1
|
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.
Collapse
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
| |
Collapse
|
2
|
Ricciardi GA, Cabrera JP, Martínez O, Matta J, Vilchis H, Perez Ríos JJ, Carazzo CA, Dittmar M, Yurac R. Predicting early complications in patients with spinal gunshot wounds: A multicenter study. BRAIN & SPINE 2024; 4:102766. [PMID: 38510628 PMCID: PMC10951780 DOI: 10.1016/j.bas.2024.102766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/17/2024] [Accepted: 02/14/2024] [Indexed: 03/22/2024]
Abstract
Introduction There is a wide variation in the clinical presentation of spinal gunshot wounds ranging from isolated minor stable fractures to extremely severe injuries with catastrophic neurological damage. Research question we aim to analyze the risk factors for early complications and impact of surgical treatment in patients with spinal gunshot wounds. Material and methods This is a multicentre retrospective case-control study to compare patients with spinal gunshot wounds who had early complications with those who did not. The following matching criteria were used: sex (1:1), injury level (1:1) and age (±5 years). Univariate and multivariate analyses were performed using logistic regression. Results Results: Among 387 patients, 36.9 % registered early complications, being persistent pain (n = 32; 15 %), sepsis/septic shock (n = 28; 13 %), pneumonia (n = 27; 13 %) and neurogenic bladder (n = 27; 12 %) the most frequently reported. After case-control matched analysis, we obtained 133 patients who suffered early complications (cases) and 133 patients who did not as control group, not differing significantly in sex (p = 1000), age (p = 0,535) and injury level (p = 1000), while the 35 % of complications group required surgical treatment versus 15 % of the non-complication group (p < 0.001). On multivariable analysis, significant predictors of complications were surgical treatment for spinal injury (OR = 3.50, 95 % CI = 1.68-7.30), dirty wound (3.32, 1.50-7.34), GCS ≤8 (3.56, 1.17-10.79), hemodynamic instability (2.29, 1.07-4.88), and multiple bullets (1.97, 1.05-3.67). Discussion and conclusion Spinal gunshot wounds are associated with a high risk of early complications, especially when spinal surgery is required, and among patients with dirty wound, low level of consciousness, hemodynamic instability, and multiple bullets.
Collapse
Affiliation(s)
- Guillermo A. Ricciardi
- Orthopaedics and Traumatology, Centro Médico Integral Fitz Roy, Acevedo 865, C1414, Buenos Aires, Argentina
| | - Juan P. Cabrera
- Department of Neurosurgery, Hospital Clínico Regional de Concepción, San Martín 1436, 4070022, Concepción, Bío Bío, Chile
- Faculty of Medicine, University of Concepción, Janequeo esquina, Av. Chacabuco S/N, Concepción, Bío Bío, Chile
| | - Oscar Martínez
- Hospital Universitario Dr. José E. González, Av. Dr. José Eleuterio González S/N, Mitras Centro, 64460, Monterrey, N.L., Mexico
| | - Javier Matta
- Hospital Militar Central, v. 3C No. 49 – 02, CP 110231, Bogotá, Colombia
| | - Hugo Vilchis
- Unidad Médica de Alta Especialidad, Hospital de Traumatología y Ortopedia, Lomas Verdes IMSS, Avenida Lomas Verdes 52, Sta Cruz Acatlan, 53150, Naucalpan de Juárez, Méx., Mexico
| | - Jeasson Javier Perez Ríos
- Clínica de Columna “Dr. Manuel Dufoo Olvera”, Calz. San Juan de Aragón 285, Granjas Modernas, Gustavo A. Madero, 07460, Ciudad de México CDMX, Mexico
| | - Charles A. Carazzo
- Neurosurgery, University of Passo Fundo, São Vicente de Paulo Hospital, R. Teixeira Soares, 808 - Centro, Passo Fundo, RS, 99010-080, Brazil
| | - Michael Dittmar
- Centro Médico Puerta de Hierro, Av. Empresarios, Puerta de Hierro, 45116, Zapopan, Jal., Mexico
| | - Ratko Yurac
- Department of Orthopedic and Traumatology, Universidad del Desarrollo, Av Plaza 680, 7610658, Las Condes, Región Metropolitana, Chile
- Spine Unit, Department of Traumatology, Clínica Alemana, Av Vitacura 5951, Vitacura, Región Metropolitana, Santiago, Chile
| | - the AO Spine Latin America Trauma Study Group
- Orthopaedics and Traumatology, Centro Médico Integral Fitz Roy, Acevedo 865, C1414, Buenos Aires, Argentina
- Department of Neurosurgery, Hospital Clínico Regional de Concepción, San Martín 1436, 4070022, Concepción, Bío Bío, Chile
- Faculty of Medicine, University of Concepción, Janequeo esquina, Av. Chacabuco S/N, Concepción, Bío Bío, Chile
- Hospital Universitario Dr. José E. González, Av. Dr. José Eleuterio González S/N, Mitras Centro, 64460, Monterrey, N.L., Mexico
- Hospital Militar Central, v. 3C No. 49 – 02, CP 110231, Bogotá, Colombia
- Unidad Médica de Alta Especialidad, Hospital de Traumatología y Ortopedia, Lomas Verdes IMSS, Avenida Lomas Verdes 52, Sta Cruz Acatlan, 53150, Naucalpan de Juárez, Méx., Mexico
- Clínica de Columna “Dr. Manuel Dufoo Olvera”, Calz. San Juan de Aragón 285, Granjas Modernas, Gustavo A. Madero, 07460, Ciudad de México CDMX, Mexico
- Neurosurgery, University of Passo Fundo, São Vicente de Paulo Hospital, R. Teixeira Soares, 808 - Centro, Passo Fundo, RS, 99010-080, Brazil
- Centro Médico Puerta de Hierro, Av. Empresarios, Puerta de Hierro, 45116, Zapopan, Jal., Mexico
- Department of Orthopedic and Traumatology, Universidad del Desarrollo, Av Plaza 680, 7610658, Las Condes, Región Metropolitana, Chile
- Spine Unit, Department of Traumatology, Clínica Alemana, Av Vitacura 5951, Vitacura, Región Metropolitana, Santiago, Chile
| |
Collapse
|
3
|
Freria CM, Graham L, Azimi A, Lu P. Adaptation of a cervical bilateral contusive spinal cord injury for study of skilled forelimb function. Exp Neurol 2023; 360:114275. [PMID: 36379273 DOI: 10.1016/j.expneurol.2022.114275] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/23/2022] [Accepted: 11/09/2022] [Indexed: 11/15/2022]
Abstract
We present an updated, clinically relevant model of moderately severe bilateral cervical level 6 contusive spinal cord injury (SCI) in the rat. This model is more clinically relevant than previous models due it its severity, yet animals readily survive the lesion. The C6 bilateral lesion is administered to Fischer 344 rats using the Infinite Horizons impactor adjusted to a 200 kdyne force with a 3.5 mm impactor head. The lesion results in loss of 60 ± 10% of the spinal cord area, including virtually the entire dorsal half of the spinal cord and complete interruption of the main corticospinal tract. Skilled forelimb performance declines by 60 ± 10% compared to the pre-operative baseline and deficits are sustained over time. This model is a substantial step closer to mimicking the most common level (cervical) and more severe form of SCI in humans and should provide a superior tool for assessing the likelihood that experimental interventions may promote motor recovery after SCI in humans.
Collapse
Affiliation(s)
- Camila Marques Freria
- Dept. of Neurosciences, University of California - San Diego, La Jolla, CA, United States of America.
| | - Lori Graham
- Dept. of Neurosciences, University of California - San Diego, La Jolla, CA, United States of America
| | - Ali Azimi
- Dept. of Neurosciences, University of California - San Diego, La Jolla, CA, United States of America
| | - Paul Lu
- Veterans Administration San Diego Healthcare System, San Diego, CA, United States of America; Dept. of Neurosciences, University of California - San Diego, La Jolla, CA, United States of America.
| |
Collapse
|
4
|
Cingoz ID, Kaya I, Sahin MC, Kilcarslan B, Yuceer N. Spine and spinal cord injuries in Syria war: treatment and outcome. Spinal Cord 2023; 61:169-174. [PMID: 36575225 DOI: 10.1038/s41393-022-00870-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 12/28/2022]
Abstract
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.
