Gunshot wounds to the spinal cord

Gunshot Wounds to the Lumbosacral Spine: Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

Indications for surgical decompression of gunshot wounds to the lumbosacral spine are controversial and based on limited data.

METHODS

A systematic review of literature was conducted to identify studies that directly compare neurologic outcomes following operative and non-operative management of gunshot wounds to the lumbosacral spine. Studies were evaluated for degree of neurologic improvement, complications, and antibiotic usage. An odds ratio and 95% confidence interval were calculated for dichotomous outcomes which were then pooled by random-effects model meta-analysis.

RESULTS

Five studies were included that met inclusion criteria. The total rate of neurologic improvement was 72.3% following surgical intervention and 61.7% following non-operative intervention. A random-effects model meta-analysis was carried out which failed to show a statistically significant difference in the rate of neurologic improvement between surgical and non-operative intervention (OR 1.07; 95% CI 0.45, 2.53; P = 0.88). In civilian only studies, a random-effects model meta-analysis failed to show a statistically significant difference in the rate of neurologic improvement between surgical and non-operative intervention (OR 0.75; 95% CI 0.21, 2.72; P = 0.66). Meta-analysis further failed to show a statistically significant difference in the rate of neurologic improvement between patients with either complete (OR 4.13; 95% CI 0.55, 30.80; P = 0.17) or incomplete (OR 0.38; 95% CI 0.10, 1.52; P = 0.17) neurologic injuries who underwent surgical and non-operative intervention. There were no significant differences in the number of infections and other complications between patients who underwent surgical and non-operative intervention.

CONCLUSIONS

There were no statistically significant differences in the rate of neurologic improvement between those who underwent surgical or non-operative intervention. Further research is necessary to determine if surgical intervention for gunshot wounds to the lumbosacral spine, including in the case of retained bullet within the spinal canal, is efficacious.

Operative Versus Nonoperative Management of Civilian Gunshot Wounds to the Spinal Cord: Novel Use of the Functional Independence Measure for Validated Outcomes

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.

Surgical Management of Civilian Gunshot-Induced Spinal Cord Injury: Is It Overutilized?

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

Assess appropriate utilization of surgery for civilian gunshot-induced spinal cord injuries (CGSWSCI) according to literature standards in a large cohort.

SUMMARY OF BACKGROUND DATA

CGSWSCI are mechanically stable injuries that rarely require surgery. Nonetheless, we continue to see high numbers of these patients undergo surgical treatment. This study compares indications for surgeries performed in a large cohort of CGSWSCI patients to established indications for surgical management of such injuries. The rate of over-utilization of surgical management was calculated.

METHODS

Four hundred eighty-nine CGSWSCI patients transferred for rehabilitation to our institution between 2000 and 2014 were identified. Retrospective chart review was performed to identify patients who underwent initial surgical treatment, the specific surgeries performed, and indications given. We assessed appropriateness of surgery according to literature standards. Patients treated surgically were followed to assess for complications and the need for additional intervention and compared to nonsurgical patients. Secondarily, visual analog scale pain scores (0-10) and patient perceived improvement were compared between surgical and nonsurgical patients after telephone survey of both groups.

RESULTS

Of 489 patients, 91 (18%) underwent initial surgery. Of 91 surgeries, 69 (75%) were not indicated by literature standards. Five of 91 (5.5%) of initially operated patients required a secondary surgery compared with two of 398 (0.5%) of the nonoperative group (P = 0.003). Over-utilization rate of the entire cohort was 14.1%. No difference was seen for pain scores or patient perceived improvement between operative and nonoperative patients.

CONCLUSION

We report a high overutilization rate (14%) of surgery for CGSWSCI in our cohort. Surgical management was associated with higher infection and secondary surgery rates compared to nonsurgical management. Surgery done without a clear, demonstrable benefit poses unnecessary risk to patients and accumulates unwarranted healthcare costs.

LEVEL OF EVIDENCE

3.

Civilian gunshot injuries of the spinal cord: a systematic review of the current literature

BACKGROUND

The principles that guide management of spinal cord injury (SCI) derive from injury resulting from blunt trauma, not gunshot wounds. Civilian gunshot-induced spinal cord injury (CGSWSCI) is a common, potentially serious cause of neurological deficit; there is disagreement about whether the same approaches used for SCI caused by blunt-force trauma should apply to gunshot-induced SCI.

