Cervical spine injury from gunshot wounds

Spinal gunshot wounds: A retrospective, multicenter, cohort study

INTRODUCTION AND OBJECTIVE

To describe the demographic and clinical characteristics and treatment of patients with spinal gunshot wounds across Latin America.

MATERIAL AND METHODS

Retrospective, multicenter cohort study of patients treated for gunshot wounds to the spine spanning 12 institutions across Latin America between January 2015 and January 2022. Demographic and clinical data were recorded, including the time of injury, initial assessment, characteristics of the vertebral gunshot injury, and treatment.

RESULTS

Data on 423 patients with spinal gunshot injuries were extracted from institutions in Mexico (82%), Argentina, Brazil, Colombia, and Venezuela. Patients were predominantly male civilians in low-risk-of-violence professions, and of lower/middle social status, and a sizeable majority of gunshots were from low-energy firearms. Vertebral injuries mainly affected the thoracic and lumbar spine. Neurological injury was documented in n=320 (76%) patients, with spinal cord injuries in 269 (63%). Treatment was largely conservative, with just 90 (21%) patients treated surgically, principally using posterior open midline approach to the spine (n=79; 87%). Injury features distinguishing surgical from non-surgical cases were neurological compromise (p=0.004), canal compromise (p<0.001), dirty wounds (p<0.001), bullet or bone fragment remains in the spinal canal (p<0.001) and injury pattern (p<0.001). After a multivariate analysis through a binary logistic regression model, the aforementioned variables remained statistically significant except neurological compromise.

CONCLUSIONS

In this multicenter study of spinal gunshot victims, most were treated non-surgically, despite neurological injury in 76% and spinal injury in 63% of patients.

Spinal gunshot wounds: A retrospective, multicenter, cohort study

INTRODUCTION AND OBJECTIVE

To describe the demographic and clinical characteristics and treatment of patients with spinal gunshot wounds across Latin America.

MATERIAL AND METHODS

Retrospective, multicenter cohort study of patients treated for gunshot wounds to the spine spanning 12 institutions across Latin America between January 2015 and January 2022. Demographic and clinical data were recorded, including the time of injury, initial assessment, characteristics of the vertebral gunshot injury, and treatment.

RESULTS

Data on 423 patients with spinal gunshot injuries were extracted from institutions in Mexico (82%), Argentina, Brazil, Colombia, and Venezuela. Patients were predominantly male civilians in low-risk-of-violence professions, and of lower/middle social status, and a sizeable majority of gunshots were from low-energy firearms. Vertebral injuries mainly affected the thoracic and lumbar spine. Neurological injury was documented in 320 (76%) patients, with spinal cord injuries in 269 (63%). Treatment was largely conservative, with just 90 (21%) patients treated surgically, principally using posterior open midline approach to the spine (79; 87%). Injury features distinguishing surgical from non-surgical cases were neurological compromise (P = 0.004), canal compromise (P < 0.001), dirty wounds (P < 0.001), bullet or bone fragment remains in the spinal canal (P < 0.001) and injury pattern (P < 0.001). After a multivariate analysis through a binary logistic regression model, the aforementioned variables remained statistically significant except neurological compromise.

CONCLUSIONS

In this multicenter study of spinal gunshot victims, most were treated non-surgically, despite neurological injury in 76% and spinal injury in 63% of patients.

Civilian Ballistic Injuries to the Atlantoaxial Spine: A Single Institution Case Series

STUDY DESIGN

Retrospective case series.

OBJECTIVE

Describe the injury characteristics of ballistic fractures involving the atlantoaxial spine.

SUMMARY OF BACKGROUND DATA

Civilian gunshot wounds to the spine are an increasingly common injury in the United States. Civilian studies have focused on ballistic injuries to the entire spine as opposed to a region-specific fashion. Only a single 10-patient case series investigating ballistic fractures to the upper cervical spine (C1 and C2) exists, leaving a large gap in the understanding of this injury complex.

METHODS

A retrospective chart review was performed. Extracted data included patient demographics, neurological status on presentation, 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.

