Gunshot Spinal Injury: Factors Determining Treatment and Outcome

Spine and spinal cord injuries in Syria war: treatment and outcome

STUDY DESIGN

This was a retrospective, comparative 6-year study.

OBJECTIVES

This study aimed to retrospectively analyze patients who were treated at Kilis State Hospital for spine and spinal cord injuries during the Syrian civil war and to compare the treatment results with the literature.

SETTING

Kilis State Hospital, Kilis, Turkey.

METHODS

In our study, 84 patients who were treated for spine and spinal cord injuries between December 2011 and May 2017 were examined. Patient age, sex, injury type, injury region, neurological status, time from injury to treatment, treatment methods, surgical methods applied, and complications were evaluated.

RESULTS

Of the patients, 72 were male, and 12 were female. The mean age of the patients was 23.2 ± 7.3 years. Fifty-two patients were treated surgically. Surgical treatment was applied to 44 patients with neurological deficits. At least 1-grade neurological improvement was observed in 77.3% (n = 34) of patients with neurological deficits who underwent surgical treatment. Surgical treatment was performed on 18 (34.6%) patients in the first 24 h, 27 (51.9%) patients within 24-72 h, and 7 patients (13.5%) between 72 h and 5 days. Neurological improvement was observed in all patients with neurological deficits who underwent surgical treatment in the first 24 h.

CONCLUSIONS

Early surgery (in the first 24 h) had a positive effect on the neurological recovery of the patients in our study. Thus, patients with spine and spinal cord injuries rendered a surgical-treatment decision should be operated on in a timely manner, particularly within the first 24 h.

Treatment of gunshot wounds of the spine using full-endoscopic surgery: analysis of a small clinical series

Objective. To assess the effectiveness of the treatment of gunshot wounds of the spine using percutaneous full-endoscopic technique.

Material and Methods. Three patients with gunshot shrapnel wounds of the spine were treated using percutaneous full endoscopy.

Results. The patients underwent a removal of foreign bodies (metal fragments) at the cervical, thoracic and lumbosacral levels of the spine using percutaneous full endoscopic surgery. The operations were carried out without complications, with minimal additional trauma to soft tissues and the spinal motion segment. In all three cases, there was a positive dynamics in the form of regression of the pain syndrome. There were no infectious complications.

Conclusion. The successful use of percutaneous full endoscopy in the surgical treatment of blind shrapnel wounds of the spine is shown. The results indicate the expediency of further research and development of this area to address the issue of introducing the technique into the routine practice of treating gunshot wounds both in peacetime in neurosurgical hospitals and centers of spinal neurosurgery, and in wartime at the stages of specialized care.

Successful Removal of a Bullet from the Spinal Canal of a GSW Victim in the Level of L5: Case Report

INTRODUCTION AND IMPORTANCE

Gunshot wounds (GSWs), for increasing violence in urban areas globally and especially among the young population, have been significant causes of morbidity and mortality. These are the most common cause of spinal cord injuries, followed by traffic accidents. The priority of the therapeutic team is to save the victim and then minimise the permanent neural deficits. The indications for lumbosacral decompressive spinal surgery have remained challenging.

CASE PRESENTATION

A 25-year-old man victim of a gunshot in his left flank presented to the emergency department in hemodynamic shock and lethargy status. Resuscitating with fluids, he underwent damage control surgery (DCS). Sources of 2.5 l of intra-abdominal blood were detected of multiple intestinal and mesentery perforations beside the left ureter complete cut. The left psoas muscle was through and through perforated, too, and the bullet was stuck between the vertebrae. On the fifth day after DCS, the bullet surgical removal of the bullet was done in which L2-S1 laminectomy approaching the crushed Conus terminalis was completed. After the operation, his left foot drop and walking ability were improved.

CLINICAL DISCUSSION

Surgical treatment for gunshot wounds in the spinal column is controversial, but the emphasis is on providing advanced trauma life support. Definite treatment of such lesions mainly focuses on maintaining spinal stability, decreasing neurologic deficits as much as possible, and preventing complications.

CONCLUSION

A patient indicates neurological surgery who is young with incomplete or progressive neurology deficits, unstable spine, or complete injury with persistent neural compression.

Civilian Gun Shot Wounds Associated With Spinal Injuries

STUDY DESIGN

Retrospective.

OBJECTIVE

To evaluate functional outcomes and characteristics associated with gunshot wound (GSW) to the spine.

METHODS

Patients with GSW to the spine managed at a Level 1 Trauma Center from January 2003 to December 2017 were enrolled. Patient demographics, diagnoses, level of injury, American Spinal Injury Association (ASIA) score, ambulatory status at follow-up, bowel and bladder function, clinical improvement, and mortality were evaluated. Clinical improvement was defined as a progression in ambulatory status category at latest follow up.

