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Johnson C, Batbold A, Ahmadpour A, Benson D, Das P, Herman M, Lee M, Ramos E, Dafrawy ME. A predictive model of motor deficit in civilian ballistic lumbosacral spine injuries. Spine J 2024; 24:446-453. [PMID: 37980958 DOI: 10.1016/j.spinee.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/04/2023] [Accepted: 11/12/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND CONTEXT Civilian gunshot wounds to the spine are an increasingly common injury in the USA. A majority of the available research is focused on a military population suffering high energy missile injury. Minimal research has focused on civilian ballistic injuries to the lumbosacral spine as the available studies focus on the entire spine due to limited numbers. PURPOSE Characterize ballistic injuries to the lumbosacral spine and develop a model to predict the presence of neurological deficit based upon a patients presenting fracture morphology. STUDY DESIGN Retrospective chart review. PATIENT SAMPLE One hundred forty-eight consecutive patients that were presented to an urban level 1 trauma center with ballistic injures to the spine involving the levels L1-S2. OUTCOMES MEASURES Neurological status at presentation and final follow up using the American Spinal Injury Association (ASIA) Impairment Scale. METHODS IRB approval was obtained, and retrospective chart review was performed. Extracted data included patient demographics, neurological status on presentation and final follow-up, fracture morphology, assessment of stability, other associated injuries, and surgical procedures performed. Proportional analysis was performed to characterize the fractures and their associated neurological injuries. Chi-square testing was done to identify fracture characteristics associated with neurologic injury. A multiple logistical regression was performed using fracture characteristics highly associated with neurological deficit to develop a model to predict neurologic deficit. The model was then validated with a receiver operator curve. RESULTS Of the 148 patients, 14 patients underwent spinal surgery with the most common indication being decompression and foreign body removal. There was a high incidence of intra-abdominal injury (73.6%). Fractures were characterized by level, affected vertebral component, and spinal canal involvement. Neurological injury was classified using the ASIA scale at presentation and final follow up. Odds-ratios of vertebral fracture characteristics showed neurologic deficit was highly associated with pedicle fractures (OR=9.07 [4.14-21.54] - 95% CI), lamina fractures (OR=6.42 [3.16-13.62] - 95% CI), facet fractures (OR=5.95 [2.90-12.79] - 95% CI), intra-canal bone (OR=12.79 [5.98-29.05] - 95% CI), and an intra-canal trajectory (OR=1078 [4.48-28.98]) - 95% CI. Multiple logistic regression was performed to construct a predictive model of neurologic deficit which showed that intra-canal trajectory, pedicle fracture and facet fracture are associated with neurologic deficit. An ROC curve was made with an area of 0.849 ([0.7853 to 0.9128 - 95% CI], p<.0001) demonstrating a good model fit. CONCLUSIONS Ballistic injuries to the lumbosacral spine involve complex injury patterns in an often polytraumatized patient. Fractures involving the pedicle, lamina, and facet are highly associated with neurologic injury, as is a trans-canal trajectory. A patients fracture morphology can be used to predict if a neurologic deficit is present.
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Affiliation(s)
- Christopher Johnson
- Department of Orthopaedic Surgery and Rehabilitation, University of Chicago, 5841 S. Maryland Ave. Room E302/P211, Chicago, IL 60637, USA.