RESULTS

Thirty-six patients were identified, with 86% being male with an average patient age of 30.0 ± 10.36 years (mean ± SD). Fracture morphology was characterized using proportional analysis. Initial neurological exams were either ASIA A or ASIA E, without any incomplete injuries noted. Patients who sustained a transcanal injury did not show any neurological improvement. The initial in-hospital mortality rate was 5.6%, with a 1-year mortality rate of 8.3%. There is a high incidence of associated vascular injury (66%) and mandible fracture (33%).

CONCLUSIONS

Ballistic penetrating trauma to the atlantoaxial spine often results in complex injury patterns necessitating multidisciplinary care with high rates of morbidity and mortality. If neurological deficits are present initially, they are often complete. Two thirds of patients sustained an associated vascular injury, which should be screened for with CT angiography.

Predicting early complications in patients with spinal gunshot wounds: A multicenter study

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.

Gunshot Wounds: Ballistics, Pathology, and Treatment Recommendations, with a Focus on Retained Bullets

As the epidemic of gunshot injuries and firearm fatalities continues to proliferate in the United States, knowledge regarding gunshot wound (GSW) injury and management is increasingly relevant to health-care providers. Unfortunately, existing guidelines are largely outdated, written in a time that high-velocity weapons and deforming bullets were chiefly restricted to military use. Advances in firearm technology and increased accessibility of military grade firearms to civilians has exacerbated the nature of domestic GSW injury and complicated clinical decision-making, as these weapons are associated with increased tissue damage and often result in retained bullets. Currently, there is a lack of literature addressing recent advances in the field of projectile-related trauma, specifically injuries with retained bullets. This review aims to aggregate the available yet dispersed findings regarding ballistics, GSW etiology, and treatment, particularly for cases involving retained projectiles.

Civilian Gun Shot Wounds Associated With Spinal Injuries

STUDY DESIGN

Retrospective.

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Investigational Therapies for Gunshot Wounds to the Spine: A Narrative Review

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.

Case Report: Full-Endoscopic Surgery for Bullet Wounds of the Spine: A Report of Three Cases

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.

Vertebral artery injury due to air rifle: A case report

INTRODUCTION

This case report presents a rare case of vertebral artery and spinal cord injury due to air rifle pellet.

CASE PRESENTATION

A previously healthy 19-year-old male was shot on his left neck incidentally during recreational air rifle game. He was taken to the other hospital before being referred to our hospital.

CLINICAL FINDINGS AND INVESTIGATIONS

The patient presented with total loss of motoric function on his left side of the body together with sensoric function on the contralateral side from the level of C5 and below. Signs of stroke were also spotted on the patient's face. The cervical plain radiograph and CT scan were carried out preoperatively to depict pellet fragments. Meanwhile, the CT angiography which was commenced postoperatively revealed the left vertebral artery injury.

INTERVENTIONS

Surgery comprising of pellet fragments removal, decompression and posterior stabilization of the cervical spine was carried out to retrieve the pellet fragments, which were embedded at the posterior epidural space.

RELEVANCE AND IMPACT

Our findings were consistent with the vertebral artery injury and Brown-Sequard syndrome. Hence, these clinical entities should be considered in the setting of penetrating cervical trauma.

Management of cerebrospinal fluid leak from cervical gunshot wounds with external ventricular drainage: a small case series

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.

Retained bullet in the cervical spinal canal and the associated surgical management conundrum: case report and review of the literature

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.

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

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

A case series of penetrating spinal trauma: comparisons to blunt trauma, surgical indications, and outcomes

OBJECTIVE

While blunt spinal trauma accounts for the majority of spine trauma, penetrating injuries affect a substantial number of patients. The goal of this study was to examine the epidemiology of penetrating spine injuries compared with blunt injuries and review the operative interventions and outcomes in the penetrating spine injury group.

METHODS

The prospectively maintained trauma database was queried for spinal fractures from 2012 to 2018. Charts from patients with penetrating spine trauma were reviewed.

