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Santangelo G, Wathen C, Pieters T, George DD, Worley L, Macaluso D, Dagli MM, Catanzaro S, Gu B, Welch WC, Petrov D, Vates GE, Ozturk AK, Schuster J, Stone JJ. Multi-institutional review of characteristics and management of gunshot wounds to the spine. Spine J 2024; 24:1553-1560. [PMID: 38740190 DOI: 10.1016/j.spinee.2024.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND CONTEXT Gunshot wounds (GSWs) to the vertebral column represent an important cause of morbidity and mortality in the United States, constituting approximately 20% of all spinal injuries. The management of these injuries is an understudied and controversial topic, given its heterogeneity and lack of follow-up data. PURPOSE To characterize the management and follow-up of GSWs to the spine. STUDY DESIGN/SETTING A multi-institutional retrospective review of the experience of two urban Level 1 trauma centers. PATIENT SAMPLE Patients with GSWs to the spine between 2010-2021. OUTCOME MEASURES Measures included work status, follow-up healthcare utilization, and pain management were collected. METHODS Charts were reviewed for demographics, injury characteristics, surgery and medical management, and follow-up. Statistical analysis included T-tests and ANOVA for comparisons of continuous variables and chi-square testing for categorical variables. All statistics were performed on SPSS v24 (IBM, Armonk, NY). RESULTS A total of 271 patients were included for analysis. The average age was 28 years old, 82.7% of patients were black, 90% were male, and 76.4% had Medicare/Medicaid. The thoracic spine (35%) was most commonly injured followed by lumbar (33.9%) and cervical (25.6%). Cervical GSW was associated with higher mortality (p<.001); 8.7% of patients developed subsequent osteomyelitis/discitis, 71.3% received prophylactic antibiotics, and 56.1% of cervical GSW had a confirmed vertebral or carotid artery injury. ASIA scores at presentation were most commonly A (26.9%), D (20.7%), or E (19.6%), followed by C (7.4%) and B (6.6%). 18.8% of patients were unable to be assessed at presentation. ASIA score declined in only 2 patients, while 15.5% improved over their hospital stay. Those who improved were more likely to have ASIA B injury (p<.001). Overall, 9.2% of patients underwent spinal surgery. Of these, 33% presented as ASIA A, 21% as ASIA B, 29% as ASIA C, and 13% as ASIA D. Surgery was not associated with an improvement in ASIA score. CONCLUSIONS Given the ubiquitous and heterogeneous experience with GSWs to the spine, rigorous attempts should be made to define this population and its clinical and surgical outcomes. Here, we present an analysis of 11 years of patients presenting to two large trauma centers to elucidate patterns in presentation, management, and follow-up. We highlight that GSWs to the cervical spine are most often seen in young black male patients. They were associated with high mortality and high rates of injury to vertebral arteries and that surgical intervention did not alter rates of discitis/osteomyelitis or propensity for neurologic recovery; moreover, there was no incidence of delayed spinal instability in the study population.
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Affiliation(s)
- Gabrielle Santangelo
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Neurosurgery, University of Rochester, 601 Elmwood Ave., Rochester, NY 14620, USA.
