient with ce-

rebral abscess secondary to halo pin penetra-

tion. He then developed several other associ-

ated complications during hospitalization.

Keywords: Cerebral Abscess; Cranial Pin; Halo

Orthosis Device; Inner Tabl e of Skull; Complication

1. INTRODUCTION

1.1. History and Presentation

A 50-year-old male presented to the University of

Florida emergency department (ED) with a history of

slurred speech and word finding difficulty. Two months

ago, his C2 fracture was stabilized with a halo device.

The injury resulted from an ATV accident. At the time of

initial discharge, he was neurologically intact. Loose

screws had required retightening in clinic five weeks

prior to this latest admission. Three weeks prior to arrival

in the ED, he had develop ed swelling of his face and p in

sites as well as purulent drainage around the pin sites.

This resolved with antibiotic treatment (amoxicillin-

clavulanate). One day prior to arrival, slurred speech and

word finding difficulty developed. The patient stated that

he awakened disoriented the night previous, noted

slurred speech, and had difficulty with specific words,

although he knew what he wanted to say. Two hours later,

he felt that the problems had resolved. However, he also

indicated that his handwriting looked like “gibberish”.

After phone consultation, he presented to the neurosur-

gery clinic. A diagnosis of cerebral infection was consid-

ered and the patient was sent to Emergency Department

for furthe r workup.

1.2. Examination

On examination, the patient was alert, awake, oriented,

and hemodynamically stable. Vital signs were within

normal limits. No abnormalities or localizing findings

were found on neurological examination. Speech was

completely intact. There was, however, erythema and a

small amount of purulent drainage from the pin sites. He

was afebrile and the white blood cell count (WBC) was

7000/cu mm. There were no signs of systemic infection.

1.3. Initial Treatment and Course

Head CT showed a new left parietal infarct and ade-

quate healing of the cervical spine fracture (Figure 1).

The halo was removed. Continued immobilization was

accomplished with a hard cervical collar. MRI & MRA

of the head and neck demonstrated meningitis, left fron-

tal cerebritis, and a left parietal intraparenchymal ab-

scess. The abscess appeared related to skull penetration

of the halo screws. Antibioitic treatment was initiated

with piperacilin-tazobactam. Surgical intervention was

planned (Figures 2(a) and (b)). Initial cultures were not

sent.

K. C. Chou et al. / Natural Science 1 (2009) 505-507

506

Figure 1. CT brain without contrast. Ill defined area

of hypodensity in left parietal lobe with vasogenic

edema incompletely visualized due to halo device.

(a) (b)

Figure 2. (a)-(b) MRI T1 pre and post contrast. Intracranial

infection with diffuse meningeal thickening and enhancement,

13 × 16 × 14 mm left parietal ring enhancing fluid collection

with adjacent vasogenic edema most consistent with abscess.

1.4. Hospital Course

Evacuation of the abscess was through a left frontal

and parietal craniotomy. Intra-op cultures grew a small

amount of MSSA. Two days postop, after being trans-

ferred to the floor, the patient experienced an un-wit-

nessed fall. Prior to the event, he had experienced in-

creasing confusion. A nurse went into room to check on

the patient and found him on the floor awakes but still

confused with his c-collar in place. An emergent CT scan

demonstrated a 6.5 × 4.5 cm hematoma within the pre-

vious left parietal operative bed. He was again returned

to the OR for hematoma evacuation (Figure 3). Postop,

his neurological status continued to improve. The Infec-

tious Disease service recommended a six-week course of

oxacillin.

2. DISCUSSION

Cerebral abscess related to a halo screw represents a

rare complication and requires early recognition [5]. To

date minimal information has appeared in the critical

care related literature. Halo devices have many advan-

tages. The halo effectively maintains spinal column

alignment. It can be easily applied and has minimal in-

terferences with mandibular function. Furthermore it pro-

vides earlier mobilization.

