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Arpa A, Ozturk PA, Sanrı O, Yilmaz A. Pediatric case of a penetrating lumbar spinal injury. Childs Nerv Syst 2024; 40:593-596. [PMID: 37855878 DOI: 10.1007/s00381-023-06180-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 10/10/2023] [Indexed: 10/20/2023]
Abstract
PURPOSE Penetrating spinal injuries are generally extremely rare and are seldom encountered in pediatric patients. The non-compliance of pediatric patients with physical examination can sometimes delay diagnosis and treatment. Here, we present a case of a child who had a fall and suffered penetrating spinal trauma due to a small glass fragment. CASE REPORT A penetrating foreign body was detected in the lumbar spinal region of a 2-year-old patient with complaints of increased restlessness on physical activity followed by difficulty in walking. The patient was operated on and followed up without any complications in the perioperative and late postoperative periods. CONCLUSION A detailed physical examination is necessitated in the pediatric age group because of insufficient anamnesis. The high number of patients per physician, especially in societies having a low socioeconomic standard, prevents detailed examinations, and unnecessary examinations may cause delays in diagnosis. However, one must note that the skin findings of pediatric patients can be very helpful, especially in pediatric neurosurgery, and examination should not be neglected.
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Affiliation(s)
- Abdurrahman Arpa
- Department of Neurosurgery, Dicle University Medical Faculty, Diyarbakir, Turkey
| | - Pinar Aydın Ozturk
- Department of Neurosurgery, Dicle University Medical Faculty, Diyarbakir, Turkey.
| | - Omer Sanrı
- Department of Neurosurgery, Şırnak Public Hospital, Sirnak, Turkey
| | - Adil Yilmaz
- Department of Neurology, Private Batı Hospital, Diyarbakir, Turkey
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Goh BC, Striano BM, Crawford AM, Tobert DG, Fogel HA, Cha TD, Schwab JH, Bono CM, Hershman SH. Surgical Intervention is Associated With Improvements in the ASIA Impairment Scale in Gunshot-induced Spinal Injuries of the Thoracic and Lumbar Spine. Clin Spine Surg 2022; 35:323-327. [PMID: 35276720 DOI: 10.1097/bsd.0000000000001308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 02/02/2022] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective cohort study of patients from the National Spinal Cord Injury Statistical Center (NSCISC). OBJECTIVE The aim was to compare the outcomes of patients with gunshot-induced spinal injuries (GSIs) treated operatively and nonoperatively. SUMMARY OF BACKGROUND DATA The treatment of neurological deficits associated with gunshot wounds to the spine has been controversial. Treatment has varied widely, ranging from nonoperative to aggressive surgery. METHODS Patient demographics, clinical information, and outcomes were extracted. Surgical intervention was defined as a "laminectomy, neural canal restoration, open reduction, spinal fusion, or internal fixation of the spine." The primary outcome was the American Spinal Injury Association (ASIA) Impairment Scale. Statistical comparisons of baseline demographics and neurological outcomes between operative and nonoperative cohorts were performed. RESULTS In total, 961 patients with GSI and at least 1-year follow-up were identified from 1975 to 2015. The majority of patients were Black/African American (55.6%), male (89.7%), and 15-29 years old (73.8%). Of those treated surgically (19.7% of all patients), 34.2% had improvement in their ASIA Impairment Scale score at 1 year, compared with 20.6% treated nonoperatively. Overall, surgery was associated with a 2.0 [95% confidence interval (CI): 1.4-2.8] times greater likelihood of ASIA Impairment Scale improvement at 1 year. Specifically, benefit was seen in thoracic (odds ratio: 2.5; 95% CI: 1.4-4.6) and lumbar injuries (odds ratio: 1.7; 95% CI: 1.1-3.1), but not cervical injuries. CONCLUSIONS While surgical indications are always determined on an individualized basis, in our review of GSIs, surgical intervention was associated with a greater likelihood of neurological recovery. Specifically, patients with thoracic and lumbar GSIs had a 2.5 and 1.7-times greater likelihood of improvement in their ASIA Impairment Scale score 1 year after injury, respectively, if they underwent surgical intervention.