| | - Connor Wathen
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas Pieters
- Department of Neurosurgery, University of Rochester, 601 Elmwood Ave., Rochester, NY 14620, USA
| | - Derek D George
- Department of Neurosurgery, University of Rochester, 601 Elmwood Ave., Rochester, NY 14620, USA
| | - Logan Worley
- Department of Neurosurgery, University of Rochester, 601 Elmwood Ave., Rochester, NY 14620, USA
| | - Dominick Macaluso
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mert Marcel Dagli
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sandra Catanzaro
- Department of Neurosurgery, University of Rochester, 601 Elmwood Ave., Rochester, NY 14620, USA
| | - Ben Gu
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - William C Welch
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dmitry Petrov
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - G Edward Vates
- Department of Neurosurgery, University of Rochester, 601 Elmwood Ave., Rochester, NY 14620, USA
| | - Ali K Ozturk
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - James Schuster
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan J Stone
- Department of Neurosurgery, University of Rochester, 601 Elmwood Ave., Rochester, NY 14620, USA
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Barnett HM, Seeds AN, Dowell KR, Nehra D, Crane DA. Timing of surgical intervention after firearm-related spinal cord injury. J Spinal Cord Med 2024:1-8. [PMID: 39087884 DOI: 10.1080/10790268.2024.2379069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2024] Open
Abstract
CONTEXT Surgical management of firearm-related spinal cord injury (SCI) remains controversial, and there are no clear guidelines. Time to surgery, surgical indications, and patient characteristics on initial presentation in this group are not well understood, and these factors may impact the potential for neurologic recovery after operative intervention. OBJECTIVE To understand the timing and factors affecting the timing of operative intervention after firearm-related SCI. METHODS In a retrospective cohort study, patients with traumatic SCI from July 2012 to July 2022 (n = 1569) were identified from our level 1 trauma center Trauma Registry. Data was obtained from the trauma registry and chart review. Rates and timing of surgical intervention, initial injury severity measures, and general hospital outcomes were compared between firearm-related SCI and blunt trauma SCI. RESULTS Patients with firearm-related SCI were less likely to undergo surgery compared to other etiologies (24.3% vs. 70.2%, P < 0.0001). Time to surgery for firearm-related SCI was longer than for other etiologies (49.2 ± 92.9 vs. 30.6 h ± 46.0, P = 0.012). Multiple measures of initial injury severity, including Injury Severity Score, Glasgow Coma Score, and emergency department disposition demonstrated more severe injury among patients with firearm-related SCI, and these patients often required other emergent surgeries prior to spine surgery (52%). CONCLUSIONS There was a longer time to spine surgery among patients with firearm-related SCI compared to blunt trauma SCI, and patients with firearm-related SCI were more severely injured on initial presentation. Further research is needed to understand the complex relationship between patient injury severity, surgical intervention, surgical timing, and outcomes after firearm-related SCI.
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Affiliation(s)
- Heather M Barnett
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Alicia N Seeds
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Katrina R Dowell
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Deepika Nehra
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Deborah A Crane
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
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Moreira TS, Moreira S, Teixeira-Vaz A. Brown-Séquard Syndrome Following a Thoracic Spine Stab Wound: A Case Report. Cureus 2023; 15:e46917. [PMID: 37954796 PMCID: PMC10639128 DOI: 10.7759/cureus.46917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2023] [Indexed: 11/14/2023] Open
Abstract
Nonmissile penetrating spine injury represents a small percentage of spinal cord injuries (SCIs), estimated at 0.8% in Western countries. This paper presents a detailed case report of a 28-year-old man with a history of substance use who suffered multiple injuries following a violent incident. The patient was found with a knife embedded in his thoracic spine, prompting immediate medical intervention. Computed tomography and postoperative magnetic resonance imaging revealed the extent of spinal cord and anatomical involvement. A thorough physical medicine and rehabilitation evaluation was conducted post-surgery, leading to a diagnosis of Brown-Séquard syndrome with associated sensorimotor deficits. This paper highlights the challenges posed by penetrating SCIs while reviewing the literature.