Garfin et al. [6] reviewed 179 cases to identify risks

with the external halo device and found that pin loosen-

ing occurred in 36% of patients, pin site infectio n in 20%,

severe pin discomfort in 18%, dysphagia in 2%, and

dural penetration in 1%.

A cerebral abscess can occur through improper pin

placement with penetration of the (inner table) due

topoor hygiene, or loosening or over-torqued cranial pins

[7]. Saeed et al. described 16 cases of halo pin associated

cerebral abscess [8]. The most common presenting symp-

tom was headache (8 cases), followed by fever (4 cases),

nausea/vomiting (3 cases), focal neurological deficits (2

cases), altered mental status (2 cases), and localized pain

(2 cases). The most common location of the abscess was

the parietotemporal area. S. aureus was isolated in 14 of

the 16 cases. The remaining cases showed S. epidermidis,

Peptococcus, or no organisms.

Penetration of the pins through the inner table of the

skull can create a direct route into the intracranial cavity.

Pins are constructed so that there is a sharp point and a

broader body to prevent such occurrence. However, it

may still occur particularly in an area of thin bone. “Safe”

zones have been recommended such as the posterolateral

aspects of the calvaria where the density of bone is

greater. This area corresponds to the 4 o’clock and 8

o’clock positions. The 12 o’clock position involves the

anterior calvaria or glabella and the 6 o’clock location

represents the posterior calvaria or posterior occipital

protuberance. Although the scar created by placement

Figure 3. CT without contrast after fall and evacuation (on

right). Large left parietal operative site hemorrhage and extra

axial blood collection with associated mass effect with herni-

ation and hydrocephalus.

R. Patel et al. / Case Reports in Clinical Medicine 2 (2013) 505-507

507

through the temporalis muscle is within the hairline and

more aesthetic, penetration of the pins through the tem-

poralis muscle is painful and may impede the ability to

chew without discomfort. The bone underlying this area

is also thinner and prone to puncture with repeated pin

loosenin g [9] .

Initial pin placement requires appropriate torque to

prevent loosening and possible skull penetration. Rizzolo

et al. [10] compared 102 patients with a pin torque of

either 6 or 8 inch-pounds. Thosepins inserted with 6

inch-lbs torque had fewer complications, including loos-

ening, infection, pin change, or loss of pin. Pande et al.

[11] reported a case of transient brain injury from pin

penetration into thetemporoparietal region of the brain

[11]. This developed 6 hours after the halo was retight-

ened. The patient demonstrated drowsiness, facial

asymmetry, and a weak left hand grip. There was no in-

fection and the patient recovered. The pin was replaced.

Poor pin site hygiene can also lead toinfection. Water

and mild soap are recommended for cleaning the sites.

Agents including povidone-iodine, hydrogen peroxide,

and chlorhexidine have shown higher infection rates [12].

Also, excessive cleaning can lead to excess granulation

tissue around the pins and subsequent loosening.

Re-tightening of the pins generally occurs at 24 hours

and again after 1 week. Also routine follow up should be

done at 4 - 6 week inter vals.

Antibiotic therapy has been more successful when

begun prior to actual abscess formation. Once an abscess

develops, surgical evacuation completed with antibiotic

therapy becomes the only available option. Some cases

have presented as orbital pain, aphasia, seizure, lethargy,

disorientation, or psychosis [13,14]. As previously men-

tioned, even if adequately treated, these symptoms can

be associated with serious long term cerebral paren-

chyma damage. These include interference with the nor-

mal propagation of electrical impulses, and the site now

becomes a potential seizure focus [5 ,6].

3. CONCLUSION

Patients with halo placement are often in the ICU.

Awareness of potential complications from these devices

must be part of the clinicians’ competence. Those with

halo pins and a clinical picture suggestive of infection

require close and detailed evaluation. Pin site infection

should be promptly treated to prevent pin penetration

into the brain and possible deep cranial infection. Early

recognition may reduce morbidity.

REFERENCES

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