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Santangelo G, Wathen C, Pieters T, George DD, Worley L, Macaluso D, Dagli MM, Catanzaro S, Gu B, Welch WC, Petrov D, Vates GE, Ozturk AK, Schuster J, Stone JJ. Multi-institutional review of characteristics and management of gunshot wounds to the spine. Spine J 2024:S1529-9430(24)00216-X. [PMID: 38740190 DOI: 10.1016/j.spinee.2024.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND CONTEXT Gunshot wounds (GSWs) to the vertebral column represent an important cause of morbidity and mortality in the United States, constituting approximately 20% of all spinal injuries. The management of these injuries is an understudied and controversial topic, given its heterogeneity and lack of follow-up data. PURPOSE To characterize the management and follow-up of GSWs to the spine. STUDY DESIGN/SETTING A multi-institutional retrospective review of the experience of two urban Level 1 trauma centers. PATIENT SAMPLE Patients with GSWs to the spine between 2010-2021. OUTCOME MEASURES Measures included work status, follow-up healthcare utilization, and pain management were collected. METHODS Charts were reviewed for demographics, injury characteristics, surgery and medical management, and follow-up. Statistical analysis included T-tests and ANOVA for comparisons of continuous variables and chi-square testing for categorical variables. All statistics were performed on SPSS v24 (IBM, Armonk, NY). RESULTS A total of 271 patients were included for analysis. The average age was 28 years old, 82.7% of patients were black, 90% were male, and 76.4% had Medicare/Medicaid. The thoracic spine (35%) was most commonly injured followed by lumbar (33.9%) and cervical (25.6%). Cervical GSW was associated with higher mortality (p<.001); 8.7% of patients developed subsequent osteomyelitis/discitis, 71.3% received prophylactic antibiotics, and 56.1% of cervical GSW had a confirmed vertebral or carotid artery injury. ASIA scores at presentation were most commonly A (26.9%), D (20.7%), or E (19.6%), followed by C (7.4%) and B (6.6%). 18.8% of patients were unable to be assessed at presentation. ASIA score declined in only 2 patients, while 15.5% improved over their hospital stay. Those who improved were more likely to have ASIA B injury (p<.001). Overall, 9.2% of patients underwent spinal surgery. Of these, 33% presented as ASIA A, 21% as ASIA B, 29% as ASIA C, and 13% as ASIA D. Surgery was not associated with an improvement in ASIA score. CONCLUSIONS Given the ubiquitous and heterogeneous experience with GSWs to the spine, rigorous attempts should be made to define this population and its clinical and surgical outcomes. Here, we present an analysis of 11 years of patients presenting to two large trauma centers to elucidate patterns in presentation, management, and follow-up. We highlight that GSWs to the cervical spine are most often seen in young black male patients. They were associated with high mortality and high rates of injury to vertebral arteries and that surgical intervention did not alter rates of discitis/osteomyelitis or propensity for neurologic recovery; moreover, there was no incidence of delayed spinal instability in the study population.
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Affiliation(s)
- Gabrielle Santangelo
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Neurosurgery, University of Rochester, 601 Elmwood Ave., Rochester, NY 14620, USA.