RESULTS

51 patients with GSW of the spine were identified. 48 (94.1%) were male and 3 (5.9%) were female, with a mean age of 27 years-old (range 15-56). 38 (74.5%) were Caucasian, 7 (13.7%) were African American, 1 (2.0%) Asian-American, and 5 (9.8%) were Other/Unknown. 46 (90.2%) patients had GSW related spinal fractures and 44 (86.3%) had neurological deficits. Among patients with neurologic deficits, 5 (9.8%) had Cauda Equina Syndrome, 1 (2%) had Brown-Sequard Syndrome, and 38 (74.5%) spinal cord injuries: ASIA A 26 (68.4%); ASIA B 3 (7.9%); ASIA C 7 (18.4%); ASIA D 2 (5.3%). At mean follow-up time of 4.2 years (SD 3.9), 27 (52.9%) patients were wheelchair bound, 11 (21.6%) were ambulating with assistance, and 13 (25.5%) had normal ambulation. ASIA grade (A or B) was significantly, P < 0.00001, associated with being wheelchair bound and having neurogenic bowel or bladder at follow-up.

CONCLUSIONS

Most spinal GSW patients (70.6%) did not have any clinical improvement in ambulatory status and most injuries were ASIA A.

Isolated L5 nerve root injury without osseous disruption in a case of gunshot injury to the paediatric spine—A case report

INTRODUCTION

There exists sparse literature on Gunshot injuries (GSI) to the pediatric spine, its natural course, management protocols and outcomes following surgical intervention. Here, we present a projectile injury to the paediatric lumbar spine without any osseous disruption in a 5-year-old child requiring surgical management.

CASE PRESENTATION

A 5-year-old child presented with a gunshot injury to the pediatric lumbar spine. On radiological imaging, there was no osseous disruption and an intraspinal canal projectile was embedded in an organised infected complex, compressing onto the left-sided L5 traversing nerve root with resultant grade 4 motor power of the left Extensor Hallucis Longus (EHL). Under fluoroscopic guidance using two separate mini-open incisions, the pellets were extracted. One from the spinal canal through left-sided L4 laminotomy and the other from the right paraspinal region. Post-surgical decompression and pellet retrieval there was gradual recovery to grade 5 motor power of Left EHL and improvement in the general condition of the child.

CONCLUSION

The absence of osseous disruption can be attributed to the size of the projectile, widely spaced interlaminar spaces in the lumbar spine due to the absence of lumbar lordosis in the pediatric group and flexibility of the pediatric spine owing to its ligamentous laxity.

Gunshot injury to spine: An institutional experience of management and complications from a developing country

PURPOSE

Gunshot wounds are the second leading cause of spinal cord injuries. Surgical intervention for gunshot injury to the spine carries a high rate of complications. There is a scarcity of data on civilian gunshot injuries to the spine in Pakistan. Approximately 60 cases over the last 10 years have been recoded, with unusual presentation and neurological recovery. Thus it is imperative to fill this gap in data, by reviewing cases of civilian gunshot injuries to spine presenting at a tertiary care hospital (Aga Khan University Hospital, Karachi).

METHODS

This is a retrospective cohort study. Patients of all ages who presented to the emergency department of Aga Khan University Hospital, with gunshot injuries to spine between January 2005 and December 2016 were included in the study. Data were collected on neurological status (American Spinal Injury Association score was used for the initial and follow-up neurological assessment), extent of cord transection, motor and sensory deficits. The patients were further grouped into those with cord transection, and those with fractures of the bony spine but an intact spinal cord. These patients were then followed and the outcomes were recorded.

RESULTS

A total of 40 patients were identified. The mean ± SD of patients age was (30.9 ± 9.5) years. Of the 40 patients with gunshot wounds, 31 had the medical imaging performed at the facility, and hence they were included in this categorization. The remaining 9 patients were excluded from this additional grouping. Thirteen patients were managed surgically and 27 patients underwent the conservative management. The mean ± SD of follow-up was (8.7 ± 7.2) months. In our study, the thoracic spine was the most commonly injured region in gunshot injuries. Of the 31 patients with medical imaging performed at our institute, 17 (54.8%) had cord transection, of whom 8 (47%) ultimately developed paraplegia.

CONCLUSION

The prognosis of gunshot injuries to the spine can be varied depending on whether the spinal cord is intact or transected. This will help healthcare providers to plan the further management of the patient and counsel them accordingly.

Does Surgical Intervention Help with Neurological Recovery in a Lumbar Spinal Gun Shot Wound? A Case Report and Literature Review

The third leading cause of spinal injuries are gunshot wounds to the spine, accounting for 15.2% of all spinal cord injuries. Treatment for gunshot wound spinal cord injuries (GSWSCI) remains variable, with indications for surgery being controversial. There is no clear evidence or guidelines that can help spine surgeons decide and direct surgical intervention. With the paucity of available literature, we report an interesting case of a gunshot injury to the lumbar spine at L1-L2, discuss the presentation and outcome, and evaluate relevant literature. A 27-year-old incarcerated male patient presented with a conus cauda equina asymmetrical injury involving the lower extremities and required initial medical stabilization in the intensive care unit (ICU). He subsequently underwent delayed surgical treatment with decompression and fragment resection at L1-L2. The patient improved neurologically to the American Spinal Injury Association (ASIA) Classification D and eventually regained nearly all lower extremity neurological function. Despite considerable evidence favoring the conservative management of GSWSCI and the absence of guidelines or recommendations on surgical interventions, our case report demonstrates that surgical intervention in appropriately selected patients can yield good recovery of neurological function and improvement in the quality of life. The key remains careful patient selection, the appropriate location of the retained fragment, and the extent of neurological injury that occurred. We feel surgical decompression and fragment removal, along with debridement, can result in good neurological recovery and long-term outcomes.