QUESTIONS/PURPOSES

We reviewed the literature to answer the following questions regarding presentation and outcome of gunshot wound-induced SCI: (1) Are there differences in recovery prognosis between complete SCI and other patterns of SCI in CGSWSCI. (2) Does the use of steroids improve neurological recovery? (3) Does surgery to remove the bullet affect neurological recovery in CGSWSCI? (4) Does surgery result in an increased risk of complications of treatment?

METHODS

We performed a systematic literature review of articles related to civilian gunshot injuries to the spine. Information relating to incidence, pattern of neurological injury, associated injuries, treatment, neurological outcome, and associated complications was extracted. Three independent reviewers assessed the strength of evidence present in the literature by examining quality, quantity, and consistency of results.

RESULTS

A total of 15 articles met the predetermined inclusion criteria. Complete SCIs are associated with the worst functional recovery regardless of treatment. Steroids do not appear to have any added benefit in terms of restoring sensory and motor function. There appears to be some neurologic benefit to surgical decompression with intracanalicular bullet retrieval in patients with an incomplete lesion and a cauda equina syndrome. Complication rates are greater in operated patients.

CONCLUSIONS

These findings should be interpreted with caution because of considerable heterogeneity among the studies in the literature on gunshot-induced SCI and because of generally poor-quality study design and a high associated risk of selection bias. Supportive management should be the primary method of care, whereas surgery should be an option in case of radiographic evidence of a static compression on the spinal cord. Future studies are necessary to develop better treatment guidelines for patients with gunshot wound-associated SCI.

Operative Management of a Sacral Gunshot Injury via Minimally Invasive Techniques and Instrumentation

Gunshot wounds to the spine account for 13% to 17% of all gunshot injuries and occur predominantly in the thoracic region. Minimally invasive spine surgery procedures implementing serial muscle dilation and the use of a tubular retracting system with a working channel minimize soft tissue trauma, facilitate less bony and soft tissue resection, decrease blood loss, minimize scarring and improve cosmesis, decrease hospitalization, and reduce postoperative pain and narcotic usage in comparison to more open, traditional approaches. Although minimally invasive spine surgery techniques and instrumentation have gained considerable attention, their application in the management of gunshot injuries to the sacrum has not been reported. The following is a brief case report of a 21-year-old male who sustained a gunshot injury to the sacrum who was managed operatively via minimally invasive spine surgery techniques and instrumentation.

Cauda equina repair in the rat: part 1. Stimulus-evoked EMG for identifying spinal nerves innervating intrinsic tail muscles

Cauda equina injuries may produce severe leg and pelvic floor dysfunction, for which no effective treatments exist. We are developing a rat cauda equina injury model to allow nerve root identification and surgical repair. One possible difficulty in implementing any repair strategy after trauma in humans involves the correct identification of proximal and distal ends of nerve roots separated by the injury. Two series of studies were carried out. In Series 1, we electrically stimulated segmental contributors to the dorsal and ventral caudales nerves in order to characterize the recruitment patterns of muscles controlling rat tail movements. In Series 2, we attempted to identify individual nerve roots forming the cauda equina by both level of origin and function (i.e., dorsal or ventral), based solely upon the recruitment patterns in response to electrical stimulation. For Series 1 studies, electrical stimulation of the segmental contributors showed that all nerve roots-from the sixth lumbar to the first coccygeal-contributed to recruitment of muscles found at the base of the tail. Intrinsic tail muscles lying more distally in the tail showed a more root-specific pattern of innervation. For Series 2, the rate of successful identification of an unknown nerve root as being ventral was very high (>95%), and only somewhat lower (approximately 80%) for dorsal roots. Correctly identifying the level of origin of that root was more difficult, but for ventral roots this rate still exceeded 90%. Using the rat cauda equina model, we have shown that stimulus-evoked EMG can be used to identify ventral nerve roots innervating tail muscles with a high degree of accuracy. These findings support the feasibility of using this conceptual approach for identifying and repairing damaged human cauda equina nerve roots based on stimulus-evoked recruitment of muscles in the leg and pelvic floor.