| | - Connor Wathen
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas Pieters
- Department of Neurosurgery, University of Rochester, 601 Elmwood Ave., Rochester, NY 14620, USA
| | - Derek D George
- Department of Neurosurgery, University of Rochester, 601 Elmwood Ave., Rochester, NY 14620, USA
| | - Logan Worley
- Department of Neurosurgery, University of Rochester, 601 Elmwood Ave., Rochester, NY 14620, USA
| | - Dominick Macaluso
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mert Marcel Dagli
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sandra Catanzaro
- Department of Neurosurgery, University of Rochester, 601 Elmwood Ave., Rochester, NY 14620, USA
| | - Ben Gu
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - William C Welch
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dmitry Petrov
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - G Edward Vates
- Department of Neurosurgery, University of Rochester, 601 Elmwood Ave., Rochester, NY 14620, USA
| | - Ali K Ozturk
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - James Schuster
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan J Stone
- Department of Neurosurgery, University of Rochester, 601 Elmwood Ave., Rochester, NY 14620, USA
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Esipov AV, Antonov GI, Manukovsky VA, Movsisyan AB, Ivanov II, Kravtsov MN, Timonin SY. [Endoscopic treatment of mine-explosive spine injuries: 3 clinical cases and literature review]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2023; 87:83-91. [PMID: 37325830 DOI: 10.17116/neiro20238703183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Modern warfare is characterized by common mine-explosive injuries. The last ones are accompanied by multiple injuries, large area of damage and severe clinical status of victims. OBJECTIVE To demonstrate treatment of mine-explosive spinal injuries using modern minimally invasive endoscopic techniques. MATERIAL AND METHODS The authors present 3 victims with various mine-explosive injuries. Endoscopic removal of fragments from the lumbar and cervical spine was successful in all cases. DISCUSSION Most of victims with injuries of the spine and spinal cord do not require urgent surgery and can underwent surgical treatment after clinical stabilization. At the same time, minimally invasive techniques provide surgical treatment with minimal risk and earlier rehabilitation, as well as reduce the risk of infectious complications associated with foreign bodies. CONCLUSION Careful selection of patients for spinal video endoscopy will ensure positive outcomes. Minimization of iatrogenic postoperative injuries is especially important in patients with combined trauma. However, well-experienced surgeons should perform these procedures at the stage of specialized medical care.
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Affiliation(s)
- A V Esipov
- National Medical Research Center of High Medical Technologies - Vishnevsky Central Military Clinical Hospital, Moscow, Russia
| | - G I Antonov
- National Medical Research Center of High Medical Technologies - Vishnevsky Central Military Clinical Hospital, Moscow, Russia
| | - V A Manukovsky
- National Medical Research Center of High Medical Technologies - Vishnevsky Central Military Clinical Hospital, Moscow, Russia
| | - A B Movsisyan
- National Medical Research Center of High Medical Technologies - Vishnevsky Central Military Clinical Hospital, Moscow, Russia
| | - I I Ivanov
- National Medical Research Center of High Medical Technologies - Vishnevsky Central Military Clinical Hospital, Moscow, Russia
| | - M N Kravtsov
- Federal State Budgetary Military Educational Institution of Higher Education «Military Medical Academy named after S.M. Kirov» of the Ministry of Defense of the Russian Federation, St. Petersburg, Russia
| | - S Yu Timonin
- National Medical Research Center of High Medical Technologies - Vishnevsky Central Military Clinical Hospital, Moscow, Russia
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Abstract
Objective Injuries associated with firearms are a significant health burden. However, there is no comprehensive study of firearm spinal injuries over a large population. It was the purpose of this study to analyze the demographics of spinal firearm injuries across the entire United States for all ages using a national database. Methods A retrospective review of prospectively collected data using the Inter-University Consortium for Political and Social Research Firearm Injury Surveillance Study 1993-2015 (ICPSR 37276) was performed. The demographic variables of patients with spinal injuries due to firearms were analyzed with statistical analyses accounting for the weighted, stratified nature of the data, using SUDAAN 11.0.01™ software (RTI International, Research Triangle Park, North Carolina, 2013). A p-value of < 0.05 was considered statistically significant. Results For the years 1993 through 2015, there were an estimated 2,667,896 emergency department (ED) visits for injuries due to firearms; 10,296 of these injuries (0.4%) involved the spine. The vast majority (98.2%) were due to powder firearm gunshot wounds. Those with a spine injury were more likely to have been injured in an assault (83.7% vs. 60.2%), involved a handgun (83.5% vs. 60.2%), were male (90.8% vs. 86.4%), were admitted to the hospital (86.8% vs. 30.9%), and were seen in urban hospitals (86.7 vs. 64.6%). The average age was 28 years with very few on those < 14 years of age. Illicit drug involvement was over four times as frequent in those with a spine injury (34.7% vs. 8.0%). The cervical spine was involved in 30%, thoracic in 32%, lumbar in 32%, and sacrum in 6%. A fracture occurred in 91.8% and neurologic injury in 33%. Injuries to the thoracic spine had the highest percentage of neurologic involvement (50.4%). There was an annual percentage decrease for patients with and without spine involvement in the 1990s, followed by increases through 2015. The average percentage increase for patients with a spine injury was 10.3% per year from 1997 onwards (p < 10-6), significantly greater than the 1.5% for those without spinal involvement (p = 0.0001) from 1999 onwards. Conclusions This nation-wide study of spinal injuries associated with firearms covering all ages can be used as baseline data for future firearm studies. A reduction in the incidence of such injuries can be guided by our findings but may be difficult due to sociopolitical barriers (e.g. socioeconomic status of the injured patients, differences in political opinion regarding gun control in the US, and geospatial patterns of firearm injury).