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Affiliation(s)
- Brian C Goh
- Harvard Combined Orthopaedic Residency Program
| | | | | | - Daniel G Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Harold A Fogel
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Thomas D Cha
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Stuart H Hershman
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Platt A, Dafrawy MHE, Lee MJ, Herman MH, Ramos E. Gunshot Wounds to the Lumbosacral Spine: Systematic Review and Meta-Analysis. Global Spine J 2022; 12:1247-1253. [PMID: 34275384 PMCID: PMC9210234 DOI: 10.1177/21925682211030873] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVES Indications for surgical decompression of gunshot wounds to the lumbosacral spine are controversial and based on limited data. METHODS A systematic review of literature was conducted to identify studies that directly compare neurologic outcomes following operative and non-operative management of gunshot wounds to the lumbosacral spine. Studies were evaluated for degree of neurologic improvement, complications, and antibiotic usage. An odds ratio and 95% confidence interval were calculated for dichotomous outcomes which were then pooled by random-effects model meta-analysis. RESULTS Five studies were included that met inclusion criteria. The total rate of neurologic improvement was 72.3% following surgical intervention and 61.7% following non-operative intervention. A random-effects model meta-analysis was carried out which failed to show a statistically significant difference in the rate of neurologic improvement between surgical and non-operative intervention (OR 1.07; 95% CI 0.45, 2.53; P = 0.88). In civilian only studies, a random-effects model meta-analysis failed to show a statistically significant difference in the rate of neurologic improvement between surgical and non-operative intervention (OR 0.75; 95% CI 0.21, 2.72; P = 0.66). Meta-analysis further failed to show a statistically significant difference in the rate of neurologic improvement between patients with either complete (OR 4.13; 95% CI 0.55, 30.80; P = 0.17) or incomplete (OR 0.38; 95% CI 0.10, 1.52; P = 0.17) neurologic injuries who underwent surgical and non-operative intervention. There were no significant differences in the number of infections and other complications between patients who underwent surgical and non-operative intervention. CONCLUSIONS There were no statistically significant differences in the rate of neurologic improvement between those who underwent surgical or non-operative intervention. Further research is necessary to determine if surgical intervention for gunshot wounds to the lumbosacral spine, including in the case of retained bullet within the spinal canal, is efficacious.
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Affiliation(s)
- Andrew Platt
- Department of Neurosurgery, University of Chicago, IL, USA,Andrew Platt, Department of Neurosurgery, University of Chicago, 5841 S. Maryland Ave, MC 3026, J341, Chicago, IL 60637, USA.
| | | | - Michael J. Lee
- Department of Orthopaedic Surgery, University of Chicago, IL, USA
| | | | - Edwin Ramos
- Department of Neurosurgery, University of Chicago, IL, USA
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Letter. Neurosurgery 2020; 86:E575-E578. [DOI: 10.1093/neuros/nyz571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 12/07/2019] [Indexed: 11/14/2022] Open
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Kelly ML, Roach MJ, Nemunaitis G, Chen Y. Surgical and Nonsurgical Treatment of Penetrating Spinal Cord Injury: Analysis of Long-term Neurological and Functional Outcomes. Top Spinal Cord Inj Rehabil 2019; 25:186-193. [PMID: 31068749 PMCID: PMC6496967 DOI: 10.1310/sci2502-186] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Objective: To describe long-term neurological and functional outcomes for patients with penetrating spinal cord injury (PSCI) following surgical (SX) and nonsurgical (NSX) treatment. Methods: We identified all patients with PSCI in the Spinal Cord Injury Model Systems database from 1994-2015. Patients with PSCI were divided into surgical (SX) and nonsurgical (NSX) groups. Outcomes were measured using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) and the Functional Independence Measure (FIM) motor scores. Outcomes were then analyzed separately for patients with complete and incomplete PSCI during acute hospitalization, SCI rehabilitation, and 1-year follow-up. Results: For patients with complete PSCI, acute hospital length of stay (LOS) was increased in the SX group (19 days vs 14 days; p < .0001) while median FIM motor scores were similar at 1-year follow-up (74 vs 75; p = .4). The percentage of patients with complete PSCI remained similar between groups at discharge from SCI rehabilitation (88% vs 88%; p = 0.5). For patients with incomplete PSCIs, acute hospital LOS was similar between groups (13 vs 11; p = .3) and no difference was observed in ASIA Impairment Scale improvement at discharge from rehabilitation (38% vs 37%; p = .9) or in FIM scores at 1 year (84 vs 85; p = .6). Conclusion: Surgery for patients with complete PSCI is associated with increased acute hospital LOS for complete PSCI and is not associated with improvement in neurological or functional outcomes in patients with either complete or incomplete PSCI.