A guidance channel seeded with autologous Schwann cells for repair of cauda equina injury in a primate model

BACKGROUND/OBJECTIVE

To evaluate an implantable guidance channel (GC) seeded with autologous Schwann cells to promote regeneration of transected spinal nerve root axons in a primate model.

METHODS

Schwann cells were obtained from sural nerve segments of monkeys (Macaca fascicularis; cynomolgus). Cells were cultured, purified, and seeded into a PAN/PVC GC. Approximately 3 weeks later, monkeys underwent laminectomy and dural opening. Nerve roots of the L4 through L7 segments were identified visually. The threshold voltage needed to elicit hindlimb muscle electromyography (EMG) after stimulation of intact nerve roots was determined. Segments of 2 or 3 nerve roots (each approximately 8-15 mm in length) were excised. The GC containing Schwann cells was implanted between the proximal and distal stumps of these nerve roots and attached to the stumps with suture. Follow-up evaluation was conducted on 3 animals, with survival times of 9 to 14 months.

RESULTS

Upon reexposure of the implant site, subdural nerve root adhesions were noted in all 3 animals. Several of the implanted GC had collapsed and were characterized by thin strands of connective tissue attached to either end. In contrast, 3 of the 8 implanted GC were intact and had white, glossy cables entering and exiting the conduits. Electrical stimulation of the tissue cable in each of these 3 cases led to low-threshold evoked EMG responses, suggesting that muscles had been reinnervated by axons regenerating through the repair site and into the distal nerve stump. During harvesting of the GC implant, sharp transection led to spontaneous EMG in the same 3 roots showing a low threshold to electrical stimulation, whereas no EMG was seen when harvesting nerve roots with high thresholds to elicit EMG. Histology confirmed large numbers of myelinated axons at the midpoint of 2 GC judged to have reinnervated target muscles.

CONCLUSIONS

We found a modest rate of successful regeneration and muscle reinnervation after treatment of nerve root transection with a Schwann cell-seeded, implanted synthetic GC. Newer treatments, which include the use of absorbable polymers, neurotrophins, and antiscar agents, may further improve spinal nerve regeneration for repair of cauda equina injury.

The association of rehabilitation and war

PURPOSE

To examine the assumed association of war and the development of rehabilitation through a review of the pertinent literature.

METHODS

Search in the Medline databases from 1942-2002 for papers that described the impact of war on rehabilitation services and their practice, and the study of the relevant identified reports. The following search terms were used: history of rehabilitation, medicine and war, rehabilitation and war, rehabilitation of war casualties.

RESULTS

In WWI physical and occupational therapy became adjuncts in the treatment of military orthopaedic casualties, artificial limb services were set-up and workshops and factories for vocational rehabilitation were created. During WWII further developments occurred, mainly in the field of amputation of limbs and spinal cord injuries. Additional advances took place in all armed conflicts after WWII, particularly in the field of brain injury.

CONCLUSION

The literature review indicates that the assumed association of rehabilitation and war is correct. Rehabilitation services have developed partly in association with war and the experience of rehabilitating war casualties supplied valuable principles and practices to rehabilitation medicine enriching the specialty and contributing to the health care systems of the involved countries.

A Novel Approach to the Treatment of Gunshot Injuries to the Sacrum

Two patients (a 17-year-old male and a 19-year-old female) sustained single gunshot wounds to the abdomen. Given the nature of their wounds and presumed peritoneal penetration they were taken urgently to the operating room for exploratory laparotomy. Both patients sustained multiple intra-abdominal injuries including gastric and small and large bowel perforations. Given the extensive nature of these injuries both patients required bowel resections. Upon further exploration they were both noted to have significant bleeding from the bony aspect of their sacrum. A surgical hemostat (CoStasis; Cohesion Technologies, Inc., Palo Alto, CA) (4.5–9.0 cm3) was directly applied to the injured area of the sacrum in both cases after standard surgical hemostatic techniques were unsuccessful. After application no further attempts of hemostatic control by standard methods were attempted. In both cases the sacral bleeding ceased without any further surgical intervention. Postoperatively neither patient rebled from the sacral injuries. Penetrating injuries to the sacrum can be life threatening and difficult to control with standard surgical hemostatic techniques. CoStasis, a new surgical hemostat, was effective in obtaining immediate and definitive hemostatic control. Future prospective trials on the use of CoStasis in trauma patients are warranted.