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Affiliation(s)
- Randall T Loder
- Orthopaedic Surgery, Riley Hospital for Children, Indianapolis, USA
| | - Abhipri Mishra
- Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Bradley Atoa
- Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Allison Young
- Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, USA
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Crutcher CL, Wilson JM, DiGiorgio AM, Fannin ES, Shields JA, Morrow KD, Tender GC. Minimally Invasive Management of Civilian Gunshot Wounds to the Lumbar Spine: A Case Series and Technical Report. Oper Neurosurg (Hagerstown) 2020; 19:219-225. [DOI: 10.1093/ons/opaa030] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 01/01/2020] [Indexed: 12/21/2022] Open
Abstract
Abstract
BACKGROUND
Treatment of penetrating gunshot wounds (GSW) to the spine remains controversial. The decision to operate is often based on surgeon preference and experience. We present a case series of 7 patients who underwent minimally invasive thoracolumbar/sacral decompression and bullet removal at a level 1 trauma center.
OBJECTIVE
To describe the use of minimally invasive techniques to achieve decompression and bullet removal for GSW to the spine.
METHODS
From 2010 to 2017, 7 patients with spinal GSW underwent minimally invasive decompression and bullet removal at an academic level 1 trauma center.
RESULTS
Patient ages ranged from 20 to 55 yr (mean: 31 yr). The mechanisms of injury were GSW to the abdomen/pelvis (n = 6) and direct GSW to the spine (n = 1). Based on the neurological examination, the injuries were characterized as complete (n = 1) or incomplete (n = 6). Decompression and bullet removal were performed using a tubular retractor system. All patients with incomplete injuries who had postdischarge follow-up demonstrated some neurologic recovery. There were no postoperative wound infections, cerebrospinal fluid (CSF) fistulas, or other complications related to the procedure.
CONCLUSION
Minimally invasive decompression and bullet removal is a safe technique that may help reduce the risk of postoperative infections and CSF fistulas in patients with GSW to the lumbar spine compared to the standard open technique. This approach appears to be particularly beneficial in patients with incomplete injuries and neuropathic pain refractory to medical treatment.
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Affiliation(s)
- Clifford L Crutcher
- Department of Neurosurgery, Louisiana State University Health Science Center, New Orleans, Louisiana
| | - John M Wilson
- Department of Neurosurgery, Louisiana State University Health Science Center, New Orleans, Louisiana
| | - Anthony M DiGiorgio
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Erin S Fannin
- Department of Neurosurgery, Louisiana State University Health Science Center, New Orleans, Louisiana
| | - Jessica A Shields
- Department of Neurosurgery, Louisiana State University Health Science Center, New Orleans, Louisiana
| | - Kevin D Morrow
- Department of Neurosurgery, Louisiana State University Health Science Center, New Orleans, Louisiana
| | - Gabriel C Tender
- Department of Neurosurgery, Louisiana State University Health Science Center, New Orleans, Louisiana
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Morrow KD, Podet AG, Spinelli CP, Lasseigne LM, Crutcher CL, Wilson JD, Tender GC, DiGiorgio AM. A case series of penetrating spinal trauma: comparisons to blunt trauma, surgical indications, and outcomes. Neurosurg Focus 2019; 46:E4. [DOI: 10.3171/2018.12.focus18577] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 12/07/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEWhile blunt spinal trauma accounts for the majority of spine trauma, penetrating injuries affect a substantial number of patients. The goal of this study was to examine the epidemiology of penetrating spine injuries compared with blunt injuries and review the operative interventions and outcomes in the penetrating spine injury group.METHODSThe prospectively maintained trauma database was queried for spinal fractures from 2012 to 2018. Charts from patients with penetrating spine trauma were reviewed.RESULTSA