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Affiliation(s)
- Michael Liam Kelly
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio
| | - Mary Joan Roach
- Center for Healthcare Research and Policy, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio
| | - Gregory Nemunaitis
- Department of Physical Medicine and Rehabilitation, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio
| | - Yuying Chen
- Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Birmingham, Alabama
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Piatt J. Penetrating spinal injury in childhood: the influence of mechanism on outcome. An epidemiological study. J Neurosurg Pediatr 2018; 22:384-392. [PMID: 29979127 DOI: 10.3171/2018.3.peds1890] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Penetrating injury of the spine in childhood commonly causes profound and life-long disability, but it has been the object of very little study. The goal of the current report is to document temporal trends in the nationwide incidence of this condition and to highlight the differences between penetrating injuries and closed injuries. METHODS The Kids' Inpatient Database was queried for spinal injuries in 1997, 2000, 2003, 2006, 2009, and 2012. Penetrating mechanism was determined by diagnostic coding for open injuries and by mechanistic codes for projectiles and knives. Nationwide annual incidences were calculated using weights provided for this purpose. Unweighted data were used as a cross-sectional sample to compare closed and penetrating injuries with respect to demographic and clinical factors. The effect of penetrating mechanism was analyzed in statistical models of death, adverse discharge, and length of stay (LOS). RESULTS The nationwide incidence of penetrating spinal injury in patients less than 18 years of age trended downward over the study period. Patients with penetrating injury were older and much more predominantly male than patients with closed injuries. They resided predominantly in zip codes with lower median household incomes, and they were much more likely to have public health insurance or none at all. They were predominantly black or Hispanic. The risk of hospital death was no different, but penetrating injuries were associated with much higher rates of adverse discharge after LOS, averaging twice as long as closed injuries. Brain, visceral, and vascular injuries were powerful predictors of hospital death, as was upper cervical level of injury. The most powerful predictor of adverse discharge and LOS was spinal cord injury, followed by brain, visceral, and vascular injury and penetrating mechanism. CONCLUSIONS Because its pathophysiology requires no elucidation, because the consequences for quality of life are dire, and because the population at risk is well defined, penetrating spinal injury in childhood ought to be an attractive target for public health interventions.
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Lawless MH, Lytle EJ, McGlynn AF, Engler JA. Surgical management of penetrating spinal cord injury primarily due to shrapnel and its effect on neurological outcome: a literature review and meta-analysis. J Neurosurg Spine 2018; 28:63-71. [DOI: 10.3171/2017.5.spine161037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThis study was performed to determine whether decompression of penetrating spinal cord injury (SCI) due to explosive shrapnel leads to greater neurological recovery than conservative management.METHODSIn accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive literature search using PubMed/MEDLINE, Web of Science, Google Scholar, and the Defense Technical Information Center public site was conducted on May 2, 2016. Studies that described penetrating SCI with shrapnel as an etiology, included surgical and/or conservative management, and demonstrated admission and follow-up neurological status were eligible for inclusion in this study. Odds ratios were calculated for the overall effect of surgical treatment on neurological recovery. Funnel plots were used to evaluate publication bias.RESULTSFive case series (Level IV evidence) met the study criteria, and 2 of them had estimable odds ratios for use in the Forest plot analysis. Among the patients from all 5 studies, 65% were injured by shrapnel, 25% by high-velocity bullet, 8% by low-velocity bullet, and 2% by an unknown cause. A total of 288 patients were included in the overall odds ratio calculations. Patients were stratified by complete and incomplete SCI. The meta-analysis showed no significant difference in outcomes between surgical and conservative management in the complete SCI cohort or the incomplete SCI cohort. Overall rates of improvement for complete SCI were 25% with surgery and 27% with conservative treatment (OR 1.07, 95% CI 0.44–2.61, p = 0.88); for incomplete SCI, 70% with surgery and 81% with conservative treatment (OR 1.67, 95% CI 0.68–4.05, p = 0.26).CONCLUSIONSThis study demonstrates no clear benefit to surgical decompression of penetrating SCI due predominantly to shrapnel. There is a considerable need for nonrandomized prospective cohort studies examining decompression and stabilization surgery for secondary and tertiary blast injuries.