Collapse
Affiliation(s)
- Ilker D Cingoz
- Department of Neurosurgery, Faculty of Medicine, Usak University, Usak, Turkey.
| | - Ismail Kaya
- Department of Neurosurgery, Faculty of Medicine, Usak University, Usak, Turkey
| | - Meryem C Sahin
- Department of Medical Services and Techniques, Vocational School of Health Services, Usak University, Usak, Turkey
| | - Bilal Kilcarslan
- Department of Neurosurgery, Denizli State Hospital, Denizli, Turkey
| | - Nurullah Yuceer
- Department of Neurosurgery, Faculty of Medicine, Izmir Katip Çelebi University, Izmir, Turkey
| |
Collapse
|
5
|
Gizatullin SK, Aliev ZS, Stanishevsky AV, Kristosturov AS, Davydov DV, Onnitsev IE. Treatment of gunshot wounds of the spine using full-endoscopic surgery: analysis of a small clinical series. HIRURGIÂ POZVONOČNIKA (SPINE SURGERY) 2022. [DOI: 10.14531/ss2022.4.77-85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- Sh. Kh. Gizatullin
- Main Military Clinical Hospital n.a. N.N. Burdenko
3 Gospitalnaya sq., Moscow, 105094, Russia
| | - Z. Sh. Aliev
- Main Military Clinical Hospital n.a. N.N. Burdenko;
Military Hospital No. 426
3 Gospitalnaya sq., Moscow, 105094, Russia;
2 Nevskaya str., Samara, 443110, Russia
| | - A. V. Stanishevsky
- Main Military Clinical Hospital n.a. N.N. Burdenko
3 Gospitalnaya sq., Moscow, 105094, Russia
| | - A. S. Kristosturov
- Main Military Clinical Hospital n.a. N.N. Burdenko
3 Gospitalnaya sq., Moscow, 105094, Russia
| | - D. V. Davydov
- Main Military Clinical Hospital n.a. N.N. Burdenko
3 Gospitalnaya sq., Moscow, 105094, Russia
| | - I. E. Onnitsev
- Main Military Clinical Hospital n.a. N.N. Burdenko
3 Gospitalnaya sq., Moscow, 105094, Russia
| |
Collapse
|
6
|
Muacevic A, Adler JR, Ouedraogo F, Joel R, Bowman B. Gunshot Wound to the Spine With Delayed Radiculopathy: A Case Report. Cureus 2022; 14:e32385. [PMID: 36632267 PMCID: PMC9829442 DOI: 10.7759/cureus.32385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2022] [Indexed: 12/14/2022] Open
Abstract
Gunshot wounds (GSWs) to any part of the body can leave a trail of insidious complications. When the spinal cord is the injured organ, these sequelae can be debilitating to the patient and often exhaust all known therapeutic approaches available to the providers. The management of pain associated with GSWs to the spine is often a clinical challenge and there is often a question as to whether or not surgical intervention can help with pain relief in these cases. Here, we present a 45-year-old woman who experienced delayed radicular pain following a GSW to the spine with a retained bullet at the level of the lumbosacral canal. After an unsuccessful comprehensive multimodal analgesia, the patient underwent surgical removal of the bullet, which did not successfully provide a substantial lasting analgesic effect. This case demonstrates the potential for surgical failure and supports the general recommendation of more conservative management in this population.
Collapse
|
7
|
Pourhajshokr N, Sadeggi MS, Ghobadi J, Khanghah AS, Ezzativand H. Successful removal of a bullet from the spinal canal of a GSW victim in the level of L5: Case report. Int J Surg Case Rep 2022; 101:107779. [DOI: 10.1016/j.ijscr.2022.107779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022] Open
|
8
|
Rosales R, Amirianfar E, Appeadu M, Gater D, Price C. Spinal cord stimulation for neuropathic pain following traumatic spinal cord injury: a case report. Spinal Cord Ser Cases 2022; 8:80. [PMID: 36109507 PMCID: PMC9478097 DOI: 10.1038/s41394-022-00546-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 08/23/2022] [Accepted: 08/26/2022] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Neuropathic pain is a common complication of spinal cord injury (SCI), and is notoriously difficult to adequately treat. Gunshot wounds (GSW) near the spinal cord may cause intractable chronic pain through spinal/nerve root transection, or reactive tissue formation resulting in nerve root compression from retained bullet fragments (RBF). CASE PRESENTATION This case report describes a 30-year-old man with a T12 AIS B incomplete spinal cord injury with paraplegia secondary to multiple GSW who presented with severe bilateral lower extremity dysesthesias and muscle spasms. Symptoms failed to improve with oral antispasmodic medications. After being diagnosed with Complex regional pain syndrome (CRPS) type I secondary to an SCI via GSW, he underwent a spinal cord stimulator (SCS) trial, which improved his symptoms by greater than 80%. DISCUSSION Neuropathic pain refractory to conservative treatment may benefit from SCS. Effects of therapy go beyond gate-theory in SCI patients, and may benefit patients at the cellular and molecular level. Our case demonstrates the effectiveness of SCS treatment in a patient who developed CRPS type 1 after GSW resulting in SCI.
Collapse
Affiliation(s)
- Richard Rosales
- Department of Physical Medicine and Rehabilitation at University of Miami/Jackson Memorial Hospital, Miami, FL, USA.
| | - Edwin Amirianfar
- Department of Physical Medicine and Rehabilitation at University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Michael Appeadu
- Department of Physical Medicine and Rehabilitation at University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - David Gater
- Department of Physical Medicine and Rehabilitation at University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Chane Price
- Department of Physical Medicine and Rehabilitation at University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| |
Collapse
|
9
|
George DD, Houk C, Pieters TA, Towner JE, Stone JJ. Meningitis due to intra-abdominal cerebrospinal fluid fistula following gunshot wound successfully treated with antibiotics and blood patch: A case report and literature review. Surg Neurol Int 2022; 13:308. [PMID: 35928328 PMCID: PMC9345101 DOI: 10.25259/sni_390_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/04/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Penetrating spinal cord injury (PSCI) represents an average of 5.5% of all SCIs among civilians in the United States. The formation of a cerebrospinal fluid (CSF) fistula following PSCI occurs in approximately 9% of cases. Intra-abdominal CSF fistulae are rarely reported. Case Description: We present the case of a 28-year-old Caucasian female who suffered a single gunshot wound to the abdomen with a missile fragment lodged within the left L2 pedicle and transverse process without obvious canal compromise. The patient developed bacterial meningitis 13 days after the initial injury, treated with IV antibiotics. CT myelogram demonstrated intra-abdominal ventral CSF fistula from the left L2–L3 neuroforamen. The patient was successfully treated with fluoroscopy-guided dorsal autologous blood patch graft. Conclusion: This case highlights a rare complication of PSCI successfully managed with the use of a blood patch graft.