RESULTS

A total of 1130 patients were evaluated for traumatic spinal fractures; 154 injuries (13.6%) were secondary to penetrating injuries. Patients with penetrating injuries were significantly younger (29.2 years vs 44.1 years, p < 0.001), more likely male (87.7% vs 69.2%, p < 0.001), and more commonly African American (80.5% vs 33.3%, p < 0.05). When comparing primary insurers, the penetrating group had a significantly higher percentage of patients covered by Medicaid (60.4% vs 32.6%, p < 0.05) or prison (3.9% vs 0.1%, p < 0.05) or being uninsured (17.5% vs 10.3%, p < 0.05). The penetrating group had a higher Injury Severity Score on admission (20.2 vs 15.6, p < 0.001) and longer hospital length of stay (20.1 days vs 10.3 days, p < 0.001) and were less likely to be discharged home (51.3% vs 65.1%, p < 0.05). Of the penetrating injuries, 142 (92.2%) were due to firearms. Sixty-three patients (40.9%) with penetrating injuries had a concomitant spinal cord or cauda equina injury. Of those, 44 (69.8%) had an American Spinal Injury Association Impairment Scale (AIS) grade of A. Ten patients (15.9%) improved at least 1 AIS grade, while 2 patients (3.2%) declined at least 1 AIS grade. Nine patients with penetrating injuries underwent neurosurgical intervention: 5 for spinal instability, 4 for compressive lesions with declining neurological examination results, and 2 for infectious concerns, with some patients having multiple indications. Patients undergoing neurosurgical intervention did not show a significantly greater change in AIS grade than those who did not. No patient experienced a complication directly related to neurosurgical intervention.

CONCLUSIONS

Penetrating spinal trauma affects a younger, more publicly funded cohort than blunt spinal trauma. These patients utilize more healthcare resources and are more severely injured. Surgery is undertaken for limiting progression of neurological deficit, stabilization, or infection control.

Chinese expert consensus on the treatment of modern combat-related spinal injuries

The battlefield treatments of spinal and spinal cord injury vary from civilian settings. However, there is no unified battlefield treatment guidelines for spine trauma in PLA. An expert consensus is reached, based on spine trauma epidemiology and the concepts of battlefield treatment combined with the existing levels of military medical care in modern warfare. Since the specialized treatment for spine trauma are no significant difference between civilian settings and modern war, the first aid, emergency treatment and early treatment of spine trauma are introduced separately in three levels in this consensus. In Level I facilities, the fast and accurate evaluation of spine trauma followed by fixation and stabilization are recommended during the first-aid stage. Re-evaluation, further treatment for possible hemorrhagic shock, dyspnea and infection are recommended at Level II facilities. At Level III facilities, it is recommended to strengthen the intensive care and the prevention of urinary system and lung infection for the wounded with severe spinal injury, however, spinal surgery is not recommended in a battlefield hospital. The grading standard for evidence evaluation and recommendation was used to reach this expert consensus.

Neurological recovery following traumatic spinal cord injury: a systematic review and meta-analysis

OBJECTIVE

Predicting neurological recovery following traumatic spinal cord injury (TSCI) is a complex task considering the heterogeneous nature of injury and the inconsistency of individual studies. This study aims to summarize the current evidence on neurological recovery following TSCI by use of a meta-analytical approach, and to identify injury, treatment, and study variables with prognostic significance.

METHODS

A literature search in MEDLINE and EMBASE was performed, and studies reporting follow-up changes in American Spinal Injury Association (ASIA) Impairment Scale (AIS) or Frankel or ASIA motor score (AMS) scales were included in the meta-analysis. The proportion of patients with at least 1 grade of AIS/Frankel improvement, and point changes in AMS were calculated using random pooled effect analysis. The potential effect of severity, level and mechanism of injury, type of treatment, time and country of study, and follow-up duration were evaluated using meta-regression analysis.