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Affiliation(s)
| | - Evan J. Lytle
- 3Neurosurgery, Providence-Providence Park Hospital, Michigan State University College of Human Medicine, Southfield, Michigan; and
| | | | - John A. Engler
- 4Department of Neurosurgery, Naval Medical Center, Portsmouth, Virginia
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Trelles M, Dominguez L, Tayler-Smith K, Kisswani K, Zerboni A, Vandenborre T, Dallatomasina S, Rahmoun A, Ferir MC. Providing surgery in a war-torn context: the Médecins Sans Frontières experience in Syria. Confl Health 2015; 9:36. [PMID: 26674297 PMCID: PMC4678579 DOI: 10.1186/s13031-015-0064-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 11/08/2015] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Since 2011, civil war has crippled Syria leaving much of the population without access to healthcare. Various field hospitals have been clandestinely set up to provide basic healthcare but few have been able to provide quality surgical care. In 2012, Medecins Sans Frontieres (MSF) began providing surgical care in the Jabal al-Akrad region of north-western Syria. Based on the MSF experience, we describe, for the period 5th September 2012 to 1st January 2014: a) the volume and profile of surgical cases, b) the volume and type of anaesthetic and surgical procedures performed, and c) the intraoperative mortality rate. METHODS A descriptive study using routinely collected MSF programme data. Quality surgical care was assured through strict adherence to the following minimum standards: adequate infrastructure, adequate water and sanitation provisions, availability of all essential disposables, drugs and equipment, strict adherence to hygiene requirements and universal precautions, mandatory use of sterile equipment for surgical and anaesthesia procedures, capability for blood transfusion and adequate human resources. RESULTS During the study period, MSF operated on 578 new patients, of whom 57 % were male and median age was 25 years (Interquartile range: 21-32 years). Violent trauma was the most common surgical indication (n-254, 44 %), followed by obstetric emergencies (n-191, 33 %) and accidental trauma (n-59, 10 %). In total, 712 anaesthetic procedures were performed. General anaesthesia without intubation was the most common type of anaesthesia (47 % of all anaesthetics) followed by spinal anaesthesia (25 %). A total of 831 surgical procedures were performed, just over half being minor/wound care procedures and nearly one fifth, caesarean sections. There were four intra-operative deaths, giving an intra-operative mortality rate of 0.7 %. CONCLUSIONS Surgical needs in a conflict-afflicted setting like Syria are high and include both combat and non-combat indications, particularly obstetric emergencies. Provision of quality surgical care in a complex and volatile setting like this is possible providing appropriate measures, supported by highly experienced staff, can be implemented that allow a specific set of minimum standards of care to be adhered to. This is particularly important when patient outcomes - as a reflection of quality of care - are difficult to assess.
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Affiliation(s)
- Miguel Trelles
- />Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB), Surgery, Anaesthesia, Gynaecology, and Emergency Medicine Unit, Brussels, Belgium
| | - Lynette Dominguez
- />Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB), Surgery, Anaesthesia, Gynaecology, and Emergency Medicine Unit, Brussels, Belgium
| | - Katie Tayler-Smith
- />MSF-OCB, Operational Research Unit, MSF-Luxembourg, Luxembourg, Luxembourg
| | | | | | | | | | - Alaa Rahmoun
- />MSF-OCB, MSF Syria project, Latakia Governorate, Syria
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Smith J, Roberts B, Knight A, Gosselin R, Blanchet K. A systematic literature review of the quality of evidence for injury and rehabilitation interventions in humanitarian crises. Int J Public Health 2015; 60:865-72. [PMID: 26298446 PMCID: PMC4636531 DOI: 10.1007/s00038-015-0723-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 07/03/2015] [Accepted: 07/08/2015] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Humanitarian crises continue to pose a significant threat to health; the United Nations estimates that 144 million people are directly affected by conflict or environmental disasters. During most humanitarian crises, surgical and rehabilitative interventions remain a priority. OBJECTIVES This review assessed the quality of evidence that informs injury and physical rehabilitation interventions in humanitarian crises. METHODS Peer-reviewed and grey literature sources were assessed in a systematic manner. Selected papers were evaluated using quality criteria based on a modified version of the STROBE protocol. RESULTS 46 papers met the inclusion criteria. 63 % of the papers referred to situations of armed conflict, of which the Yugoslav Wars were the most studied crisis context. 59 % of the studies were published since the year 2000. However, only two studies were considered of a high quality. CONCLUSIONS While there is now a greater emphasis on research in this sector, the volume of evidence remains inadequate given the growing number of humanitarian programmes worldwide. Further research is needed to ensure a greater breadth and depth of understanding of the most appropriate interventions in different settings.