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Affiliation(s)
- Tiago S Moreira
- Physical Medicine and Rehabilitation Department, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Susana Moreira
- Physical Medicine and Rehabilitation Department, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Ana Teixeira-Vaz
- Physical Medicine and Rehabilitation Department, Centro Hospitalar Universitário de São João, Porto, PRT
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Kaliaperumal C. Microsurgical repair of severed thoracic spinal cord and clinical outcome: technical case report. Chin Neurosurg J 2022; 8:16. [PMID: 35879810 PMCID: PMC9310421 DOI: 10.1186/s41016-022-00286-0] [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: 09/17/2021] [Accepted: 06/27/2022] [Indexed: 11/15/2022] Open
Abstract
Background This report describes a case of successful repair of severed thoracic spine in a young man who presented with a penetrating stab injury to spine resulting in Brown-Séquard syndrome. Surgical technique and post-operative management is discussed. Case presentation A 34-year-old fit and well healthy man was admitted with a history of stab injury to the thoracic spine at thoracic T2/3 level with ASIA impairment score (AIS) score D with an incomplete spinal cord affecting his left lower limb with complete paralysis and right lower limb paresis with impaired sensation below T6 level to L5. Neuroimaging confirmed a penetrating knife injury traversing the T2/3 level causing hemi-section of the spinal cord confirmed intraoperatively. He underwent an urgent exploratory surgery of his spine and a T2/3 laminectomy was performed to aid removal of the knife. The dura was noted to be contused and severed spinal cord was noted to be severed with associated cord oedema. A microsurgical repair of the severed cord was performed with duroplasty followed by intense neuro-rehabilitation. On a 3 month follow up his AIS score is E with lower limb power is 5/5 bilaterally and he is able to mobilise independently up to 8–10 steps without any supportive aid and with crutches he is independently functional and mobile. Conclusion This is the first documented case of microsurgical repair of severed thoracic spinal cord secondary to traumatic knife injury. In the management of such scenario, apart from the removal of foreign body, repair of the cord with duroplasty should be carefully considered. The role of spinal neuroplasticity in healing following timely repair of the spinal cord along with intense rehabilitation remains the key. This had resulted in a good clinical and functional outcome with in a 18-month follow up.
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Abstract
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.
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Affiliation(s)
- Laurence Ge
- Department of Orthopaedics & Rehabilitation, University of Rochester School of Medicine and Dentistry, Rochester, New York, NY, USA
| | - Ayodeji Jubril
- Department of Orthopaedics & Rehabilitation, University of Rochester School of Medicine and Dentistry, Rochester, New York, NY, USA
| | - Addisu Mesfin
- Department of Orthopaedics & Rehabilitation, University of Rochester School of Medicine and Dentistry, Rochester, New York, NY, USA,Addisu Mesfin, Orthopaedic Surgery, Neurosurgery & Public Health, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Box 665, Rochester, New York, NY 14642, USA.
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Jones TJ, Stanley AL, McCarthy MJH. Transoral Gunshot Injury Resulting in Mechanical Block to Cervical Rotation: A Case Report. JBJS Case Connect 2021; 11:01709767-202106000-00125. [PMID: 34129534 DOI: 10.2106/jbjs.cc.20.01007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We report a case of self-inflicted transoral gunshot injury in a 24-year-old man resulting in mechanical block to cervical rotation. Anterior surgical removal of the pellet was successful with the patient experiencing no early or long-term functional deficits. CONCLUSION Given the rarity of a cervical spine injury from gunshot wound without long-term complications, this unique case supports the role of early operative management in such injuries.
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Affiliation(s)
- Tyler J Jones
- School of Medicine, Cardiff University, Cardiff, United Kingdom
| | | | - Michael J H McCarthy
- Cardiff and Vale Orthopaedic Center, University Hospital Llandough, Penarth, United Kingdom
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Castillo Amaya C, Prieto Meré JA, Cobar Bustamante A, Herrera Ovalle RM, Alonzo F. Stab injury to the spine without neurological involvement: a report of a rare case. J Surg Case Rep 2021; 2021:rjab163. [PMID: 34025969 PMCID: PMC8130762 DOI: 10.1093/jscr/rjab163] [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: 02/15/2021] [Accepted: 04/05/2021] [Indexed: 11/14/2022] Open
Abstract
The annual incidence of traumatic spinal cord injury worldwide is 35 patients per million; this incidence is likely to be much higher in Latin America, where stab injuries are a common incidence. Stab injuries to the spine represent a small percentage of these cases; these are rare injuries; its management may differ compared with other penetrating injuries; these injuries are frequently complicated with neurological damage; the most common clinical manifestation is Brown–Sequard syndrome, and the most common segment involved is the thoracic region; stab injuries to the lumbar spine are rarely found in the literature. The management of patients without neurological involvement is controversial due to the risk of neurologic deterioration intraoperatively. However, failure to adequately intervene increases the risk of permanent neurological deficit, worsening functional outcomes, cerebral fluid leakage and infections. A short review of the literature and a case report are presented.