Collapse
|
10
|
Somuncu D, Gartenberg A, Cho W. Investigational Therapies for Gunshot Wounds to the Spine: A Narrative Review. Clin Spine Surg 2022; 35:233-240. [PMID: 34670987 DOI: 10.1097/bsd.0000000000001258] [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: 10/08/2020] [Accepted: 09/15/2021] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a narrative review. OBJECTIVE The objective of this study was to review the standards of care and triage protocol for gunshot wounds to the spine, highlighting innovative future treatment options that may be implemented in patients with spinal cord injury (SCI). SUMMARY OF BACKGROUND DATA With the increased availability of firearms among the United States population, gunshot wounds to the spine are becoming a clinically relevant and devastating issue. Such injuries result in severe and diverse complications. SCIs due to gunshot wounds are the leading cause of morbidity and mortality, as they often result in complete or incomplete paraplegia. Current standards of care focus on preventing further damage rather than total cure or treatment of SCI. METHODS A literature review was performed on the standards of care, triage protocol, associated conditions, current therapeutic options, and innovative treatment options for patients with gunshot wounds to the spine. RESULTS The general standards of care for spinal gunshot wounds involve maintaining or renewal of mechanical spinal steadiness and neurological activity while limiting complications of treatment. Current treatment options include management of mean arterial pressure goals, drug therapies consisting of antibiotics, and surgical approaches. With recent innovations in molecular biology and cell transplantation, potentially new and promising treatment options for patients with SCI exist. These options include cell transplantation therapies, platelet-rich plasma administration, exosomal treatments, and mitochondrial-targeted therapeutics. Stem cell transplantation is promising, as several clinical studies have been completed. However, loss-to-follow-up, lack of long-term evaluation, and questionable randomization has limited the use of stem cells in the standard of care practice. Although not studied on human models to a gunshot wound, exosomal and mitochondrial-based treatment options have been studied both in vitro and in animal models with SCI. CONCLUSION Newly emerging molecular and cellular therapy modalities for SCI contribute to the recovery process and may be utilized in conjunction with the current modalities for better outcomes.
Collapse
Affiliation(s)
- Doruk Somuncu
- Bahçeşehir University School of Medicine, Istanbul, Turkey
| | - Ariella Gartenberg
- Department of Orthopaedic Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Woojin Cho
- Department of Orthopaedic Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| |
Collapse
|
11
|
Schneider N, Blutke A, Parzefall B. Recovery after inadvertent intramedullary microchip implantation at C1–C2 in a kitten. JFMS Open Rep 2022; 8:20551169221081398. [PMID: 35321496 PMCID: PMC8935412 DOI: 10.1177/20551169221081398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Case summary A 15-week-old male British Shorthair cat was presented for peracute paralysis immediately after microchip implantation. Neurological examination revealed a non-ambulatory tetraparesis and left thoracic limb plegia localised to C1–C5 spinal cord segments. CT of the cervical spine showed a diagonally orientated metallic foreign body (microchip transponder, 10 mm in length) within the vertebral canal at the level of C1–C2, resulting in a penetrating spinal cord injury. Based on concerns about further iatrogenic spinal cord injury through surgery, medical management was chosen. Despite the severe clinical signs, the kitten returned to ambulation within 6 days of the injury, with controlled urination and defecation. Continuous neurological improvement was seen for up to 6 weeks after the injury at which point a mild-to-moderate ambulatory tetraparesis and ataxia remained, with an overall good quality of life. Follow-up CT at the age of 13 months revealed a relative cranial displacement and rotation of the microchip towards the foramen magnum, while the cat’s neurological status was unchanged. Relevance and novel information This case demonstrated a cervical penetrating spinal cord injury in a growing cat caused by a microchip, which was successfully managed with medical treatment, suggesting that this might be an option for patients at risk of severe surgery-related complications or where owners reject surgery.
Collapse
Affiliation(s)
- Nina Schneider
- Neurology Department, Small Animal Clinic Oberhaching, Oberhaching, Germany
| | - Andreas Blutke
- Institute for Experimental Genetics, Helmholtz Zentrum München, Neuherberg, Germany
| | - Birgit Parzefall
- Neurology Department, Small Animal Clinic Oberhaching, Oberhaching, Germany
| |
Collapse
|
12
|
de los Cobos D, Powers A, Behrens JP, Mattei TA, Salari P. Surgical removal of a migrating intraspinal bullet: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE21132. [PMID: 35855464 PMCID: PMC9245739 DOI: 10.3171/case21132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 03/09/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND
Management of gunshot wounds to the spine with subsequent spinal cord injury is a controversial topic among spine surgeons. Possible complications of retained intradural bullets include delayed neurological deficits, spinal instability, and lead toxicity. The authors’ purpose is to review the potential complications of retained intraspinal bullets and the surgical indications for intraspinal bullet removal.
OBSERVATIONS
The authors describe a case of a patient who developed cauda equina symptoms following a gunshot wound to the lumbar spine with a migrating retained intraspinal bullet. Because of neurological changes, the patient underwent surgical removal of the bullet. At the postoperative clinic visit 2 weeks following bullet removal, the patient reported resolution of her symptoms.
LESSONS
Gunshot wounds to the spine are challenging cases. The decision to proceed with surgical management in the event of retained bullet fragments is multifactorial and relies heavily on the patient’s neurological status. A current review of the literature suggests that, in cases of cauda equina injuries and the development of neurological deficits in patients with retained intraspinal fragments, there is benefit from surgical decompression and bullet removal. Careful preoperative planning is required, and consideration of spinal alignment with positional changes is crucial.
Collapse
Affiliation(s)
| | | | | | - Tobias A. Mattei
- Neurosurgery, Saint Louis University School of Medicine, St. Louis, Missouri
| | | |
Collapse
|
13
|
Sajid MI, Ahmad B, Mahmood SD, Darbar A. Gunshot injury to spine: An institutional experience of management and complications from a developing country. Chin J Traumatol 2020; 23:324-328. [PMID: 32891484 PMCID: PMC7718504 DOI: 10.1016/j.cjtee.2020.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/01/2020] [Accepted: 07/14/2020] [Indexed: 02/04/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Mir Ibrahim Sajid
- Medical College, Aga Khan University, Karachi, 74880, Pakistan,Corresponding author.
| | - Bushra Ahmad
- Department of Neurosurgery, Aga Khan University Hospital, Karachi, 74880, Pakistan
| | | | - Aneela Darbar
- Department of Neurosurgery, Aga Khan University Hospital, Karachi, 74880, Pakistan
| |
Collapse
|
14
|
Retained bullet in the cervical spinal canal and the associated surgical management conundrum: case report and review of the literature. Spinal Cord Ser Cases 2020; 6:77. [PMID: 32826864 PMCID: PMC7441479 DOI: 10.1038/s41394-020-00326-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/05/2020] [Accepted: 08/09/2020] [Indexed: 11/09/2022] Open
Abstract
Introduction Gunshot wounds (GSW) to the cervical spine remain uncommon. Surgery often does not yield significant neurological improvement and the decision to utilize surgery depends on a number of factors. We describe the case of a 28 year-old male suffering a complete spinal cord injury (SCI) secondary to a bullet lodged in the cervical spinal canal. We present the unique radiological findings and review the indications for and utility of spine surgery for cervical GSW. Case presentation The patient was a 28 year-old male involved in a motor vehicle accident immediately after sustaining a gunshot wound to the cervical spine. Neurologic exam revealed a complete SCI at the C4 level. CT scan revealed a retained bullet in the spinal canal at the C4/5 level without vascular injury or unstable vertebral fracture. He was managed nonoperatively, however, he remained ventilator dependent and ultimately expired secondary to cardiac arrest from a suspected pulmonary embolism. Discussion We present a case of complete SCI secondary to a retained bullet in the cervical spine. These cases can be managed both operatively and nonoperatively. Given the high risk of morbidity and overall poor neurological recovery after surgical intervention for SCI secondary to GSW, physicians must understand the appropriate indications for surgical intervention. These indications include, but are not limited to, progressive neurological deficit, cerebrospinal fluid leak, spinal instability, and acute lead toxicity.
Collapse
|
15
|
Karaeminogullari O, Ozer O. Percutaneous Transforaminal Endoscopic Removal of Spinal Shrapnel. World Neurosurg 2020; 142:179-183. [PMID: 32652273 DOI: 10.1016/j.wneu.2020.06.226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 06/29/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Gunshot injuries are one of the most common causes of the penetrating injuries of the spine. The victims of these injuries usually have neurologic deficits. Percutaneous endoscopic lumbar surgery is one of the most popular surgical spine interventions. We report a case with incomplete radiculopathy due to shrapnel located in L5 foramen that was removed by percutaneous endoscopic technique. CASE DESCRIPTION A 23-year-old man sustaining a gunshot injury penetrating to the abdomen presented to our hospital. His first examination revealed a single gunshot wound with entry hole in the left low lumbar region without exit hole and right lower abdominal quadrant tenderness. Plain radiographs and computed tomography showed a bullet in the abdomen and left L5 transverse process fracture and shrapnel in L5 foraminal zone. The bullet was removed by abdominal surgeons without any surgical plan for the shrapnel in the foramen. He was referred to our clinic 3 weeks after discharge. Without any further neurologic deterioration, he had uninterrupted severe pain that was mostly unbearable during the night. Despite gradually increasing dosages of different drugs, his pain relief was insufficient. Percutaneous transforaminal endoscopic removal of the shrapnel was planned. CONCLUSIONS Despite the absence of a universally approved algorithm in the treatment of spinal gunshot injuries, endoscopic technique can be kept in mind for a minimal access and invasiveness in case of indication for removal. With experience in endoscopic procedures and familiarity with surgical anatomy, the treatment of this unique case was completed successfully.
