Can surgery improve neurological function in penetrating spinal injury? A review of the military and civilian literature and treatment recommendations for military neurosurgeons

An update on civilian spinal gunshot wounds: treatment, neurological recovery, and complications

STUDY DESIGN

Retrospective analysis of inpatient and outpatient data from a single academic trauma center.

OBJECTIVE

To test the effectiveness of a conservative treatment algorithm for civilian spinal gunshot wounds (CSGSWs) by comprehensively evaluating neurological status and recovery, fracture type, concomitant injuries, indications for surgery, and complications.

SUMMARY OF BACKGROUND DATA

Few large studies exist to guide treatment of CSGSWs, and none have been published in nearly 20 years.

METHODS

A search of International Classification of Diseases, Ninth Revision (ICD-9) codes was performed for all hospital patients treated from 2003 to 2011 by either neurosurgery or orthopedic surgery to identify 159 consecutive patients who sustained CSGSWs. Mean follow-up was 13.6 months. American Spinal Injury Association grading was used to assess neurological injury.

RESULTS

Fifty percent of patients had neurological deficits from CSGSW. Complete spinal injury was the most common injury grade; thoracic injuries had the most risk of complete injury (P < 0.001). Nearly 80% of patients had concomitant injuries to other organs. Operative treatment was more likely in patients with severe neurological injuries (P = 0.008) but was not associated with improved neurological outcomes (P = 1.00). Nonoperative treatment did not lead to any cases of late spinal instability or neurological deterioration. Overall, 31% of patients had an improvement of at least 1 American Spinal Injury Association grade by final follow-up. Nearly half of patients experienced at least 1 GSW-related complication; risk of complications was associated with neurological injury grade (P < 0.001) and operative treatment (P = 0.04).

CONCLUSION

The vast majority of CSGSWs should be managed nonoperatively, regardless of neurological grade or number of spinal columns injured. Indications for surgery include spinal infection and persistent cerebrospinal fluid leaks.

LEVEL OF EVIDENCE

3.

Combat-related intradural gunshot wound to the thoracic spine: significant improvement and neurologic recovery following bullet removal

The vast majority of combat-related penetrating spinal injuries from gunshot wounds result in severe or complete neurological deficit. Treatment is based on neurological status, the presence of cerebrospinal fluid (CSF) fistulas, and local effects of any retained fragment(s). We present a case of a 46-year-old male who sustained a spinal gunshot injury from a 7.62-mm AK-47 round that became lodged within the subarachnoid space at T9-T10. He immediately suffered complete motor and sensory loss. By 24-48 hours post-injury, he had recovered lower extremity motor function fully but continued to have severe sensory loss (posterior cord syndrome). On post-injury day 2, he was evacuated from the combat theater and underwent a T9 laminectomy, extraction of the bullet, and dural laceration repair. At surgery, the traumatic durotomy was widened and the bullet, which was laying on the dorsal surface of the spinal cord, was removed. The dura was closed in a water-tight fashion and fibrin glue was applied. Postoperatively, the patient made a significant but incomplete neurological recovery. His stocking-pattern numbness and sub-umbilical searing dysthesia improved. The spinal canal was clear of the foreign body and he had no persistent CSF leak. Postoperative magnetic resonance imaging of the spine revealed contusion of the spinal cord at the T9 level. Early removal of an intra-canicular bullet in the setting of an incomplete spinal cord injury can lead to significant neurological recovery following even high-velocity and/or high-caliber gunshot wounds. However, this case does not speak to, and prior experience does not demonstrate, significant neurological benefit in the setting of a complete injury.

Publication patterns of comparative effectiveness research in spine neurosurgery

OBJECT

The purpose of this study was to investigate publication patterns for comparative effectiveness research (CER) on spine neurosurgery.

METHODS

The authors searched the PubMed database for the period 1980-2012 using the key words "cost analysis," "utility analysis," "cost-utility," "outcomes research," "practical clinical research," "comparator trial," and "comparative effectiveness research," linked with "effectiveness" and "spine neurosurgery."