| | - Anudariya Batbold
- Department of Neurological Surgery, University of Chicago, 5841 S. Maryland Ave. MC 3026, Chicago, IL 60637, USA
| | - Arjang Ahmadpour
- Department of Neurological Surgery, University of Chicago, 5841 S. Maryland Ave. MC 3026, Chicago, IL 60637, USA
| | - Dillon Benson
- Department of Orthopaedic Surgery and Rehabilitation, University of Chicago, 5841 S. Maryland Ave. Room E302/P211, Chicago, IL 60637, USA
| | - Paramita Das
- Department of Neurological Surgery, University of Chicago, 5841 S. Maryland Ave. MC 3026, Chicago, IL 60637, USA
| | - Martin Herman
- Department of Neurological Surgery, University of Chicago, 5841 S. Maryland Ave. MC 3026, Chicago, IL 60637, USA
| | - Michael Lee
- Department of Orthopaedic Surgery and Rehabilitation, University of Chicago, 5841 S. Maryland Ave. Room E302/P211, Chicago, IL 60637, USA
| | - Edwin Ramos
- Department of Neurological Surgery, University of Chicago, 5841 S. Maryland Ave. MC 3026, Chicago, IL 60637, USA
| | - Mostafa El Dafrawy
- Department of Orthopaedic Surgery and Rehabilitation, University of Chicago, 5841 S. Maryland Ave. Room E302/P211, Chicago, IL 60637, USA
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Beucler N, Haikal C, Kaya JM. A Penetrating Lumbar Spine Injury With Misleading Neurological Symptoms. Mil Med 2023; 188:e440-e444. [PMID: 33852015 DOI: 10.1093/milmed/usab137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/24/2021] [Accepted: 03/31/2021] [Indexed: 01/11/2023] Open
Abstract
Penetrating spinal injuries require specific neurosurgical attention. To date, there are no guidelines regarding emergency neurosurgical management of such injuries and the decision whether to operate is made individually, based on the neurological examination and the analysis of any imaging available. We report the case of a 22-year-old patient who sustained two gunshots in the thighs and one in the lumbar spine. Clinical examination revealed neurological deficit in both legs prevailing on the right side. Discussion between the radiologist and the neurosurgeon concluded to an injury to the left S1 nerve root within the spinal canal, and to the right sciatic nerve. Thus, there was no need for a decompressive laminectomy. In the light of the current literature, penetrating spinal injuries rarely require an extensive surgical exploration; indications for such a procedure include incomplete neurological deficit with persistent neurological compression, cerebrospinal fluid leakage, and obvious instability. Furthermore, penetrating spinal injuries are rarely encountered, even for military neurosurgeons. Their surgical management and especially the need for laminectomy, stabilization, and dural sac watertight closure are still a matter of debate. An expert consensus statement would give food to surgeons facing penetrating spinal injuries.
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Affiliation(s)
- Nathan Beucler
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France.,Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, Ile-de-France 75230, France
| | - Christelle Haikal
- Radiology Department, Timone University Hospital, APHM, Marseille, Provence-Alpes-Côte d'Azur 13005, France
| | - Jean-Marc Kaya
- Neurosurgery Department, Nord University Hospital, APHM, Marseille, Provence-Alpes-Côte d'Azur 13015, France
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Esipov AV, Antonov GI, Manukovsky VA, Movsisyan AB, Ivanov II, Kravtsov MN, Timonin SY. [Endoscopic treatment of mine-explosive spine injuries: 3 clinical cases and literature review]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2023; 87:83-91. [PMID: 37325830 DOI: 10.17116/neiro20238703183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Modern warfare is characterized by common mine-explosive injuries. The last ones are accompanied by multiple injuries, large area of damage and severe clinical status of victims. OBJECTIVE To demonstrate treatment of mine-explosive spinal injuries using modern minimally invasive endoscopic techniques. MATERIAL AND METHODS The authors present 3 victims with various mine-explosive injuries. Endoscopic removal of fragments from the lumbar and cervical spine was successful in all cases. DISCUSSION Most of victims with injuries of the spine and spinal cord do not require urgent surgery and can underwent surgical treatment after clinical stabilization. At the same time, minimally invasive techniques provide surgical treatment with minimal risk and earlier rehabilitation, as well as reduce the risk of infectious complications associated with foreign bodies. CONCLUSION Careful selection of patients for spinal video endoscopy will ensure positive outcomes. Minimization of iatrogenic postoperative injuries is especially important in patients with combined trauma. However, well-experienced surgeons should perform these procedures at the stage of specialized medical care.