total of 1130 patients were evaluated for traumatic spinal fractures; 154 injuries (13.6%) were secondary to penetrating injuries. Patients with penetrating injuries were significantly younger (29.2 years vs 44.1 years, p < 0.001), more likely male (87.7% vs 69.2%, p < 0.001), and more commonly African American (80.5% vs 33.3%, p < 0.05). When comparing primary insurers, the penetrating group had a significantly higher percentage of patients covered by Medicaid (60.4% vs 32.6%, p < 0.05) or prison (3.9% vs 0.1%, p < 0.05) or being uninsured (17.5% vs 10.3%, p < 0.05). The penetrating group had a higher Injury Severity Score on admission (20.2 vs 15.6, p < 0.001) and longer hospital length of stay (20.1 days vs 10.3 days, p < 0.001) and were less likely to be discharged home (51.3% vs 65.1%, p < 0.05). Of the penetrating injuries, 142 (92.2%) were due to firearms. Sixty-three patients (40.9%) with penetrating injuries had a concomitant spinal cord or cauda equina injury. Of those, 44 (69.8%) had an American Spinal Injury Association Impairment Scale (AIS) grade of A. Ten patients (15.9%) improved at least 1 AIS grade, while 2 patients (3.2%) declined at least 1 AIS grade. Nine patients with penetrating injuries underwent neurosurgical intervention: 5 for spinal instability, 4 for compressive lesions with declining neurological examination results, and 2 for infectious concerns, with some patients having multiple indications. Patients undergoing neurosurgical intervention did not show a significantly greater change in AIS grade than those who did not. No patient experienced a complication directly related to neurosurgical intervention.CONCLUSIONSPenetrating spinal trauma affects a younger, more publicly funded cohort than blunt spinal trauma. These patients utilize more healthcare resources and are more severely injured. Surgery is undertaken for limiting progression of neurological deficit, stabilization, or infection control.
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Affiliation(s)
| | | | - Casey P. Spinelli
- 2School of Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana
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Escamilla JAC, Ross JÁG, Atanasio JMP, Martínez GC, Cisneros AG, Avila JJ. Spinal Gunshot Wounds: Pattern and Associated Lesions in Civilians. Asian Spine J 2018; 12:648-655. [PMID: 30060372 PMCID: PMC6068414 DOI: 10.31616/asj.2018.12.4.648] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 12/05/2017] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN Retrospective, descriptive case series study. PURPOSE To investigate the frequency, bone pattern, and associated lesions to the spine of gunshot wounds. OVERVIEW OF LITERATURE Gunshot wounds are penetrating in nature and are caused by a bullet or projectile. These are becoming more common and are associated with significant sequelae, requiring long and costly multidisciplinary treatment. Associated spinal cord injuries (SCIs) in the civilian population represent 13%-17% of all spinal traumas. Spinal gunshot wounds are commonly thought to be stable; however, there is potential acute and chronic spinal instability if the bullet passes transversely, fracturing either both pedicles or both facet joints. METHODS We obtained data from the clinical files of patients with spinal gunshot wounds treated by spine surgeons. We performed a statistical analysis to obtain the pattern and frequency of the injuries. RESULTS We included 54 patients (48 men [89%] and six women [11%]). Eight patterns of spinal gunshot wounds were identified; 61% (33 patients) had complete SCI. The thoracic spine was most frequently affected, with 88% of patients having SCI; 75%, hemopneumothorax; 28%, pulmonary lesions; and 16%, hepatic lesions. The presence of pedicle fractures had an odds ratio of 3.64 for SCI. CONCLUSIONS The two main bone patterns are the vertebral body and posterior arch with pedicle fractures as modifiers, given that they are at a high risk for SCI. The spinal pattern and associated lesions were related to the bullet's path, with the vertebral body having the highest frequency of associated lesions. Vertebral body burst fracture was the main indication for instrumentation.
