Surgical management of penetrating spinal cord injury primarily due to shrapnel and its effect on neurological outcome: a literature review and meta-analysis

Acute penetrating injury of the spinal cord by a wooden spike with delayed surgery: a case report

Rarely, penetrating injuries to the spinal cord result from wooden objects, creating unique challenges to mitigate neurological injury and high rates of infection and foreign body reactions. We report a man who sustained a penetrating cervical spinal cord injury from a sharpened stick. While initially tetraparetic, he rapidly recovered function. The risks of neurological deterioration during surgical removal made the patient reluctant to consent to surgery despite the impalement of the spinal cord. A repeat MRI on day 3 showed an extension of edema indicating progressive inflammation. On the 7^th day after injury, fever and paresthesias occurred with a large increase in serum inflammatory indicators, and the patient agreed to undergo surgical removal of the wooden object. We discuss the management nuances related to wood, the longitudinal evolution of MRI findings, infection risk, surgical risk mitigation and technique, an inflammatory marker profile, long-term recovery, and the surprisingly minimal neurological deficits associated with low-velocity midline spinal cord injuries. The patient had an excellent clinical outcome. The main lessons are that a wooden penetrating central nervous system injury has a high risk for infection, and that surgical removal from the spinal cord should be performed soon after injury and under direct visualization.

How War Has Shaped Neurosurgery

Many strides have been made in neurosurgery during times of war, helping to improve the outcomes of patients in dire circumstances. World War I introduced the concepts of early operation for trauma, forward-operating hospitals, and galeal sutures as well as techniques for careful debridement. It laid the groundwork for neurosurgery to become a specialty within medicine as well. World War II brought about the use of expedited medical evacuation, mobile neurosurgical units, improved resuscitation strategies, cranioplasty, and early laminectomy with decompression. The Korean and Vietnam Wars built on concepts from World Wars I and II, helping to establish the importance of watertight dural closure, external drainage systems after cranial trauma, multidisciplinary care, and infection prevention strategies. In the post-Vietnam period, we have seen significant technological advances allowing neurosurgeons to move farther ahead than most throughout history could have imagined. The significance of secondary brain injury, vascular injury, and the underlying pathophysiology of traumatic insults has been elucidated over the years since the Vietnam War, allowing for great advances in the care of our patients. Each major war throughout history has contributed greatly to the specialty of neurosurgery, each with its own innovations culminating in guidelines, strategies, and standards of practice that allow us to deliver the highest standard of care to our patients.

Breaking the Mold: Surgical Exploration for Spinal Impalement Injury Without Neurological Deficit

Spinal cord injuries (SCI) are a significant burden on society, particularly affecting the working population. Traumatic SCI can result from violent confrontations, involving firearms, knives, or edged weapons. Although surgical techniques for these injuries are not well defined, surgical exploration, decompression, and removal of the foreign body are currently indicated for patients with spinal stab wound injuries with neurologic impairment. We present a case of a 32-year-old male patient who presented to the emergency department with a stab injury with a knife. Radiographs and CT scans revealed a broken knife blade with a midline trajectory in the lumbar spine, moving toward the vertebral body of L2 occupying less than 10% of the intramedullary canal. The patient underwent surgery, and the knife was successfully extracted without any complications. Post-operative MRI showed no signs of cerebrospinal fluid (CSF) leak, and the patient did not exhibit any sensorimotor deficit. The acute trauma life support (ATLS) procedure must be followed while treating a patient with penetrating spinal trauma with or without neurological impairment. After availing appropriate investigations, any attempt to remove a foreign object should be done. Although spinal stab wound injuries are uncommon in developed nations, they continue to be a source of traumatic cord damage in underdeveloped countries. Our case highlights the successful surgical management of a spinal stab wound injury with a good outcome.

Spine and spinal cord injuries in Syria war: treatment and outcome

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.

Advancements in the treatment of traumatic spinal cord injury during military conflicts

Significant advancements in the treatment of spinal cord injury (SCI) were developed in the setting of military conflicts, partly due to the large numbers of injuries sustained by service members. No effective SCI treatment options existed into the early 20th century, and soldiers who sustained these injuries were usually considered untreatable. Extensive progress was made in SCI treatment during and after World War II, as physical therapy was increasingly encouraged for patients with SCI, multidisciplinary teams oversaw care, pathophysiology was better understood, and strategies were devised to prevent wound infection and pressure sores. Recent conflicts in Iraq and Afghanistan have caused a substantial rise in the proportion of SCIs among causes of casualties and wounds, largely due to new forms of war and weapons, such as improvised explosive devices. Modern military SCIs resulting from blast mechanisms are substantively different from traumatic SCIs sustained by civilians. The treatment paradigms developed over the past 100 years have increased survival rates and outcomes of soldiers with SCI. In this paper, the authors review the role of military conflicts in the development of therapeutic interventions for SCI and discuss how these interventions have improved outcomes for soldiers and civilians alike.

Delayed return of urinary continence following the removal of neglected sacral shrapnel

Background

Globalisation of terrorism has led to an increase in the number of injuries from the explosion of improvised explosive devices, with complications resulting from the retained shrapnel. It had been found that a third of those who sustained penetrating spinal cord injuries are from explosions. Retained foreign body in the sacral canal segment is rare, especially shrapnel presenting with urinary incontinence. Moreover, the one who had a dramatic recovery of urinary continence following removal of neglected sacral canal shrapnel. We report a case of a delayed improvement (recovery) in urinary continence following removal of neglected sacral canal shrapnel remotely aided by a pelvic floor exercise.