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Affiliation(s)
- A V Esipov
- National Medical Research Center of High Medical Technologies - Vishnevsky Central Military Clinical Hospital, Moscow, Russia
| | - G I Antonov
- National Medical Research Center of High Medical Technologies - Vishnevsky Central Military Clinical Hospital, Moscow, Russia
| | - V A Manukovsky
- National Medical Research Center of High Medical Technologies - Vishnevsky Central Military Clinical Hospital, Moscow, Russia
| | - A B Movsisyan
- National Medical Research Center of High Medical Technologies - Vishnevsky Central Military Clinical Hospital, Moscow, Russia
| | - I I Ivanov
- National Medical Research Center of High Medical Technologies - Vishnevsky Central Military Clinical Hospital, Moscow, Russia
| | - M N Kravtsov
- Federal State Budgetary Military Educational Institution of Higher Education «Military Medical Academy named after S.M. Kirov» of the Ministry of Defense of the Russian Federation, St. Petersburg, Russia
| | - S Yu Timonin
- National Medical Research Center of High Medical Technologies - Vishnevsky Central Military Clinical Hospital, Moscow, Russia
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Minimally invasive retrieval of a bullet settling into the thoracic spinal canal in a pediatric patient: A case report. NEUROCIRUGIA (ENGLISH EDITION) 2023; 34:44-47. [PMID: 36623892 DOI: 10.1016/j.neucie.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/28/2021] [Indexed: 01/09/2023]
Abstract
A 10-year-old boy presented to neurosurgery department after a gunshot wound to the upper thoracic spine. The bullet entered through the right deltoid muscle and lodged inside the spinal canal at T1 level. The patient arrived conscious and obeying commands; however, he experienced a loss of sensation below T3 level, loss of reflexes below the injured T1 level, loss of anal sphincter tone and paraplegia in the lower limbs (American Spinal Injury Association grade-A). Imaging studies revealed an intra-canalicular metallic bullet at the T1 level. The patient underwent urgent operation using a tubular retractor system and the microscope. Subsequently, the bullet was successfully retrieved. Postoperatively, the patient made a significant recovery and by the end of the 6th month, he was able to walk independently despite some gait instability. A minimally invasive approach for intra-canalicular bullet removal in the thoracic region is a safe and effective technique in pediatric patients.
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Bin-Alamer O, Bhenderu LS, Stuebe C, Sagoo NS, Palmisciano P, Haider M, Aoun SG, Haider AS. Penetrating spinal cord injury: a systematic review and meta-analysis of clinical features and treatment outcomes. Spinal Cord 2022; 60:845-853. [DOI: 10.1038/s41393-022-00813-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 05/08/2022] [Accepted: 05/12/2022] [Indexed: 11/09/2022]
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Kravtsov MN, Manukovsky VA, Bulyshchenko GG, Mirzametov SD, Byvaltsev VA. Case Report: Full-Endoscopic Surgery for Bullet Wounds of the Spine: A Report of Three Cases. Front Surg 2022; 9:873365. [PMID: 35402482 PMCID: PMC8990913 DOI: 10.3389/fsurg.2022.873365] [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: 02/10/2022] [Accepted: 02/28/2022] [Indexed: 11/17/2022] Open
Abstract
Objectives To determine the feasibility and evaluate effectiveness of full-endoscopic surgery in gunshot wound of the spine. Methods Three clinical cases of lumbar and thoracic spine bullet wounds made by firearms and traumatic weapons are described. Percutaneous endoscopic surgery was performed to extract bullet from the spinal canal. The results are compared to the data from literature. Results Percutaneous endoscopic approach to spinal canal with a possibility to extract a bullet, decompression of nerve roots, defect closure of the dura mater is demonstrated. Conclusion Good clinical outcomes allows to recommend percutaneous endoscopic surgery to manage similar lumbar and thoracic spine bullet wounds at the tertiary care level.