Collapse
Affiliation(s)
| | - Ozgur Ozer
- Department of Orthopaedics and Traumatology, Bayindir Hospital, Ankara, Turkey.
| |
Collapse
|
16
|
Gutierrez A, Su YS, Vaughan KA, Miranda S, Chen HI, Petrov D, Malhotra NR, Schuster JM. Penetrating Spinal Column Injuries (pSI): An Institutional Experience with 100 Consecutive Cases in an Urban Trauma Center. World Neurosurg 2020; 138:e551-e556. [DOI: 10.1016/j.wneu.2020.02.173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 02/27/2020] [Accepted: 02/28/2020] [Indexed: 10/24/2022]
|
17
|
Towner JE, Pieters TA, Maurer PK. Lead Toxicity From Intradiscal Retained Bullet Fragment: Management Considerations and Recommendations. World Neurosurg 2020; 141:377-382. [PMID: 32442733 DOI: 10.1016/j.wneu.2020.05.112] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/12/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Lead toxicity (plumbism) secondary to retained lead missiles in synovial joint spaces is a rare complication after gunshot injuries. Management of lead missiles in the intradiscal space regarding potential lead toxicity is less certain. CASE DESCRIPTION We reviewed the literature regarding lead toxicity secondary to intradiscal bullets particularly concerning incidence, management, and outcomes. A lack of high-quality published data precludes a meta-analysis from taking place. Only four reports of lead toxicity secondary to missiles in the intradiscal space have been published. Including an additional case presented in this report, our review of the literature has led us to make several management recommendations, largely based on both the available literature and our current report. CONCLUSIONS First, there is insufficient evidence for removing retained lead missiles solely to mitigate the risk of lead toxicity. Second, chelation therapy in addition to surgical removal of the lead source is a valuable adjunct in the perioperative period and should be undertaken with the assistance of medical toxicology. Third, a retained missile does not mandate a simultaneous stabilization procedure in lieu of other indications based on the data available at this time.
Collapse
Affiliation(s)
- James E Towner
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA.
| | - Thomas A Pieters
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Paul K Maurer
- Department of Neurosurgery, Rochester Regional Health, Rochester, New York, USA
| |
Collapse
|
18
|
Regional and Institutional Practice Variations in Decompressive Spine Surgery for Patients with Penetrating Spinal Injury in the United States. World Neurosurg 2020; 137:e263-e268. [DOI: 10.1016/j.wneu.2020.01.151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/18/2020] [Accepted: 01/20/2020] [Indexed: 11/18/2022]
|
19
|
Athavale AM, Fu CY, Bokhari F, Bajani F, Hart P. Incidence of, Risk Factors for, and Mortality Associated With Severe Acute Kidney Injury After Gunshot Wound. JAMA Netw Open 2019; 2:e1917254. [PMID: 31825505 PMCID: PMC6991197 DOI: 10.1001/jamanetworkopen.2019.17254] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
IMPORTANCE Acute kidney injury increases the risk of mortality in hospitalized patients. However, incidence of severe acute kidney injury (SAKI) and its association with mortality in civilians with gunshot wounds (GSWs) is not known. OBJECTIVE To determine the incidence of and risk factors associated with SAKI and acute kidney injury requiring dialysis (AKI-D) after GSWs and the association of SAKI and AKI-D with mortality among civilians in the United States. DESIGN, SETTING, AND PARTICIPANTS This retrospective cross-sectional study included civilians with GSW reported to the National Trauma Data Bank between July 1, 2010, and June 30, 2015. Torso GSWs were included in study; GSWs to the head were excluded. The data were analyzed between September and November 2018. EXPOSURE Civilians with GSW. MAIN OUTCOMES AND MEASURES Incidence of SAKI and AKI-D; association of SAKI and AKI-D with mortality. RESULTS Most of the 64 059 civilian GSWs affected men (57 431 [89.7%]) and racial/ethnic minorities (36 205 [56.5%] African American individuals; 9681 [15.1%] Hispanic individuals). Incidence of SAKI was 2.3% (1450 of 64 059), and incidence of AKI-D was 0.9% (588 of 64 059). On multivariate analysis, SAKI was associated with older age (odds ratio [OR], 1.02; 95% CI, 1.01-1.02; P < .001), male sex (OR, 1.37; 95% CI, 1.12-1.66; P = .002), diabetes (OR, 1.55; 95% CI, 1.20-2.00; P = .001), hypertension (OR, 1.76; 95% CI, 1.46-2.11; P < .001), Glasgow Coma Scale score (OR, 0.98; 95% CI, 0.96-0.99; P = .002), sepsis (OR, 13.83; 95% CI, 11.77-16.24; P < .001), hollow viscus injury (OR, 2.31; 95% CI, 2.05-2.59; P < .001), and injury severity score (OR, 1.02; 95% CI, 1.01-1.02; P < .001); AKI-D was associated with systolic blood pressure (OR, 0.99; 95% CI, 0.99-1.00; P < .001), sepsis (OR, 1.56; 95% CI, 1.18-2.04; P = .001), and injury severity score (OR, 1.01; 95% CI, 1.01-1.02; P = .001). Mortality was significantly higher in patients with AKI-D (167 of 588 patients [28.4%]) compared with patients with SAKI (172 of 862 [20.0%]) and no SAKI or AKI-D (5521 of 62 609 [8.8%]) (P < .001). Mortality was associated with older age (OR, 1.01; 95% CI, 1.01-1.01; P < .001), systolic blood pressure (OR, 0.997; 95% CI, 0.997-0.998; P < .001), Glasgow Coma Scale score (OR, 0.87; 95% CI, 0.87-0.88; P < .001), SAKI (OR, 2.32; 95% CI, 1.93-2.79; P < .001), AKI-D (OR, 1.46; 95% CI, 1.12-1.90; P < .001), hollow viscus injury (OR, 1.87; 95% CI, 1.76-1.98; P < .001), and higher injury severity score (OR, 1.01; 95% CI, 1.01-1.01; P < .001). After matching for variables except SAKI or AKI-D, patients with SAKI were twice as likely to die than patients without SAKI (320 of 1391 [23.0%] vs 158 of 1391 [11.4%]; P < .001). CONCLUSIONS AND RELEVANCE In this cross-sectional study, SAKI among civilians who experienced GSWs was associated with mortality.