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Affiliation(s)
- Carlos Castillo Amaya
- Instituto Guatemalteco de Seguridad Social, Ortopedia y Traumatología, Guatemala City, Guatemala
| | - Jose Antonio Prieto Meré
- Instituto Guatemalteco de Seguridad Social, Ortopedia y Traumatología, Guatemala City, Guatemala
| | | | | | - Francisco Alonzo
- Instituto Guatemalteco de Seguridad Social, Ortopedia y Traumatología, Guatemala City, Guatemala
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Ojukwu DI, Beutler T, Goulart CR, Galgano M. Bullet retrieval from the cauda equina after penetrating spinal injury: A case report and review of the literature. Surg Neurol Int 2021; 12:163. [PMID: 33948333 PMCID: PMC8088496 DOI: 10.25259/sni_238_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 03/24/2021] [Indexed: 11/16/2022] Open
Abstract
Background: When gunshot injuries occur to the spine, bullet fragments may be retained within the spinal canal. Indications for bullet removal include incomplete spinal cord injury, progressive loss of neurologic function including injury to the cauda equina, and dural leaks with impending risk of meningitis. Case Description: Here, we present a 34-year-old male with a missile penetrating spinal injury to the cauda equina. In addition to the computed tomography scan demonstrating retention of a bullet in the left L1/2 disc space, the scan suggested likely dural injury. The patient underwent a decompression/instrumented fusion with retrieval of the retained bullet fragment. A laminectomy was performed from T12 to L3, and at L1 and L2, a large traumatic durotomy was identified and repaired. The patient, unfortunately, continued to have bilateral lower extremity plegia with neurogenic bladder/bowel dysfunction at 1-year follow-up. Conclusion: We discuss the operative management and provide an intraoperative video showing the bullet extraction and dural closure.
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Affiliation(s)
- Disep I Ojukwu
- St. George's University, School of Medicine, Great River, New York, United States
| | - Timothy Beutler
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, New York, United States
| | - Carlos R Goulart
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, New York, United States
| | - Michael Galgano
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, New York, United States
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Fiani B, Figueras RA, Stefano FD, Gautam N, Khan A, Soula M. Nonmissile penetrating spinal injuries: Mechanisms, expectations, and management. Surg Neurol Int 2020; 11:406. [PMID: 33365169 PMCID: PMC7749954 DOI: 10.25259/sni_596_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/02/2020] [Indexed: 11/22/2022] Open
Abstract
Background: Nonmissile penetrating spinal injury (NMPSI) is an uncommon form of traumatic injury to the spine. Here, we present a comprehensive and contemporary literature review that provides insight into NMPSI-type injuries, their mechanisms, clinical practice, management, and expectations. Methods: An extensive review of the published literature was conducted in PubMed, OVID Medline, and EMBASE journals for studies of nonmissile penetrating spine injuries. Terms for search included NMPSI and nonmissile penetrating spinal cord injury. No date restrictions were used. Results: The search yielded only 17 related articles. Cross-checking of articles was conducted to exclude duplicate articles. The 17 articles were screened for their full text and English language availability. We finalized those articles pertaining to the topic. Conclusion: The mechanism of injury in NMPSI occurs in two different stages. Immediate injury is caused by direct damage to the neurological structures. The delayed injury response is caused by damage to the spinal vasculature and activated immune response pathways. Computed tomography (CT) angiograms or formal diagnostic angiograms are indicated to identify vascular injury or development of pseudoaneurysm and can be performed both preoperatively and postoperatively. Surgically, decompressive procedures include laminectomies and hemilaminectomies. Dural exploration may be indicated if a cerebrospinal fluid leak with fistula develops from dural puncture. Further research and technologies are being developed to provide patients who have suffered NMPSI with more resources for a better quality of life.