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Affiliation(s)
- Jorge Arturo Cabrera Escamilla
- Instituto Mexicano del Seguro Social, Unidad Médica de Alta Especialidad "Dr. Victorio de la Fuente Narváez", Mexico City, Mexico
| | - Jorge Álvaro González Ross
- Instituto Mexicano del Seguro Social, Unidad Médica de Alta Especialidad "Dr. Victorio de la Fuente Narváez", Mexico City, Mexico
| | - José Manuel Pérez Atanasio
- Instituto Mexicano del Seguro Social, Unidad Médica de Alta Especialidad "Dr. Victorio de la Fuente Narváez", Mexico City, Mexico
| | - Gustavo Casas Martínez
- Instituto Mexicano del Seguro Social, Unidad Médica de Alta Especialidad "Dr. Victorio de la Fuente Narváez", Mexico City, Mexico
| | - Arelhi González Cisneros
- Instituto Mexicano del Seguro Social, Unidad Médica de Alta Especialidad "Dr. Victorio de la Fuente Narváez", Mexico City, Mexico
| | - Jose Jimenez Avila
- Instituto Mexicano del Seguro Social, Unidad Médica de Alta Especialidad "Dr. Victorio de la Fuente Narváez", Mexico City, Mexico
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HERNÁNDEZ TÉLLEZ ISAACENRIQUE, MONTELONGO MERCADO EDGARDOALONSO, ARREOLA BASTIDAS JESÚSJOSÉ, LARRINÚA BETANCOURT EDUARDO, AGUILAR MERLO AVELINO. SPINE GUNSHOT WOUNDS AT THE CENTRAL MILITARY HOSPITAL IN MEXICO. COLUNA/COLUMNA 2016. [DOI: 10.1590/s1808-185120161502157642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: To compare the measurement of the Cobb angle in printed radiographs and digitalized radiographs displayed with the "PixViewer" tool. Methods: Pre-operative radiographs of 23 patients were performed in printed films and using the software "PixViewer". The same evaluator, a spine surgeon, chose the proximal and distal end vertebrae at the limit of the main curve in printed radiographs without identifying patients, and measured the Cobb angle based on these parameters. The same parameters and measurements were performed in digitalized radiographs. The measurements were compared, as well as the choice of end vertebrae. Results: The average change in the Cobb angle between the methods was 1.48±1.73°. The intraclass correlation coefficient (ICC) was 0.99, demonstrating excellent reproducibility. Conclusion: The Cobb method can be used to evaluate scoliosis through the "PixViewer" tool with the same reliability of the classic method on printed radiographs.
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Spinal cord injury resulting from gunshot wounds: a comparative study with non-gunshot causes. Spinal Cord 2016; 54:737-41. [DOI: 10.1038/sc.2016.29] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 01/17/2016] [Accepted: 02/02/2016] [Indexed: 11/08/2022]
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Rosenfeld JV, Bell RS, Armonda R. Current concepts in penetrating and blast injury to the central nervous system. World J Surg 2015; 39:1352-62. [PMID: 25446474 PMCID: PMC4422853 DOI: 10.1007/s00268-014-2874-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Aim To review the current management, prognostic factors and outcomes of penetrating and blast injuries to the central nervous system and highlight the differences between gunshot wound, blast injury and stabbing. Methods A review of the current literature was performed. Results Of patients with craniocerebral GSW, 66–90 % die before reaching hospital. Of those who are admitted to hospital, up to 51 % survive. The patient age, GCS, pupil size and reaction, ballistics and CT features are important factors in the decision to operate and in prognostication. Blast injury to the brain is a component of multisystem polytrauma and has become a common injury encountered in war zones and following urban terrorist events. GSW to the spine account for 13–17 % of all gunshot injuries. Conclusions Urgent resuscitation, correction of coagulopathy and early surgery with wide cranial decompression may improve the outcome in selected patients with severe craniocerebral GSW. More limited surgery is undertaken for focal brain injury due to GSW. A non-operative approach may be taken if the clinical status is very poor (GCS 3, fixed dilated pupils) or GCS 4–5 with adverse CT findings or where there is a high likelihood of death or poor outcome. Civilian spinal GSWs are usually stable neurologically and biomechanically and do not require exploration. The indications for exploration are as follows: (1) compressive lesions with partial spinal cord or cauda equina injury, (2) mechanical instability and (3) complications. The principles of management of blast injury to the head and spine are the same as for GSW. Multidisciplinary specialist management is required for these complex injuries.
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