RESULTS

From 1980 through April 9, 2012, neurosurgery CER publications accounted for 1.38% of worldwide CER publications (8657 of 626,330 articles). Spine neurosurgery CER accounted for only 0.02%, with 132 articles. The journal with the greatest number of publications on spine neurosurgery CER was Spine, followed by the Journal of Neurosurgery: Spine. The average annual publication rate for spine neurosurgery CER during this period was 4 articles (132 articles in 33 years), with 68 (51.52%) of the 132 articles being published within the past 5 years and a rising trend beginning in 2008. The top 3 contributing countries were the US, Turkey, and Japan, with 68, 8, and 7 articles, respectively. Only 8 regular articles (6.06%) focused on cost analysis.

CONCLUSIONS

There is a paucity of publications using CER methodology in spine neurosurgery. Few articles address the issue of cost analysis. The promotion of continuing medical education in CER methodology is warranted. Further investigations to address cost analysis in comparative effectiveness studies of spine neurosurgery are crucial to expand the application of CER in public health.

Penetrating spinal injuries and their management

Penetrating spinal trauma due to missile/gunshot injuries has been well reported in the literature and has remained the domain of military warfare more often. Civic society's recent upsurge in gunshot injuries has created a dilemma for the treating neurosurgeon in many ways as their management has always involved certain debatable and controversial issues. Both conservative and surgical management of penetrating spinal injuries (PSI) have been practiced widely. The chief neurosurgical concern in these types of firearm injuries is the degree of damage sustained during the bullet traversing through the neural tissue and the after-effects of the same in long term. We had an interesting case of a penetrating bullet injury to cervical spine at C2 vertebral level. He was operated and the bullets were removed from posterior midline approach. Usually, the management of such cases differs from region to region depending on the preference of the surgeon but still certain common principles are followed world over. Thus, we realized the need to review the literature regarding spinal injuries with special emphasis on PSI and to study the recent guidelines for their treatment in light of our case.

Military penetrating spine injuries compared with blunt

BACKGROUND CONTEXT

The nature of blunt and penetrating injuries to the spine and spinal column in a military combat setting has been poorly documented in the literature. To date, no study has attempted to characterize and compare blunt and penetrating spine injuries sustained by American servicemembers.

PURPOSE

The purpose of this study was to compare the military penetrating spine injuries with blunt spine injuries in the current military conflicts.

STUDY DESIGN/SETTING

Retrospective study.

PATIENT SAMPLE

All American military servicemembers who have been injured while deployed in Iraq (Operation Iraqi Freedom) and Afghanistan (Operation Enduring Freedom) whose medical data have been entered into the Joint Theater Trauma Registry (JTTR).

METHODS

The JTTR was queried for all American servicemembers sustaining an injury to the spinal column or spinal cord while deployed in Iraq or Afghanistan. These data were manually reviewed for relevant information regarding demographics, mechanism of injury, surgical intervention, and neurologic injury.

RESULTS

A total of 598 servicemembers sustained injuries to the spine or spinal cord. Isolated blunt injuries were recorded in 396 (66%) servicemembers and 165 (28%) sustained isolating penetrating injuries. Thirty servicemembers (5%) sustained combined blunt and penetrating injuries to the spine. The most commonly documented injuries were transverse process fractures, compression fractures, and burst fractures in the blunt-injured servicemembers versus transverse process fractures, lamina fractures, and spinous process fractures in those injured with a penetrating injury. One hundred four (17%) servicemembers sustained spinal cord injuries, comprising 10% of blunt injuries and 38% of penetrating injuries (p<.0001). Twenty-eight percent (28%) of blunt-injured servicemembers underwent a surgical procedure compared with 41% of those injured by penetrating mechanisms (p=.4). Sixty percent (n=12/20) of blunt-injured servicemembers experienced a neurologic improvement after surgical intervention at follow-up compared with 43% of servicemembers (n=10/23) who underwent a surgical intervention after a penetrating trauma (p=.28). Explosions accounted for 58% of blunt injuries and 47% of penetrating injuries, whereas motor vehicle collisions accounted for 40% of blunt injuries and 2% of penetrating injuries. Concomitant injuries to the abdomen, chest, and head were common in both groups.