The military medical management of missile injury to the spine: a review of the literature and proposal of guidelines

The management of missile injury to the spinal cord is controversial. The literature is reviewed and recommendations made about the management of these injuries. To surgeons in a country that is relatively safe such injuries are rare, this review provides useful information about this condition.

Dynamic analysis of penetrating trauma

BACKGROUND

Whereas considerable literature exists on the wounding mechanics of high velocity projectiles in the military domain, there is a paucity of such data from projectiles routinely encountered in the civilian population in the United States. This study was undertaken to develop a methodology and to determine the dynamics of penetrating trauma secondary to low velocity projectiles (200-300 m/sec). To demonstrate the feasibility of the methodology and the experimental protocol, two markedly different projectiles were chosen in the study.

METHODS

Two projectiles were discharged into a human tissue simulant; one projectile was smooth and the other was of the expansion type. High-speed video photographic analysis and synchronized trigger techniques were used to describe the path of the projectile during its travel within the simulant. The temporal transient and residual profiles demonstrating the "wound involvement" were computed.

RESULTS

Results indicated a stark contrast between the two cases. There was a ratio of approximately three-to-one in the maximum wound involvement due to penetration. Transient wave oscillations during penetration and perforation of the projectile from the tissue simulant demonstrated significant differences in amplitudes and time durations. In addition, the residual wound involvement profiles indicated differences in the injury potential.

CONCLUSIONS

This study has provided an experimental methodology to delineate the temporal dynamic behavior of penetrating projectiles. To fully quantify and differentiate the dynamic differences in the temporal behaviors of the numerous available projectiles (with various combinations in design, type of equipment, and discharge), further research in this area is clearly necessary. The present protocol lends itself to be used to systematically analyze all these behaviors. Quantified data may assist clinical personnel in the management of penetrating trauma.

Comparative study of functional recovery for surgically explored and conservatively managed spinal cord missile injuries

OBJECTIVE

In a retrospective study, the extent of functional recovery and the merits of surgical exploration versus conservative management for spinal cord injuries were evaluated for 145 casualties from the front lines of the Iran-Iraq conflict.

METHODS

Eighty-seven patients who underwent surgical exploration and 58 patients who were conservatively treated were monitored for 6 to 140 months (average, 57 +/- 31 mo) for any changes from their baseline neurological status, using the Frankel Scoring System.

RESULTS

Twenty-two of 90 patients (24.4%) with complete injuries (Frankel score A) and 53 of 55 (96.4%) with incomplete injuries (Frankel scores B, C, and D) experienced changes in their neurological status as they recovered. Improvement was noted for 42 of 87 surgically treated patients (13 of 55 with complete injuries and 29 of 32 with incomplete injuries). Among conservatively treated patients, improvement was noted for 32 of 58 (55%), including 25.7% of those with complete injuries and 100% of those with incomplete injuries. Independent walking (Frankel scores D and E) was achieved by 10 of 90 patients with complete injuries and by 52 of 55 patients with incomplete injuries. Surgery did not affect the final outcome. Thirteen of 17 (76%) cerebrospinal fluid fistulas, 13 of 15 (87%) meningitides, and 4 of 6 (67%) local septic complications were encountered in the surgically treated group.

CONCLUSION

Surgery did not enhance functional recovery from spinal cord missile injuries but did correlate with an increased prevalence of complications (fistulas, meningitis, and local sepsis). With or without surgical exploration, patients with seemingly complete cauda equina injuries demonstrated better functional outcome than did those with spinal cord injuries.

Gunshot injuries of the sacrum

Gunshots to the sacrum are unusual and present several management problems. Associated injuries and particularly sacral bleeding are troublesome. Conventional methods of hemostasis are not suitable in this setting as the spinal blood supply is very complex because it is largely derived from the longitudinal spinal arteries originating intracranially. Attempts at proximal control are difficult and could lead to neurological injury. We successfully managed brisk bleeding in three patients with sacral gunshots. After the major intra abdominal hemorrhage had been controlled, attention was turned to the sacral wounds that had been packed with sponges up to that time. The sacral defect was closed with bone wax to control bleeding definitively. Methyl cellulose was then put over the bone wax and the periosteum of the sacrum and posterior peritoneum (mobilized if necessary), sutured over the methyl cellulose. Post operatively the patients are carefully monitored for developing neurological deficit that would necessitate immediate sacral laminectomy and decompression. We advocate tamponading of the sacral wound with bone wax, covered by methyl cellulose and kept in place and held firm by the periosteum and posterior peritoneum sutured over it as a successful interim or definitive form of therapy.