Collapse
Affiliation(s)
- Ambarish M. Athavale
- Division of Nephrology, John H. Stroger Jr Hospital of Cook County, Chicago, Illinois
| | - Chih-Yuan Fu
- Chang Gung Memorial Hospital, Department of Trauma and Emergency Surgery, Chang Gung University, Taoyuan City, Taiwan
| | - Faran Bokhari
- Cook County Trauma and Burns Unit, John H. Stroger Jr Hospital of Cook County, Chicago, Illinois
| | - Francesco Bajani
- Division of Trauma, John H. Stroger Jr Hospital of Cook County, Chicago, Illinois
| | - Peter Hart
- Division of Nephrology, John H. Stroger Jr Hospital of Cook County, Chicago, Illinois
| |
Collapse
|
20
|
Womack R, Luther E, Perez-Roman RJ, Manzano GR. Heterotopic Bone Formation 20 Years After Gunshot Wound to the Cervical Spine: A Rare Cause of Progressive Cervical Myelopathy in a Previously Asymptomatic Patient. World Neurosurg 2019; 132:197-201. [DOI: 10.1016/j.wneu.2019.08.093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/10/2019] [Accepted: 08/14/2019] [Indexed: 11/29/2022]
|
21
|
Mackowsky M, Hadjiloucas N, Campbell S, Bulauitan C. Penetrating spinal cord injury: A case report and literature review. Surg Neurol Int 2019; 10:146. [PMID: 31528481 PMCID: PMC6744734 DOI: 10.25259/sni_221_2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 05/21/2019] [Indexed: 12/30/2022] Open
Abstract
Background: Penetrating spinal cord injury (pSCI) is uncommon in civilian settings. However, there is a lack of consensus regarding perioperative management and thresholds for operative intervention. This review explores the various trends in the management of pSCI along with a literature review. Case Description: A 34-year-old male presented with a gunshot wound (GSW) to the left chest. Injuries included a pneumothorax, diaphragmatic injury, splenic injury, multiple small bowel injuries, transverse colon injury, and a bullet lodged at the L5 spinal level. The patient underwent chest tube placement, an exploratory laparotomy, splenectomy, diaphragmatic repair, multiple small bowel resections, and a transverse colon resection. Later on, the patient required a lumbar laminectomy for wound debridement and bullet excision. Conclusion: The standards for the surgical management of pSCI are poorly defined. Older studies suggested that >7 days of antibiotics decreased the risk of infection associated with HVI while shorter regimens correlated with higher rates of spinal and neurologic infections (meningitis, paraspinal abscess, and osteomyelitis). Newer studies fail to confirm the benefit of extended antimicrobial therapy, noting no increased infections with 48 h or less of antibiotic use while suggesting increased risks of long-term antibiotic prophylaxis (i.e., antimicrobial resistance and Clostridium difficile infection). There is no current role for steroids in the treatment of pSCI, and routine operative management is no longer necessarily indicated.
Collapse
Affiliation(s)
- Matthew Mackowsky
- Departments of Surgery, Monmouth Medical Center, 300 Second Avenue, Long Branch
| | - Nicole Hadjiloucas
- Departments of Surgery, Monmouth Medical Center, 300 Second Avenue, Long Branch
| | - Stuart Campbell
- Departments of Surgery, Jersey Shore University Medical Center, 1945 NJ-33, Neptune City, New Jersey, USA
| | - Constantine Bulauitan
- Departments of Surgery, Jersey Shore University Medical Center, 1945 NJ-33, Neptune City, New Jersey, USA
| |
Collapse
|
22
|
Furlan JC, Gulasingam S, Craven BC. Epidemiology of War-Related Spinal Cord Injury Among Combatants: A Systematic Review. Global Spine J 2019; 9:545-558. [PMID: 31431879 PMCID: PMC6686388 DOI: 10.1177/2192568218776914] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES War-related spinal cord injuries (SCIs) are commonly more severe and complex than traumatic SCIs among civilians. This systematic review, for the first time, synthesized and critically appraised the literature on the epidemiology of war-related SCIs. This review aimed to identify distinct features from the civilian SCIs that can have an impact on the management of military and civilian SCIs. METHODS Medline, EMBASE, and PsycINFO databases were searched for articles on epidemiology of war-related SCI among combatants, published from 1946 to December 20, 2017. This review included only original publications on epidemiological aspects of SCIs that occur during an act of war. The STROBE statement was used to examine the quality of the publications. RESULTS The literature search identified 1594 publications, of which 25 articles fulfilled the inclusion and exclusion criteria. The studies were classified into the following topics: 17 articles reported demographics, level and severity of SCI, mechanism of injury and/or associated bodily injuries; 5 articles reported the incidence of war-related SCI; and 6 articles reported the frequency of SCI among other war-related bodily injuries. Overall, military personnel with war-related SCI were typically young, white men, with predominantly thoracic or lumbar level, complete (American Spinal Injury Association [ASIA] Impairment Scale A) SCI due to gunshot or explosion and often associated with other bodily injuries. Marines appear to be at a greater risk of war-related SCI than the military personal in the Army, Navy, and Air Force. CONCLUSIONS The war-related SCIs among soldiers are distinct from the traumatic SCI in the general population. The majority of the current literature is based on the American experiences in most recent wars.
Collapse
Affiliation(s)
- Julio C. Furlan
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
- Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Sivakumar Gulasingam
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
- Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - B. Catharine Craven
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
- Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
23
|
Removal of Migrating Lumbar Spine Bullet: Case Report and Surgical Video. World Neurosurg 2019; 131:62-64. [PMID: 31356981 DOI: 10.1016/j.wneu.2019.07.151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 07/18/2019] [Accepted: 07/19/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Gunshot wounds to the spine are devastating injuries. Rarely, the bullet has been reported to migrate. Migration is associated with progressive neurologic deficits that often improve with bullet removal. The authors report a case of removal of a migrating lumbar spine bullet. This is supplemented by an operative video and a review of the literature. CASE DESCRIPTION A 31-year-old man presented to the emergency department with multiple gunshot wounds and lower-extremity paresthesia. A ballistic injury occurred with an entry wound in the right posterior soft tissues, traversing the right paraspinal muscle and fracturing the left lumbar 5 pedicle and left lumbar 4 transverse process. The bullet was positioned within the spinal canal at the lumbar 3/4 interspace. His spinal injury was managed nonoperatively due to his traumatic injuries and findings of minimal neurologic deficit without cerebrospinal fluid leak. The patient returned to the neurosurgery clinic a year later and was found to have worsening low back pain, decreased sensation throughout the left leg, and radiating pain throughout the right leg. Imaging demonstrated the bullet had migrated caudally to the midlumbar 5 vertebral body. Given the patient's progressive symptoms and migration of the bullet fragment, informed consent was obtained for a laminectomy and removal of the intradural bullet fragment. CONCLUSIONS Neurosurgical treatment for gunshot wounds remains controversial. Cauda equina or lumbosacral level wounds are often incomplete and may improve with surgical decompression and bullet removal. Migrating bullet fragments throughout the spine and brain lead to worsened neurologic function, which can be reversed by removal. Movement of the bullet during surgery should be expected, and intraoperative fluoroscopy and patient positioning can help to properly localize the bullet and aid in its removal.
Collapse
|
24
|
Demontis R, d'Aloja E, Manieli C, Carai A, Boi M, Serra MP, Quartu M. Case report of sudden death after a gunshot wound to the C2 vertebral bone without direct spinal cord injury: Histopathological analysis of spinal-medullary junction. Forensic Sci Int 2019; 301:e49-e54. [PMID: 31230858 DOI: 10.1016/j.forsciint.2019.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 06/02/2019] [Accepted: 06/09/2019] [Indexed: 10/26/2022]
Abstract
Gunshot wounds (GSW) are one of the most common causes of penetrating spinal injury, however few data are available regarding GSW causing an indirect fatal nervous tissue injury, such as that induced by the concussive force secondary to the bullet penetration. This report describes a rare case of a death following a GSW spine injury at the level of C2 vertebral body, without direct contact with the spinal cord, as seen with computed tomography scan performed soon after the death. At autopsy, vertebral canal and dura mater, as well as spinal cord and medulla oblongata, appeared devoid of pathologies and/or lesions, major viscera were unaltered. The cause of death was attributed to a cardiorespiratory arrest subsequent to the GSW injury of the C2 vertebral bone. Histopathological analysis of spinal cord and medulla oblongata was performed by means of conventional stainings, and glial fibrillary acidic protein (GFAP) and Neurofilaments 200kD (NF) immunohistochemistry. Histological alterations stood out against a tissue with no other evident sign of neuropathology, and could be observed from the caudalmost part of the medulla oblongata to the level of the inferior olivary nucleus. Main structural changes were found in the white matter, involving often the adjacent gray matter, where they appeared as multiple scattered areas of degeneration, lacking the usual staining affinity, and showing a disrupted fibrillary pattern as evidenced by myelin staining, and GFAP- and NF-immunolabelling. The shock wave secondary to the impact on the C2 vertebral bone is likely to have been the cause of a widespread neuronal-axonal histopathological damage at the spinal-medullary junction and caudal medulla oblongata that is compatible with a severe fatal respiratory dysfunction and dysregulation of the autonomic pathways subserving the control of blood pressure and cardiac activity.
