Donald Corenman, MD, DC

Here is the answer.

Skull traction can be managed by a Halo (4 pin fixation), Gardner-Wells or Mayfield traction (2-3 pin fixation but only temporary for intraoperative traction). The only rigid fixation for longer term use is the Halo attached to a 4 bar torso vest. For intraoperative surgical use, the Gardner-Wells device is good for axial traction but will not control rotation as it is 2 point fixation. The Mayfield will allow axial traction and control rotation too as it is 3 point fixation. Inserting the pin requires penetrating only the outer cortex of the skull. The inner cortex should remain intact. This requires a torque driver and about 8 inch-pounds of pressure. The posterior skull is thicker and can withstand a greater torque than the anterior and lateral skull.

If the pins are for long term use (Halo with vest), pin cleaning needs to be performed daily to twice daily. This is done with a dilute solution of Betadine, saline, soap and water, dilute hydrogen peroxide or some use an alcohol solution. The alcohol is desiccating, the hydrogen peroxide is effective but both can leave larger scars. Make sure the pin sites do not crust over (eschar) as this leads to infection. The pin sites will be colonized by bacteria and the cleaning keeps this under control. Q-tips can be used to clean the pin sites but use a new Q-tip on each site as to not spread any bacteria from one pin to another. If a frank infection occurs and the pins are still solidly planted, oral antibiotics can be used. If the pin site loosens in the face of an infection, the pin will need to be moved. If the pin loosens but there is no infection, the pin can be carefully tightened with a torque driver but be very careful not to penetrate the interior cortex of the skull.

Remember that Halo vest use will immobilize the spine but not fully. A very unstable spine can still cause neurological compromise with Halo vest stabilization.

Hope this helps.

Dr. Corenman

A unilateral pars fracture of L5 is very common in tennis players and professional skiers. The serve and overhead both cause significant extension (bending backwards) of the spine and this can overload the bone causing this stress fracture. Make sure this fracture is not a facet fracture (a lower fracture in the same bone) as the facet fracture has a different prognosis.

If this is truly a unilateral pars fracture, there is a good chance it will heal but healing will take at least three months. This means no tennis or any exercise that would put your back into extension. Think of this fracture as an ankle fracture. I don’t think you would run, play tennis or lift weights with an ankle fracture- so treat it as that.

Bracing is optional but I like to use braces for this fracture as it reminds you not to bend backwards which destroys the healing potential. This fracture may not heal in spite of your carefully reduced activity. Without healing, the other side that is intact will react to the increased stress. It may go one of two ways. It may develop more bone to compensate for the increased stress (hypertrophy) which is a good development or it may eventually fracture from the overloaded stress.

If the other side does hypertrophy, the pain most likely be reduced but may not completely go away under load. Healing potential can be ascertained with a bone scan but the MRI can also give similar information without a radioactive tracer being used. I always obtain a new limited CT scan (just the fracture area and not the entire lumbar spine) in athletes to look for healing. The fracture is repairable surgically if necessary.

Hope this helps.

Upper thoracic pain is very commonly from cervical spine origin. My first question would be if you have had a cervical MRI.

The comment from your chiropractor about T1 being “pushed forward” on T2 could be an indication of something called a degenerative spondylolysthesis (see section on neckandback.com). Vertebral slips may not show up on an MRI as you are lying down for the MRI images and the slip may return to normal alignment without the affects of gravity.

Lifting heavy weights may uncover an instability of the vertebral segments that normally would not have attention paid to it. Do you develop pain immediately during a lifting session or 3-4 hours later? If you don’t lift for 3-4 days, does the pain go away?

Dr. Corenman