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Affiliation(s)
- James Smith
- Public Health in Humanitarian Crises Group, London School of Hygiene and Tropical Medicine, London, UK.
| | - Bayard Roberts
- ECOHOST-The Centre for Health and Social Change, The London School of Hygiene and Tropical Medicine, London, UK
| | - Abigail Knight
- Public Health in Humanitarian Crises Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Richard Gosselin
- Department of Orthopaedic Surgery, University of California, San Francisco, USA
| | - Karl Blanchet
- Public Health in Humanitarian Crises Group, London School of Hygiene and Tropical Medicine, London, UK
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Ozsoy KM, Menekse G, Okten AI, Guzel A. Cerebrospinal fluid fistula due to penetrating trauma. INDIAN JOURNAL OF NEUROTRAUMA 2013. [DOI: 10.1016/j.ijnt.2013.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Bhat AR, Wani MA, Kirmani AR, Alam S, Raina T, Arif S, Ramzan A, Lahawal MA. Missile injuries of spine and spinal cord in civilian Kashmir – Analysis and outcome evaluated by new Modified SKIMS-Functional Scales. INDIAN JOURNAL OF NEUROTRAUMA 2012. [DOI: 10.1016/j.ijnt.2012.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Possley DR, Blair JA, Schoenfeld AJ, Lehman RA, Hsu JR. Complications associated with military spine injuries. Spine J 2012; 12:756-61. [PMID: 22100207 DOI: 10.1016/j.spinee.2011.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2011] [Revised: 09/16/2011] [Accepted: 10/05/2011] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Daniel R Possley
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX 78234, USA.
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Kang DG, Lehman RA, Bevevino AJ, Bernstock JD. Large caliber ballistic fragment within the spinal canal. Spine J 2012; 12:869-70. [PMID: 23036147 DOI: 10.1016/j.spinee.2012.07.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 07/25/2012] [Indexed: 02/03/2023]
Affiliation(s)
- Daniel G Kang
- Department of Orthopaedic Surgery and Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
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Spinal injuries after improvised explosive device incidents: implications for Tactical Combat Casualty Care. ACTA ACUST UNITED AC 2012; 71:S413-7. [PMID: 22071997 DOI: 10.1097/ta.0b013e318232e575] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tactical Combat Casualty Care aims to treat preventable causes of death on the battlefield but deemphasizes the importance of spinal immobilization in the prehospital tactical setting. However, improvised explosive devices (IEDs) now cause the majority of injuries to Canadian Forces (CF) members serving in Afghanistan. We hypothesize that IEDs are more frequently associated with spinal injuries than non-IED injuries and that spinal precautions are not being routinely employed on the battlefield. METHODS We examined retrospectively a database of all CF soldiers who were wounded and arrived alive at the Role 3 Multinational Medical Unit in Kandahar, Afghanistan, from February 7, 2006, to October 14, 2009. We collected data on demographics, injury mechanism, anatomic injury descriptions, physiologic data on presentation, and prehospital interventions performed. Outcomes were incidence of any spinal injuries. RESULTS Three hundred seventy-two CF soldiers were injured during the study period and met study criteria. Twenty-nine (8%) had spinal fractures identified. Of these, 41% (n = 12) were unstable, 31% (n = 9) stable, and 28% indeterminate. Most patients were injured by IEDs (n = 212, 57%). Patients injured by IEDs were more likely to have spinal injuries than those injured by non-IED-related mechanisms (10.4% vs. 2.3%; p < 0.01). IED victims were even more likely to have spinal injuries than patients suffering blunt trauma (10.4% vs. 6.7%; p = 0.02). Prehospital providers were less likely to immobilize the spine in IED victims compared with blunt trauma patients (10% [22 of 212] vs. 23.0% [17 of 74]; p < 0.05). CONCLUSIONS IEDs are a common cause of stable and unstable spinal injuries in the Afghanistan conflict. Spinal immobilization is an underutilized intervention in the battlefield care of casualties in the conflict in Afghanistan. This may be a result of tactical limitations; however, current protocols should continue to emphasize the judicious use of immobilization in these patients.