Spinal cord missile injuries during the Lebanese civil war

BACKGROUND

Spinal cord injuries due to penetrating wounds are not uncommon. The management of these injuries remains controversial especially with regard to the effect of laminectomy on the neurological outcome.

METHODS

Between 1980 and 1989, 64 patients injured by bullets and shell fragments to the spinal cord were reviewed. There were 58 males and 6 females: 24 injuries (37.5%) involved the cervical spine, 37 (57.8%) the dorsal spine, and 3 (4.7%) the lumbar spine. One group (group I) consisted of 47 patients (73.4%) who had immediate and complete sensorimotor loss of function. Another group (group II) contained 13 patients (20.3%) who presented with incomplete and non-progressive spinal cord deficit. One patient (1.6%) (group III) had progressive spinal cord deficit. Three patients (4.7%) (group IV) had injuries to the cauda equina.

RESULTS

The results were analyzed using a chi-squared test when possible. In group I, 20 patients (42.5%) underwent laminectomy with no recovery, and 27 (57.5%) were treated conservatively, with 1 patient (3.7%) achieving marked improvement (p > 0.05). In group II, 3 patients (23.1%) underwent laminectomy with the 3 (100%) improved, and 10 patients (76.9%) were treated conservatively, with 8 (80%) recovering (p > 0.05).

CONCLUSIONS

Our data in groups I and II agree with previously published literature that shows no significant advantage of performing laminectomies following penetrating spinal cord injuries. Moreover, group I patients had a poor prognosis whether laminectomy was done or not, and group II patients had a good prognosis whether laminectomy was done or not.

Civilian penetrating spinal firearm injuries of the spine. Results of surgical treatment with special attention to factors determining prognosis

In this study, the cases of 17 civilians with penetrating firearm injuries of the spinal cord treated between 1968 and 1990 at the Department of Neurosurgery, Hacettepe University Faculty of Medicine, were analyzed. Relevant literature was reviewed and compared with our study. The results of treatment and other factors determining mortality rate and prognosis were evaluated. Our study and the literature both appear to indicate that operative intervention is the mainstay of treatment.

Penetrating injuries restricted to the cauda equina: a retrospective review

Thirty-three patients with penetrating injuries to the cauda equina were admitted to Ben Taub General Hospital (1980-1989). Thirty received gunshot injuries, and three had stab wounds. The average age was 30 years, and 30 patients were male. All patients had been admitted within 1 hour of injury and received spine films, myelography, or computed tomography. Deficits were "complete" if total loss of function existed and were "incomplete" if any function remained below the level of injury. Improvement at the end of followup was defined as any recovery of motor strength or regaining of a unilateral sensory level. Twenty-nine (88%) patients had incomplete neurological deficits. Of these, 15 (52%) had surgery, and of this patient group, 7 (47%) improved, 7 (47%) showed no change, and 1 (6%) worsened. Fourteen (48%) patients with incomplete deficits were treated conservatively; 10 (71%) improved, and 4 (29%) had no change. Four patients (12%) had complete deficits, 3 of whom had surgery, and all improved. One patient with a complete deficit was treated conservatively and did not improve. Ten (34%) patients had bowel or bladder dysfunction, and none improved regardless of the type of treatment. Complications (cerebrospinal fluid leak, pseudomeningocele, or wound infection) occurred in 5 (28%) operative patients and 1 (7%) conservatively treated patient. Early neurosurgical intervention for penetrating injuries of the cauda equina may be beneficial but carries an increased risk of complication.

Long term follow up of spinal cord injury caused by penetrating missiles

Eighty-four spinal cord injured patients (SCIP) injured as a result of penetrating missiles were categorised according to: neurological level of injury, age at time of injury, circumstances of injury, missile type, initial treatment, duration of injury, and ethnic background. Evaluations and comparisons were made concerning: life habits, family status, education, employment, and mental well being. A discussion of complicating factors, both physical and psychological, and their relation to the final rehabilitation result is presented.