Collapse
Affiliation(s)
- Roberto Demontis
- Department of Medical Sciences and Public Health, University of Cagliari, Italy.
| | - Ernesto d'Aloja
- Department of Medical Sciences and Public Health, University of Cagliari, Italy.
| | - Cristina Manieli
- Service of Pathological Anatomy, Azienda Ospedaliera "G. Brotzu", Cagliari, Italy.
| | - Antonio Carai
- Department of Medical Sciences and Public Health, University of Cagliari, Italy.
| | - Marianna Boi
- Department of Biomedical Sciences, Section of Cytomorphology, University of Cagliari, Italy.
| | - Maria Pina Serra
- Department of Biomedical Sciences, Section of Cytomorphology, University of Cagliari, Italy.
| | - Marina Quartu
- Department of Biomedical Sciences, Section of Cytomorphology, University of Cagliari, Italy.
| |
Collapse
|
25
|
Scott KW, Trumbull DA, Clifton W, Rahmathulla G. Does Surgical Intervention Help with Neurological Recovery in a Lumbar Spinal Gun Shot Wound? A Case Report and Literature Review. Cureus 2019; 11:e4978. [PMID: 31467812 PMCID: PMC6706263 DOI: 10.7759/cureus.4978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Kyle W Scott
- Neurosurgery, University of Florida College of Medicine, Gainesville, USA
| | | | | | | |
Collapse
|
26
|
Machado I, Garcia DDP, Tannus CS, Tanaka K, Bernardes Filho F, Costa MJBD, Queiroz RM. Spinal metallosis as a complication of a lodged bullet from a firearm wound: an image-centered case. Rev Assoc Med Bras (1992) 2019; 64:676-679. [PMID: 30673036 DOI: 10.1590/1806-9282.64.08.676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 01/06/2018] [Indexed: 11/21/2022] Open
Affiliation(s)
- Isabela Machado
- . Department of Radiology and Imaging, DOCUMENTA, São Francisco Hospital, Ribeirão Preto, SP, Brasil
| | - Daniel de Paula Garcia
- . Department of Radiology and Imaging, DOCUMENTA, São Francisco Hospital, Ribeirão Preto, SP, Brasil
| | - Carolina Souza Tannus
- . Department of Radiology and Imaging, DOCUMENTA, São Francisco Hospital, Ribeirão Preto, SP, Brasil
| | - Koji Tanaka
- . Division of Neurosurgery of the Department of Surgery and Anatomy, Hospital das Clínicas of the Faculty of Medicine of Ribeirão Preto of the University of São Paulo, Ribeirão Preto, SP, Brasil
| | - Fred Bernardes Filho
- . Division of Dermatology of the Department of Clinical Medicine, Hospital das Clínicas of the Faculty of Medicine of Ribeirão Preto of the University of São Paulo, Ribeirão Preto, SP, Brasil
| | - Mauro Jose Brandao da Costa
- Department of Radiology and Imaging, DOCUMENTA, São Francisco Hospital, Ribeirão Preto, SP, Brasil.,Department of Radiology and Imaging, SER IMAGEM, Santa Casa de Misericórdia de Sertãozinho Hospital, Sertãozinho, SP, Brasil
| | - Rodolfo Mendes Queiroz
- Department of Radiology and Imaging, DOCUMENTA, São Francisco Hospital, Ribeirão Preto, SP, Brasil.,Department of Radiology and Imaging, SER IMAGEM, Santa Casa de Misericórdia de Sertãozinho Hospital, Sertãozinho, SP, Brasil
| |
Collapse
|
27
|
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.
Collapse
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
| |
Collapse
|
28
|
Borgstedt-Bakke JH, Duel P, Rasmussen MM. Penetrating cervical traumatic spinal cord injury due to lawn mowing: an unusual case report. Acta Neurochir (Wien) 2018; 160:1917-1920. [PMID: 30116904 DOI: 10.1007/s00701-018-3657-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 08/13/2018] [Indexed: 10/28/2022]
Abstract
We present a case of a 55-year-old farmer who suddenly experienced an electric sensation in the left half of his body during lawn mowing. Neurological examination discovered neurological deficits corresponding to an incomplete spinal cord injury. Magnetic resonance imaging displayed an artifact in the cervical region. Following, a computer tomography imaging showed a metal object, located intramedullary, in the cervical spinal cord. The conclusion was a traumatic lesion from the metal object obtained during lawn mowing. The object was evacuated surgically. Three years postoperatively, the patient was improved. Caution in diagnostics following usage of heavy machinery is advised.
Collapse
|
29
|
Roach MJ, Chen Y, Kelly ML. Comparing Blunt and Penetrating Trauma in Spinal Cord Injury: Analysis of Long-Term Functional and Neurological Outcomes. Top Spinal Cord Inj Rehabil 2018; 24:121-132. [PMID: 29706756 DOI: 10.1310/sci2402-121] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background: Comparisons between patients with penetrating spinal cord injury (PSCI) and blunt spinal cord injury (BSCI) are scarce. Purpose: To describe baseline characteristics and neurological and functional outcomes for patients with BSCI and PSCI. Methods: Participants with BSCI (n = 5,316) and PSCI (n = 1,062) were extracted from the Spinal Cord Injury Model Systems database from January 1994 to January 2015. Participant injury and demographic characteristics were recorded. Outcomes were measured using the International Standards for Neurological Classification of Spinal Cord Injury and FIM motor scores. Outcomes for patients with American Spinal Injury Association Impairment Scale (AIS) complete injuries were analyzed separately from incomplete injuries at three time points: acute hospitalization, SCI rehabilitation, and 1-year follow-up. Results: Patients with PSCI compared to those with BSCI were more likely to present with complete injuries (56.8% vs 35.9%; p < .001) and were less likely to undergo spine surgery (19.6% vs 80.6%; p < .001). For incomplete injuries, no significant differences were observed between groups in FIM scores or AIS grade improvement at 1 year. For complete injuries, patients with BSCI showed an increased one-grade (15.7% vs 9.1%; p < .001) and three-grade (5.4% vs 1.9%; p = .014) AIS improvement at 1 year. Multivariate regression analysis demonstrated an independent effect for BSCI on AIS improvement at 1 year (odds ratio [OR], 1.74; 95% CI, 1.13-2.70; C-stat = 0.66). Conclusion: Patient with PSCI had more complete injuries and lower surgery rates. Patients with complete BSCI show greater AIS improvement at 1 year, and incomplete injuries show no difference in neurological improvement between groups. Overall, patients with PSCI demonstrated worse functional outcomes at 1 year.
Collapse
Affiliation(s)
- Mary Joan Roach
- Center for Healthcare Research and Policy, 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
| | - Michael L Kelly
- Department of Neurosurgery, Case Western Reserve University School of Medicine, MetroHeath Medical Center, Cleveland, Ohio
| |
Collapse
|
30
|
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.
Collapse
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
| |
Collapse
|
31
|
Khan K, Dieudonne B, Saeed S, Alothman S, Saeed Y, Gray S. Paraplegia Following Spinal Cord Contusion from an Indirect Gunshot Injury. Korean J Neurotrauma 2018; 14:32-34. [PMID: 29774197 PMCID: PMC5949521 DOI: 10.13004/kjnt.2018.14.1.32] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 03/28/2018] [Accepted: 04/14/2018] [Indexed: 11/22/2022] Open
Abstract
Spinal cord injuries are debilitating and life threatening. Paraplegia due to direct traumatic gunshot injury to the spinal cord is common. The most common cause of spinal cord injury is road traffic accidents. This is followed by spinal cord injury due to a fall from a height. Most of the spinal cord injuries due to gunshot wounds occur as a result of direct traumatic effects. We present a rare case of a 49-year-old male with trauma. He developed paraplegia after a gunshot wound injury to the neck and contusion to the spinal cord, with no direct trauma. Paraplegia due to direct gunshot injury can have many different outcomes. In our case, the patient was managed conservatively, and the outcome was favorable.