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Gao X, Wu QH, Chen WS, Chen QX, Xu K, Li FC, Yan SG. An unusual high-pressure injection injury involving the cervical spinal cord. THE JOURNAL OF BONE AND JOINT SURGERY. BRITISH VOLUME 2011; 93:1140-2. [PMID: 21768644 DOI: 10.1302/0301-620x.93b8.26116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
High-pressure injection injuries occur infrequently but are usually work-related and involve the non-dominant hand. The neck is a very rare site for such an injury. We describe the management of a 36-year-old man with a high-pressure grease-gun injection injury to his neck causing a cervical spinal cord injury. He developed severe motor and sensory changes which were relieved by surgical removal of the grease through anterior and posterior approaches.
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Affiliation(s)
- X Gao
- Department of Orthopaedics, Second Affiliated Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang 310009, China
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Mateen FJ. Neurological disorders in complex humanitarian emergencies and natural disasters. Ann Neurol 2010; 68:282-94. [PMID: 20818788 DOI: 10.1002/ana.22135] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Complex humanitarian emergencies include the relatively acute, severe, and overwhelming health consequences of armed conflict, food scarcity, mass displacement, and political strife. Neurological manifestations of complex humanitarian emergencies are important and underappreciated consequences of emergencies in populations worldwide. This review critically assesses the existing knowledge of the range of neurological disorders that accompany complex humanitarian emergencies and natural disasters in both the acute phase of crisis and the "long shadow" that follows.
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Affiliation(s)
- Farrah J Mateen
- Department of International Health, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD, USA.
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Klimo P, Ragel BT, Rosner M, Gluf W, McCafferty R. Can surgery improve neurological function in penetrating spinal injury? A review of the military and civilian literature and treatment recommendations for military neurosurgeons. Neurosurg Focus 2010; 28:E4. [DOI: 10.3171/2010.2.focus1036] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Penetrating spinal injury (PSI), although an infrequent injury in the civilian population, is not an infrequent injury in military conflicts. Throughout military history, the role of surgery in the treatment of PSI has been controversial. The US is currently involved in 2 military campaigns, the hallmark of both being the widespread use of various explosive devices. The authors reviewed the evidence for or against the use of decompressive laminectomy to treat PSI to provide a triservice (US Army, Navy, and Air Force) consensus and treatment recommendations for military neurosurgeons and spine surgeons.
Methods
A US National Library of Medicine PubMed database search that identified all literature dealing with acute management of PSI from military conflicts and civilian urban trauma centers in the post–Vietnam War period was undertaken.
Results
Nineteen retrospective case series (11 military and 8 civilian) met the study criteria. Eleven military articles covered a 20-year time span that included 782 patients who suffered either gunshot or blast-related projectile wounds. Four papers included sufficient data that analyzed the effectiveness of surgery compared with nonoperative management, 6 papers concluded that surgery was of no benefit, 2 papers indicated that surgery did have a role, and 3 papers made no comment. Eight civilian articles covered a 9-year time span that included 653 patients with spinal gunshot wounds. Two articles lacked any comparative data because of treatment bias. Two papers concluded that decompressive laminectomy had a beneficial role, 1 paper favored the removal of intracanal bullets between T-12 and L-4, and 5 papers indicated that surgery was of no benefit.
Conclusions
Based on the authors' military and civilian PubMed literature search, most of the evidence suggests that decompressive laminectomy does not improve neurological function in patients with PSI. However, there are serious methodological shortcomings in both literature groups. For this and other reasons, neurosurgeons from the US Air Force, Army, and Navy collectively believe that decompression should still be considered for any patient with an incomplete neurological injury and continued spinal canal compromise, ideally within 24–48 hours of injury; the patient should be stabilized concurrently if it is believed that the spinal injury is unstable. The authors recognize the highly controversial nature of this topic and hope that this literature review and the proposed treatment recommendations will be a valuable resource for deployed neurosurgeons. Ultimately, the deployed neurosurgeon must make the final treatment decision based on his or her opinion of the literature, individual abilities, and facility resources available.