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Affiliation(s)
- Maxim N. Kravtsov
- Department of Neurosurgery, S.M. Kirov Military Medical Academy, St. Petersburg, Russia
- Saint-Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine, St. Petersburg, Russia
- Department of Neurosurgery, North-Western State University n.a. I.I. Mechnikov, St. Petersburg, Russia
- *Correspondence: Maxim N. Kravtsov
| | - Vadim A. Manukovsky
- Saint-Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine, St. Petersburg, Russia
- Department of Neurosurgery, North-Western State University n.a. I.I. Mechnikov, St. Petersburg, Russia
| | | | | | - Vadim A. Byvaltsev
- Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia
- Department of Neurosurgery, Railway Clinical Hospital, Irkutsk, Russia
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Minimally invasive retrieval of a bullet settling into the thoracic spinal canal in a pediatric patient: A case report. Neurocirugia (Astur) 2022. [DOI: 10.1016/j.neucir.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Crutcher CL, Wilson JM, Morrow KD, Shields JA, Lasseigne LM, Culicchia F, Tender G. Management of cerebrospinal fluid leak from cervical gunshot wounds with external ventricular drainage: a small case series. J Surg Case Rep 2020; 2020:rjaa484. [PMID: 33343866 PMCID: PMC7736999 DOI: 10.1093/jscr/rjaa484] [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: 10/11/2020] [Accepted: 11/02/2020] [Indexed: 11/28/2022] Open
Abstract
Historically, the surgical management of gunshot wounds to the spine has been controversial. Repair of a persistent cerebrospinal fluid (CSF) leak is a generally agreed upon indication. The management of such CSF leaks typically involves lumbar drainage or direct surgical repair. Here, the authors report two cases of CSF diversion with an external ventricular drain (EVD) in patients with cervical gunshot wounds. Both patients had spinal canal obliteration or physiologic myelographic block at or below the level of injury. To the best of the author’s knowledge, these are the first two reports of successful EVD treatment of persistent CSF leaks related cervical gunshot wounds. The authors also propose a CSF treatment algorithm for cervical gunshot wounds that includes EVD.
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Affiliation(s)
| | - John M Wilson
- Louisiana State University Health Sciences Center, Department of Neurosurgery, New Orleans, LA, USA
| | - Kevin D Morrow
- Louisiana State University Health Sciences Center, Department of Neurosurgery, New Orleans, LA, USA
| | - Jessica A Shields
- Louisiana State University Health Sciences Center, Department of Neurosurgery, New Orleans, LA, USA
| | - Lindsay M Lasseigne
- Louisiana State University Health Sciences Center, Department of Neurosurgery, New Orleans, LA, USA
| | - Frank Culicchia
- Louisiana State University Health Sciences Center, Department of Neurosurgery, New Orleans, LA, USA
| | - Gabriel Tender
- Louisiana State University Health Sciences Center, Department of Neurosurgery, New Orleans, LA, USA
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Aljuboori Z, Sieg E. Resolution of cauda equina syndrome after surgical extraction of lumbar intrathecal bullet. Surg Neurol Int 2020; 11:214. [PMID: 32874717 PMCID: PMC7451185 DOI: 10.25259/sni_400_2020] [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: 07/02/2020] [Accepted: 07/09/2020] [Indexed: 11/04/2022] Open
Abstract
Background:
Gunshot wound (GSW) injuries to the spinal column are correlated with potentially severe neurological damage. Here, we describe a GSW to the thoracolumbar junction (e.g., T12/L1 level) which resulted in a cauda equina syndrome that resolved once the bullet was removed.
Case Description:
A 29-year-old male presented with a T12-L1 GSW; the bullet traversed the right chest and liver, entered the spinal canal at T12, and then settled at L1. He experienced excruciating burning pain in the right lower extremity/perineum and had urinary retention. On neurological examination, he exhibited severe weakness of the right iliopsoas/quadriceps (2/5) and extensor hallucis longus (1/5) which had decreased sensation in the right lower extremity in all dermatomes and urinary retention. The myelogram showed the bullet lodged intrathecally at L1; it compressed the cauda equina. Immediately after, the bullet was extracted and at 8 weeks follow-up, the patient’s right-sided motor function normalized, the sensory findings improved, and the sphincteric dysfunction resolved; the only residual deficit was minimal residual numbness in the L2-L5 distributions.
Conclusion:
Twenty percent of penetrating spinal column injuries are attributed to GSW s. The location of these injuries best determines the neurological damage and degree of recovery. Since patients with incomplete cauda equina syndromes have favorable prognoses, removal of bullets involving the T12-S1 levels may prove beneficial.
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