Collapse
Affiliation(s)
- Khuram Khan
- Department of Surgery, Harlem Hospital Center, Columbia University, New York, USA
| | - Beatrice Dieudonne
- Department of Surgery, Harlem Hospital Center, Columbia University, New York, USA
| | - Saqib Saeed
- Department of Surgery, Harlem Hospital Center, Columbia University, New York, USA
| | - Sara Alothman
- Department of Surgery, Harlem Hospital Center, Columbia University, New York, USA
| | - Yasir Saeed
- Department of Surgery, Harlem Hospital Center, Columbia University, New York, USA
| | - Sanjiv Gray
- Department of Surgery, Harlem Hospital Center, Columbia University, New York, USA
| |
Collapse
|
32
|
Özkal B. Rabdomyolize bağlı akut böbrek yetmezliği gelişen İntradural servikal ateşli silah yaralanması. ACTA MEDICA ALANYA 2018. [DOI: 10.30565/medalanya.342242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
33
|
Fan J, Wang MM, Liu YP. Retrieval of a Broken Sewing Needle from the Sacrum Aided by a Permanent Magnet: A Case Report and Literature Review. Open Med (Wars) 2018; 12:446-449. [PMID: 29318191 PMCID: PMC5757347 DOI: 10.1515/med-2017-0063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 10/18/2017] [Indexed: 11/30/2022] Open
Abstract
Penetrating sacral injuries are very rare, but foreign bodies that penetrate the sacrum often cause pain, cerebrospinal fluid leakage, and neurological symptoms. Careful preoperative medical and imaging examinations, determining the position of the foreign body, and surgical exploration are essential in the management of such cases. We present the case of a woman who visited our emergency department with a broken sewing needle in her sacrum. The incident occurred when the patient accidentally sat on the needle while sewing by hand. Pain while sitting was the main clinical finding after the accident. The patient was treated successfully by surgical exploration aided by a permanent magnet. At follow-up a few months later, she was symptom-free. In clinical practice physicians often encounter patients with metallic foreign bodies. Permanent magnets play an important role in the removal of metallic foreign bodies, and emergency department physicians should master the methods and techniques.
Collapse
Affiliation(s)
- Jian Fan
- Department of Trauma Orthopedics, Tongji hospital, Tongji University, Tongji, China
| | - Ming-Ming Wang
- Department of Trauma Orthopedics, Tengzhou Central People's Hospital, Jining Medical College, Tengzhou, China
| | - Yu-Ping Liu
- Department of Trauma Orthopedics, Tengzhou Central People's Hospital, Jining Medical College, Tengzhou, China
| |
Collapse
|
34
|
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.
Collapse
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
| |
Collapse
|
35
|
McCunniff PT, Ramey JS, Scott ML, Roach MJ, Vallier HA, Moore TA, Kelly ML. Operative Versus Nonoperative Management of Civilian Gunshot Wounds to the Spinal Cord: Novel Use of the Functional Independence Measure for Validated Outcomes. World Neurosurg 2017; 106:240-246. [PMID: 28669874 DOI: 10.1016/j.wneu.2017.06.132] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 06/21/2017] [Accepted: 06/24/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Surgery for patients with gunshot wound spinal cord injury (GSCI) remains controversial. Few recent studies provide standardized follow-up and detailed functional outcomes. To our knowledge, the research we present in this study is unique in that we are the first to incorporate Functional Independence Measure (FIM) scores as an outcomes measure for neurologic recovery in patients with GSCI. METHODS Patients with GSCI were divided into surgical and nonsurgical groups. Neurologic function was measured according to the American Spinal Injury Association impairment scale and defined as either complete or incomplete injury. Outcomes were then analyzed separately for complete and incomplete GSCI groups during hospitalization and rehabilitation. RESULTS Baseline admissions characteristics were similar between surgical and nonsurgical groups except for a greater median injury severity score in the nonsurgical group (34 vs. 27; P = 0.02). For complete GSCI, total length of stay (LOS) was significantly longer in the surgical group (52 vs. 42 days; P = 0.04), and no difference was observed in overall FIM scores (58 vs. 54; P = 0.7). For incomplete GSCI, rehabilitation LOS was longer (35 vs. 21; P = 0.02) and a trend towards longer total LOS was observed in the surgical group (40 vs. 32; P = 0.07). No difference was observed in overall FIM scores (61 vs. 62; P = 0.9). CONCLUSIONS Surgery for patients with GSCI is associated with increased LOS and is not associated with improved FIM scores for patients with either complete or incomplete spinal cord injuries.
Collapse
Affiliation(s)
- Peter T McCunniff
- Department of Orthopedic Surgery, Case Western Reserve University School of Medicine, University Hospitals, Cleveland, Ohio, USA.
| | - James S Ramey
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Meredith L Scott
- University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, USA
| | - Mary J Roach
- Center for Healthcare Research and Policy, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Heather A Vallier
- Department of Orthopedic Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Timothy A Moore
- Department of Neurosciences, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Michael L Kelly
- Department of Neurosciences, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA
| |
Collapse
|
36
|
Jeon SI, Im SB, Jeong JH, Cha JG. Long-term Fistula Formation Due to Retained Bullet in Lumbar Spine after Gunshot Injury. JOURNAL OF TRAUMA AND INJURY 2017. [DOI: 10.20408/jti.2017.30.2.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Se-Il Jeon
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Gyeonggi-do, Korea
| | - Soo Bin Im
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Gyeonggi-do, Korea
| | - Je Hoon Jeong
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Gyeonggi-do, Korea
| | - Jang Gyu Cha
- Department of Radiology, Soonchunhyang University Bucheon Hospital, Gyeonggi-do, Korea
| |
Collapse
|
37
|
Baldawa S, Shivpuje V. Migratory low velocity intradural lumbosacral spinal bullet causing cauda equina syndrome: report of a case and review of literature. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 26:128-135. [PMID: 27942941 DOI: 10.1007/s00586-016-4913-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 10/02/2016] [Accepted: 12/04/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Migration of the bullet within the spinal subarachnoid space has long been recognized as unusual complication of spinal gunshot injury. OBJECTIVE We report a case of migratory low velocity intradural lumbosacral spinal bullet causing cauda equina syndrome. The relevant literature is reviewed and all cases of migratory spinal bullet are summarised, and management strategies are discussed. STUDY DESIGN Literature review. METHODS A 32-year-old male suffered abdominal gunshot injury for which emergency laparotomy and repair of colonic perforation were performed. The bullet was seen lodged within the sacral spinal canal behind the S1 vertebral body. The probable entry point was at L2-L3 level. Caudal migration of the bullet within the spinal subarachnoid space leads to the appearance of cauda equina syndrome. RESULTS Bullet was retrieved following upper sacral and lower lumbar laminectomy. Prone positioning of the patient had lead to cranial migration of the bullet at L4 level which was confirmed on fluoroscopy. Laminectomy had to be extended upwards with the patient in reverse Trendelenburg position for bullet removal. CONCLUSIONS Caudal migration of the bullet within the lumbosacral subarachnoid space results in cauda equina syndrome. Surgical retrieval of the bullet ensures the early recovery of neurological symptoms. Prone patient positioning can influence bullet location. Intraoperative fluoroscopy prior to skin incision is essential in addition to preoperative imaging to locate the bullet and thus avoid incorrect lower level laminectomy. Trapping the bullet after durotomy using suction and dissector in reverse Trendelenburg position is a useful aid in bullet removal.