Case presentation

Our patient was a 14-year-old male who presented with a 3-year history of trauma to the lower back from an Improvised Explosive Device. He was initially associated with difficulty in walking that improved over eight months. However, the urinary incontinence persisted. He was found to be preserved with no neurological deficit in the lower limb. There was a lower back, midline wound, discharging pus. Lumbosacral imaging revealed a sacral (S2) canal Shrapnel. As a case of urinary incontinence from sacral shrapnel, he had the removal of the shrapnel, did well postoperatively, commenced on pelvic floor exercise. He became continence of urine over time.

Conclusions

Retained foreign bodies in the spinal canal are associated with complications that include neurological deficit. Neglected (long-standing) sacral shrapnel with urinary incontinence is rare; moreover, the recovery of the continence with the removal of the shrapnel is aided by the commencement of pelvic floor exercise.

Recovery after inadvertent intramedullary microchip implantation at C1–C2 in a kitten

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.

Clinical application of stem cell therapy in neurogenic bladder: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

This review aims to investigate the effect of stem cell (SC) therapy on the management of neurogenic bladder (NGB) in four neurological diseases, including spinal cord injury (SCI), Parkinson's disease (PD), multiple sclerosis (MS), and stroke, in the clinical setting.

METHODS

An electronic database search was conducted in the Cochrane Library, EMBASE, Proquest, Clinicaltrial.gov , WHO, Google Scholar, MEDLINE via PubMed, Ovid, Web of Science, Scopus, ongoing trial registers, and conference proceedings in June 2019 and updated by hand searching on 1 February 2021. All randomized controlled trials (RCTs), quasi RCTs, phase I/II clinical trials, case-control, retrospective cohorts, and comprehensive case series that evaluated the regenerative potential of SCs on the management of NGB were included. Cochrane appraisal risk of bias checklist and the standardized critical appraisal instrument from the JBI Meta-Analysis of Statistics, Assessment, and Review Instrument (JBI-MAStARI) were used to appraise the studies.

RESULTS

Twenty-six studies among 1282 relevant publications met our inclusion criteria. Only SC therapy was applied for SCI or MS patients. Phase I/II clinical trials (without control arm) were the most conducted studies, and only four were RCTs. Four studies with 153 participants were included in the meta-analysis. The main route of transplantation was via lumbar puncture. There were no serious adverse events. Only nine studies in SCI and one in MS have used urodynamics, and the others have reported improvement based on patient satisfaction. SC therapy did not significantly improve residual urine volume, detrusor pressure, and maximum bladder capacity. Also, the quality of these publications was low or unclear.

CONCLUSION

Although most clinical trials provide evidence of the safety and effectiveness of MSCs on the management of NGB, the meta-analysis results did not show a significant improvement; however, the interpretation of study results is difficult because of the lack of placebo controls.

Penetrating Spinal Cord Injury in civilians: analysis of a national database

BACKGROUND

Spinal trauma is common in polytrauma; spinal cord injury (SCI) is present in a subset of these patients. Penetrating SCI has been studied in the military; however, civilian SCI is less studied. Civilian injury pathophysiology varies given the generally lower velocity of the projectiles. We sought to investigate civilian penetrating SCI in the United States.

METHODS

We queried the National Inpatient Sample for data regarding penetrating spinal cord injury from the past 10 years (2006-2015). The National Inpatient Sample includes data of 20% of discharged patients from U.S. hospitals. We analyzed trends of penetrating SCI regarding its diagnosis, demographics, surgical management, length of stay, and hospital costs.

RESULTS

In the past 10 years the incidence of penetrating SCI in all SCI patients has remained stable with a mean of 5.5% (range 4.3%-6.6%). Of the patients with penetrating SCI, only 17% of them underwent a surgical procedure, compared with 55% for nonpenetrating SCI. Patients with penetrating SCI had a longer length of stay (average 23 days) compared with nonpenetrating SCI (15 days). Hospital charges were higher for penetrating SCI: $230,186 compared with $192,022 for closed SCI. Males patients were more affected by penetrating SCI, as well as black and Hispanic populations compared with whites.

CONCLUSIONS

Penetrating SCI represents 5.5% of all SCI patients. Men, blacks, and Hispanics are disproportionally more affected by penetrating SCI. Patients with penetrating SCI have fewer surgical interventions, but their overall length of stay and hospital costs are greater compared with nonpenetrating SCI.

Operative Intervention for Lumbar Foraminal Gunshot Wounds: Case Report and Review of the Literature

Gunshot wounds represent the second most frequent cause of spinal cord injury after vehicular trauma. The thoracic region is most commonly involved, followed by the thoracolumbar spine. Numerous studies have demonstrated that improvement of neurological recovery, especially after decompression surgery, is likely to be seen in lumbosacral spine, but not in the thoracic or cervical spine. Herein, we present a case of a gunshot wound causing lumbar 5^th nerve root compression with neurological deficits that improved remarkably after urgent decompression surgery. This signifies a potential neurological benefit to prompt surgical intervention in lumbar gunshot wounds with radiographic evidence of neural compression. A relevant review of the literature was performed along with discussion, the clinical history, and radiological findings.

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.