CONCLUSIONS

Blunt and penetrating injuries to the spinal column and spinal cord occur frequently in the current conflicts in Iraq and Afghanistan. Penetrating injuries result in significantly higher rates of spinal cord injury and trend toward increased rates of operative interventions and decreased neurologic improvement at follow-up.

Complications associated with military spine injuries

BACKGROUND CONTEXT

To assess the presence of complications associated with spine injuries in the Global War on Terror.

PURPOSE

To characterize the effect of complications in and around the battlefield during Operation Enduring Freedom and Operation Iraqi Freedom from 2001 to 2009.

STUDY DESIGN/SETTING

Retrospective study.

PATIENT SAMPLE

American servicemembers sustaining spine injury during combat.

METHODS

Extracted medical records of warriors identified by the Joint Theater Trauma Registry from October 2001 to December 2009. Complications were defined as unplanned medical events that required further intervention. Complications were classified as major or minor and further subdivided among groups, including surgical and nonsurgical management, mounted (in an armored vehicle) or dismounted at the time of injury, and blunt or penetrating trauma.

RESULTS

Major complications were encountered in 55 servicemembers (9%), and 38 (6%) sustained minor complications. Forty-four percent (n=24) of those with major complications had more than one complication. Eleven servicemembers sustained three or more complications. There were five intraoperative complications, and 50 occurred in the perioperative period. Intraoperative complications included gastrointestinal injury, dural tear, and instrument malposition. Among patients who sustained complications, precipitating spinal injuries occurred primarily in combat (n=43 [78%]) and resulted from blunt (18) or penetrating (25) mechanisms. Complications occurred in 10 (3%) of those treated nonoperatively and 45 (25%) of those receiving surgery. Complications were higher in the dismounted group (80%) as compared with those who were mounted in vehicles at the time of injury (20%). Thirty-five percent (n=24) of surgically treated, dismounted, and penetrating injured servicemembers had complications. Seventeen percent (n=8) of surgically treated and blunt injured mounted servicemembers and 20% (n=13) of dismounted servicemembers had complications. Among the dismounted and nonspinal cord-injured servicemembers, both blunt (p=.002) and penetrating injured (p<.0005) treated with surgery were correlated with complications. Only the dismounted servicemembers with spinal cord injuries because of a penetrating mechanism were also at an increased risk for complications (p<.0005).

CONCLUSIONS

Patients treated with surgery appear to be at increased complication risk regardless of the mechanism of injury. Uparmored vehicles may safeguard servicemembers from spine injuries and complications associated with their treatment. This may be reflective of the fact that less severe spinal and concomitant injuries are sustained in the precipitating trauma because of the protection afforded by the vehicle. Dismounted soldiers had more complications in all groups regardless of type of management or injury mechanism.

How bullet trajectory affects outcomes of civilian gunshot injury to the spine

We analysed retrospectively the effect of missile trajectory on outcomes from civilian gunshot injury to the spine (GSIS) between 1994 and 2008. Most of the 98 patients were male (88.8%). A minority (8%) of patients had multiple column injuries and a bone or bullet fragment in the spinal canal (14%). Neurologic injury was seen in 33%; and external bracing was applied to 30% of patients. The odds of bracing among patients with multiple levels of damage were 3.4 times than for patients with a single vertebral level of damage. The odds of paralysis among black patients were 6.33 times the odds among non-black patients. The odds of paralysis among patients with a fragment in the spinal canal were 12.99 times those without. We conclude that the supero-inferior trajectory affects the number of vertebral levels involved and consequently the need for bracing. The lateral trajectory affects neurological outcomes.