RESULTS

A total of 114 studies were included, reporting AIS/Frankel changes in 19,913 patients and AMS changes in 6920 patients. Overall, the quality of evidence was poor. The AIS/Frankel conversion rate was 19.3% (95% CI 16.2-22.6) for patients with grade A, 73.8% (95% CI 69.0-78.4) for those with grade B, 87.3% (95% CI 77.9-94.8) for those with grade C, and 46.5% (95% CI 38.2-54.9) for those with grade D. Neurological recovery was significantly different between all grades of SCI severity in the following order: C > B > D > A. Level of injury was a significant predictor of recovery; recovery rates followed this pattern: lumbar > cervical and thoracolumbar > thoracic. Thoracic SCI and penetrating SCI were significantly more likely to result in complete injury. Penetrating TSCI had a significantly lower recovery rate compared to blunt injury (OR 0.76, 95% CI 0.62-0.92; p = 0.006). Recovery rate was positively correlated with longer follow-up duration (p = 0.001). Studies with follow-up durations of approximately 6 months or less reported significantly lower recovery rates for incomplete SCI compared to studies with long-term (3-5 years) follow-ups.

CONCLUSIONS

The authors' meta-analysis provides an overall quantitative description of neurological outcomes associated with TSCI. Moreover, they demonstrated how neurological recovery after TSCI is significantly dependent on injury factors (i.e., severity, level, and mechanism of injury), but is not associated with type of treatment or country of origin. Based on these results, a minimum follow-up of 12 months is recommended for TSCI studies that include patients with neurologically incomplete injury.

Surgical and Nonsurgical Treatment of Penetrating Spinal Cord Injury: Analysis of Long-term Neurological and Functional Outcomes

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.

Stability of the Subaxial Spine after Penetrating Trauma: Do Classification Systems Apply?

OBJECTIVE

Blunt spinal trauma classification systems are well established and provide reliable treatment algorithms. To date, stability of the spine after civilian gunshot wounds (CGSWS) is poorly understood. Herein, we investigate the validity of trauma classification systems including the Thoracolumbar Injury Classification and Severity Score (TLICS), Subaxial Cervical Spine Injury Classification and Severity Score (SLIC), and Denis' three-column model when applied to spinal penetrating trauma from gunshots, while secondarily evaluating stability of these injuries.

METHODS

Gunshot injuries to the spine were identified from an institutional database from ICD-nine codes. Trauma scorings systems were applied using traditional criteria. Neurologic compromise and spinal stability were evaluated using follow-up clinic notes and radiographs.

RESULTS

Thirty-one patients with CSGSW were evaluated. There was an equal distribution of injuries amongst the spinal levels and spinal columns. Twenty patients had neurological deficits at presentation. Eight patient had a TLICS score >4. Three patients had a SLIC score >4. One patient had surgical treatment. Nonoperative treatment did not lead to spinal instability or adverse outcomes in any cases. The posterior column had a high correlation with neurologic compromise, though not statistically significant (p=.118).

CONCLUSIONS

The TLICS, SLIC, and three-column classification systems cannot be applied to CSGSW to quantify injury severity, predict outcomes, or guide treatment decision-making. Despite significant neurologic injuries and disruption of multiple spinal columns, CSGSW do not appear to result in unstable injuries requiring operative intervention. Further research is needed to identify the rare spinal gunshot injury that would benefit from immediate surgical intervention.

Penetrating spinal injury in childhood: the influence of mechanism on outcome. An epidemiological study

OBJECTIVE

Penetrating injury of the spine in childhood commonly causes profound and life-long disability, but it has been the object of very little study. The goal of the current report is to document temporal trends in the nationwide incidence of this condition and to highlight the differences between penetrating injuries and closed injuries.

METHODS

The Kids' Inpatient Database was queried for spinal injuries in 1997, 2000, 2003, 2006, 2009, and 2012. Penetrating mechanism was determined by diagnostic coding for open injuries and by mechanistic codes for projectiles and knives. Nationwide annual incidences were calculated using weights provided for this purpose. Unweighted data were used as a cross-sectional sample to compare closed and penetrating injuries with respect to demographic and clinical factors. The effect of penetrating mechanism was analyzed in statistical models of death, adverse discharge, and length of stay (LOS).