Collapse
Affiliation(s)
- Sachin Baldawa
- Department of Neurosurgery, Yashodhara Superspeciality Hospital, Solapur, Maharashtra, India. .,Department of Neurosurgery, Baldawa Hospital, Budhwar Peth, Solapur, 413002, Maharashtra, India.
| | - Vijay Shivpuje
- Department of General Surgery, Yashodhara Superspeciality Hospital, Solapur, Maharashtra, India
| |
Collapse
|
38
|
Hakan T, Çerçi A, Gürcan S, Akçay S. Firearm bullet settling into the lumbar spinal canal without causing neurological deficit: A report of two cases. Surg Neurol Int 2016; 7:S251-4. [PMID: 27213110 PMCID: PMC4866057 DOI: 10.4103/2152-7806.181978] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 04/08/2016] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Uncertainty still exists regarding the treatment of the patients presenting with gunshot wounds to the spine. Neurological insults, cerebrospinal fluid fistula, infection, lead or copper toxicity, migration of bullets, and spinal instability are included among the common challenging issues. CASE DESCRIPTION An 18-year-old woman was admitted with low back pain following a gunshot injury five days ago. She was neurologically intact. Radiological examinations showed that a bullet was settled in L4-5 disc space. The bullet was removed with a unilateral L4-5 partial hemilaminectomy and discectomy from the left side. The second case was of a 29-year-old man admitted with radiating leg pain on the right side following a gunshot injury from his left side of lower back four months ago. He had only positive straight leg raising test. Radiological studies showed two bullets, one was in the psoas muscle on the left side and the other was in spinal canal that had caused a burst fracture of the L5 vertebra. Following L5 laminectomy and bilateral L5-S1 facetectomy, the bullet was removed from the spinal canal and L5-S1 transpedicular posterior stabilization was performed. The postoperative period of both patients was unremarkable. CONCLUSION Bullet settling into the lumbar spinal canal without causing neurological deficit may require surgical intervention. Removal of bullets provided not only pain relief in both the cases but also prevented future complications such as migration of the bullets, plumbism, and neuropathic pain and instability.
Collapse
Affiliation(s)
- Tayfun Hakan
- Okan University, The Vocational School of Health Services, Tuzla, Istanbul, Turkey
- Neurosurgery Clinic, Kurtkoy Ersoy Hospital, Istanbul, Turkey
| | - Ajlan Çerçi
- Neurosurgery Clinic, Kurtkoy Ersoy Hospital, Istanbul, Turkey
| | - Serkan Gürcan
- Orthopedic Clinic, Kurtkoy Ersoy Hospital, Istanbul, Turkey
| | - Serkan Akçay
- Orthopedic Clinic, Kurtkoy Ersoy Hospital, Istanbul, Turkey
| |
Collapse
|
39
|
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]
|
40
|
Schroeder JE. Commentary on: "Bullet Fragment of the Lumbar Spine: The Decision Is More Important Than the Incision". Global Spine J 2015; 5:527. [PMID: 26682105 PMCID: PMC4671901 DOI: 10.1055/s-0035-1566291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
- Josh E. Schroeder
- Spine Surgery, Orthopedic Complex, Hadassah Medical Center, Jerusalem, Israel,Address for correspondence Josh E. Schroeder, MD Spine Surgery, Orthopedic ComplexHadassah Medical Center, JerusalemIsrael
| |
Collapse
|
41
|
Ryu B, Kim SB, Choi MK, Kim KD. Radiculopathy as Delayed Presentations of Retained Spinal Bullet. J Korean Neurosurg Soc 2015; 58:393-6. [PMID: 26587197 PMCID: PMC4652004 DOI: 10.3340/jkns.2015.58.4.393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 09/01/2015] [Accepted: 09/03/2015] [Indexed: 11/27/2022] Open
Abstract
Bullet injuries to the spine may cause injury to the anatomical structures with or without neurologic deterioration. Most bullet injuries are acute, resulting from direct injury. However, in rare cases, delayed injury may occur, resulting in claudication. We report a case of intradural bullet at the L3-4 level with radiculopathy in a 30-year-old male. After surgical removal, radicular and claudicating pain were improved significantly, and motor power of the right leg also improved. We report the case of intradural bullet, which resulted in delayed radiculopathy.
Collapse
Affiliation(s)
- Bang Ryu
- Department of Neurosurgery, Kyung Hee University Hospital, Seoul, Korea
| | - Sung Bum Kim
- Department of Neurosurgery, Kyung Hee University Hospital, Seoul, Korea
| | - Man Kyu Choi
- Department of Neurosurgery, Kyung Hee University Hospital, Seoul, Korea
| | - Kee D Kim
- Department of Neurosurgery, University of California Davis, CA, USA
| |
Collapse
|
42
|
Jakoi A, Iorio J, Howell R, Zampini JM. Gunshot injuries of the spine. Spine J 2015; 15:2077-85. [PMID: 26070284 DOI: 10.1016/j.spinee.2015.06.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 05/11/2015] [Accepted: 06/01/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal gunshot injuries (spinal GSIs) are a major cause of morbidity and mortality in both military and civilian populations. These injuries are likely to be encountered by spine care professionals in many treatment settings. A paucity of resources is available to summarize current knowledge of spinal GSI evaluation and management. PURPOSE The aim was to summarize the ballistics, epidemiology, evaluation, treatment, and outcomes of spinal GSI among civilian and military populations. STUDY DESIGN This was a review of the current literature reporting spinal GSI management. METHODS MEDLINE (PubMed) was queried for recent studies and case reports of spinal GSI evaluation and management. RESULTS Spinal GSI now comprise the third most common cause of spinal injury. Firearms that produce spinal GSI can be divided into categories of high- and low-energy depending on the initial velocity of the projectile. Neural and mechanical spinal damage varies with these types and results from several factors including direct impact, concussion waves, tissue cavitation, and thermal energy. Management of spinal GSI also depends on several factors including neurologic function and change over time, spinal stability, missile tract through the body, and concomitant injury. Surgical treatment is typically indicated for progressive neurologic changes, spinal instability, persistent cerebrospinal fluid leak, and infection. Surgical treatment for GSI affecting T12 and caudal often has a better outcome than for those cranial to T12. Surgical exploration and removal of missile fragments in the spinal canal are typically indicated for incomplete or worsening neurologic injury. CONCLUSIONS Treatment of spinal GSI requires a multidisciplinary approach with the goal of maintaining or restoring spinal stability and neurologic function and minimizing complications. Concomitant injuries and complications after spinal GSI can present immediate and ongoing challenges to the medical, surgical and rehabilitative care of the patient.
Collapse
Affiliation(s)
- Andre Jakoi
- Department of Orthopaedic Surgery, Drexel University College of Medicine, 245 N 15th St, MS 420, Philadelphia, PA 19102, USA
| | - Justin Iorio
- Department of Orthopaedic Surgery, Temple University, 3401 N Broad Street, Philadelphia, PA 19140, USA
| | - Richard Howell
- Department of Orthopaedic Surgery, Drexel University College of Medicine, 245 N 15th St, MS 420, Philadelphia, PA 19102, USA
| | - Jay M Zampini
- Department of Orthopaedic Surgery, Harvard Medical School, Division of Spine Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
| |
Collapse
|
43
|
Jiménez-Avila JM, Cobar-Bustamante AE, Cahueque-Lemus MA, Gutiérrez-Roman EA, Guzmán-Pantoja JE. FIREARM INJURIES IN THE SPINE. EFFECTIVE STRATEGY FOR DIAGNOSIS AND TREATMENT. COLUNA/COLUMNA 2015. [DOI: 10.1590/s1808-185120151403152475] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The incidence of gunshot wounds to the spine on civilians has increased alarmingly and accounts for 13% to 17% of all traumatic spinal injuries, placing them in third place among the most frequent mechanisms. However, the management of these injuries is still controversial. At present there is little information on the management of these lesions, conservative treatment (non-surgical) being recommended in most publications. Based on the current literature, we propose a procedural protocol aimed at improving the quickness of management, as well as the prognosis of the patient. For this purpose, once the patient is hemodynamically stabilized, the following should be assessed: 1) Stability; 2) Compressive extrusion; 3) Accommodation or not in the discal space, and 4) Contact with CSF. These points are relevant to make the best decision.
Collapse
Affiliation(s)
- José María Jiménez-Avila
- Hospital Centro Médico Nacional de Occidente, Mexico; Instituto Mexicano del Seguro Social, Mexico; Instituto Tecnológico de Monterrey, Mexico
| | | | | | | | | |
Collapse
|