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Affiliation(s)
- Paul Klimo
- 188th Medical Group, Wright-Patterson Air Force Base, Ohio
| | - Brian T. Ragel
- 2Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Michael Rosner
- 3Division of Neurosurgery, Walter Reed Medical Center, Washington, DC
| | - Wayne Gluf
- 4Naval Medical Center, San Diego, California; and
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Shahlaie K, Chang DJ, Anderson JT. Nonmissile penetrating spinal injury. Case report and review of the literature. J Neurosurg Spine 2006; 4:400-8. [PMID: 16703908 DOI: 10.3171/spi.2006.4.5.400] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Nonmissile penetrating spinal injuries (NMPSIs) are rare, even among the population of patients treated in large trauma centers. Patients who present with retained foreign body fragments due to stabbings represent an even smaller subset of NMPSI, and their optimal management is unclear. The authors report the case of a 42-year-old man who presented to the University of California at Davis Medical Center with a retained knife blade after suffering a stab wound to the lower thoracic spine. They discuss this case in the context of a literature review and propose management options for patients with NMPSIs in whom fragments are retained. A search of PubMed was undertaken for articles published between 1950 and 2006; the authors found 21 case reports and eight case series in the English-language literature but discovered no published guidelines on the management of cases of NMPSI with retained fragments. After clinicians undertake appropriate initial trauma evaluation and resuscitation, they should obtain plain x-ray films and computerized tomography scans to delineate the anatomical details of the retained foreign body in relation to the stab wound. Neurosurgical consultation should be undertaken in all patients with an NMPSI, whether or not foreign body fragments are present. Surgical removal of a retained foreign body is generally recommended in these patients because the fragments may lead to a worse neurological outcome. Perioperative antibiotic therapy may be beneficial, but the result depends on the nature of the penetrating agent. There is no documentation in the literature to support the use of steroid agents in patients with NMPSIs.
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Affiliation(s)
- Kiarash Shahlaie
- Department of Neurological Surgery, University of California at Davis Medical Center, Sacramento, California 95817, USA
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Abstract
BACKGROUND CONTEXT The incidence of violent crimes has risen over the past decade. With it, gunshot injuries have become increasingly more common in the civilian population. Among the most devastating injuries are gunshot wounds to the spine. PURPOSE The purpose of this article is to provide a thorough review of the pathomechanics, diagnosis and treatment of gunshot wounds to the spine. STUDY DESIGN/SETTING Literature review article. CONCLUSIONS Treatment of gunshot spine fractures differs from other mechanisms. Fractures are usually inherently stable and rarely require stabilization. In neurologically intact patients, there are few indications for surgery. Evidence of acute lead intoxication, an intracanal copper bullet or new onset neurologic deficit can justify operative decompression and/or bullet removal. Overzealous laminectomy can destabilize the spine and lead to late postoperative deformity. For complete and incomplete neural deficits at the cervical and thoracic levels, operative decompression is of little benefit and can lead to higher complication rates than nonsurgically managed patients. With gunshots to the T12 to L5 levels, better motor recovery has been reported after intracanal bullet removal versus nonoperative treatment. The use of steroids for gunshot paralysis has not improved the neurologic outcome and has resulted in a greater frequency of nonspinal complications. Although numerous recommendations exist, 7 to 14 days of broad-spectrum antibiosis has lead to the lowest rates of infection after transcolonic gunshots to the spine.
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Affiliation(s)
- Christopher M Bono
- Department of Orthopaedic Surgery, Boston Medical Center, Boston University School of Medicine, Dowling 2 North, One Boston Medical Center Place, Boston, MA 02118-2393, USA.
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Buxton N. The military medical management of missile injury to the spine: a review of the literature and proposal of guidelines. J ROY ARMY MED CORPS 2001; 147:168-72. [PMID: 11464408 DOI: 10.1136/jramc-147-02-10] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The management of missile injury to the spinal cord is controversial. The literature is reviewed and recommendations made about the management of these injuries. To surgeons in a country that is relatively safe such injuries are rare, this review provides useful information about this condition.
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Affiliation(s)
- N Buxton
- Dept of Neurosurgery, University Hospital, Nottingham NG7 2UH.
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