RESULTS

The nationwide incidence of penetrating spinal injury in patients less than 18 years of age trended downward over the study period. Patients with penetrating injury were older and much more predominantly male than patients with closed injuries. They resided predominantly in zip codes with lower median household incomes, and they were much more likely to have public health insurance or none at all. They were predominantly black or Hispanic. The risk of hospital death was no different, but penetrating injuries were associated with much higher rates of adverse discharge after LOS, averaging twice as long as closed injuries. Brain, visceral, and vascular injuries were powerful predictors of hospital death, as was upper cervical level of injury. The most powerful predictor of adverse discharge and LOS was spinal cord injury, followed by brain, visceral, and vascular injury and penetrating mechanism.

CONCLUSIONS

Because its pathophysiology requires no elucidation, because the consequences for quality of life are dire, and because the population at risk is well defined, penetrating spinal injury in childhood ought to be an attractive target for public health interventions.

Comparing Blunt and Penetrating Trauma in Spinal Cord Injury: Analysis of Long-Term Functional and Neurological Outcomes

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.

Retrieval of a Broken Sewing Needle from the Sacrum Aided by a Permanent Magnet: A Case Report and Literature Review

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.

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.

Endoscopic removal of bullets from the cranial ridge junction region via transoral and transnasal approaches: Two case reports and review of literature

Endoscopes in otolaryngology may facilitate accessing the lumens and sites such as upper cervical spine with minimally invasive surgical exposure. Here, we present 2 interesting cases of youth who underwent endoscopic removal of bullets in the cranial ridge junction region.The first case was a 20-year-old young man who underwent a gunshot in the face. A CT scan showed that a metallic foreign body located inside the right lateral body of Atlas that presented a comminuted fracture. The second case a 36-year-old man who also underwent a gunshot in the face. CT scan showed a foreign body lodged in the soft tissues before the right anterior arch of Atlas cone (C1) that presented a fracture. The bullets in these 2 patients were removed under the endoscopes with minimal damage, respectively. The patients were discharged without neck activity obstacle.The advantage of endoscopic technique is obvious because limited visualization does not damage surrounding tissues, thus decreasing surgical complications. This was an interesting experience of surgical operation in this region.

Failure of Mean Arterial Pressure Goals to Improve Outcomes Following Penetrating Spinal Cord Injury

BACKGROUND:

Increased spinal cord perfusion and blood pressure goals have been recommended for spinal cord injury (SCI). Penetrating SCI is associated with poor prognosis, but there is a paucity of literature examining the role of vasopressor administration for the maintenance of mean arterial pressure (MAP) goals in this patient population.

OBJECTIVE:

To elucidate this topic and to determine the efficacy of vasopressor administration in penetrating SCI by examining a case series of consecutive penetrating SCIs.

METHODS:

We reviewed consecutive patients with complete penetrating SCI who met inclusion and exclusion criteria, including the administration of vasopressors to maintain MAP goals. We identified 14 patients with complete penetrating SCIs with an admission American Spinal Injury Association grade of A from 2005 to 2011. The neurological recovery, complications, interventions, and vasopressor administration strategies were reviewed and compared with those of a cohort with complete blunt SCI.

RESULTS:

In our patient population, only 1 patient with penetrating SCI (7.1%) experienced neurological recovery, as determined by improvement in the American Spinal Injury Association grade, despite the administration of vasopressors for supraphysiological MAP goals for an average of 101.07 ± 34.96 hours. Furthermore, 71.43% of patients with penetrating SCI treated with vasopressors experienced associated cardiogenic complications.

CONCLUSION:

Given the decreased likelihood of neurological improvement in penetrating injuries, it may be important to re-examine intervention strategies in this population. Specifically, the use of vasopressors, in particular dopamine, with their associated complications is more likely to cause complications than to result in neurological improvement. Our experience shows that patients with acute penetrating SCI are unlikely to recover, despite aggressive cardiopulmonary management.

Gunshot injuries of the spine

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.

FIREARM INJURIES IN THE SPINE. EFFECTIVE STRATEGY FOR DIAGNOSIS AND TREATMENT

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.