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Affiliation(s)
- Brian Fiani
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, California, United States
| | - Ryan Arthur Figueras
- School of Medicine, University of California Riverside, Riverside, California, United States
| | - Frank De Stefano
- College of Osteopathic Medicine, Kansas City University of Medicine and Biosciences, Kansas City, Missouri, United States
| | - Neha Gautam
- Department of Medical Research, University of California Davis, Davis, California, United States
| | - Asif Khan
- Department of Podiatry, Beaumont Hospital, Farmington Hills, Michigan, United States
| | - Marisol Soula
- Grossman School of Medicine, New York University, New York, United States
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Mercure-Cyr R, Fourney DR. Back "pane" secondary to glass coffee table mishap: case illustration. J Neurosurg Spine 2020; 32:613-614. [PMID: 31835255 DOI: 10.3171/2019.10.spine191208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/14/2019] [Indexed: 11/06/2022]
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Dilip Chand Raja S, Rishi Mugesh K, Ajoy Prasad S, Rajasekaran S. Delayed presentation of Candidal Vertebral Osteomyelitis following penetrating spinal injury. J Clin Orthop Trauma 2019; 10:S211-S214. [PMID: 31695284 PMCID: PMC6823754 DOI: 10.1016/j.jcot.2019.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 02/16/2019] [Accepted: 02/18/2019] [Indexed: 11/29/2022] Open
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Scott KW, Trumbull DA, Clifton W, Rahmathulla G. Does Surgical Intervention Help with Neurological Recovery in a Lumbar Spinal Gun Shot Wound? A Case Report and Literature Review. Cureus 2019; 11:e4978. [PMID: 31467812 PMCID: PMC6706263 DOI: 10.7759/cureus.4978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The third leading cause of spinal injuries are gunshot wounds to the spine, accounting for 15.2% of all spinal cord injuries. Treatment for gunshot wound spinal cord injuries (GSWSCI) remains variable, with indications for surgery being controversial. There is no clear evidence or guidelines that can help spine surgeons decide and direct surgical intervention. With the paucity of available literature, we report an interesting case of a gunshot injury to the lumbar spine at L1-L2, discuss the presentation and outcome, and evaluate relevant literature. A 27-year-old incarcerated male patient presented with a conus cauda equina asymmetrical injury involving the lower extremities and required initial medical stabilization in the intensive care unit (ICU). He subsequently underwent delayed surgical treatment with decompression and fragment resection at L1-L2. The patient improved neurologically to the American Spinal Injury Association (ASIA) Classification D and eventually regained nearly all lower extremity neurological function. Despite considerable evidence favoring the conservative management of GSWSCI and the absence of guidelines or recommendations on surgical interventions, our case report demonstrates that surgical intervention in appropriately selected patients can yield good recovery of neurological function and improvement in the quality of life. The key remains careful patient selection, the appropriate location of the retained fragment, and the extent of neurological injury that occurred. We feel surgical decompression and fragment removal, along with debridement, can result in good neurological recovery and long-term outcomes.
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Affiliation(s)
- Kyle W Scott
- Neurosurgery, University of Florida College of Medicine, Gainesville, USA
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Kelly ML, Roach MJ, Nemunaitis G, Chen Y. Surgical and Nonsurgical Treatment of Penetrating Spinal Cord Injury: Analysis of Long-term Neurological and Functional Outcomes. Top Spinal Cord Inj Rehabil 2019; 25:186-193. [PMID: 31068749 PMCID: PMC6496967 DOI: 10.1310/sci2502-186] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Objective: To describe long-term neurological and functional outcomes for patients with penetrating spinal cord injury (PSCI) following surgical (SX) and nonsurgical (NSX) treatment. Methods: We identified all patients with PSCI in the Spinal Cord Injury Model Systems database from 1994-2015. Patients with PSCI were divided into surgical (SX) and nonsurgical (NSX) groups. Outcomes were measured using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) and the Functional Independence Measure (FIM) motor scores. Outcomes were then analyzed separately for patients with complete and incomplete PSCI during acute hospitalization, SCI rehabilitation, and 1-year follow-up. Results: For patients with complete PSCI, acute hospital length of stay (LOS) was increased in the SX group (19 days vs 14 days; p < .0001) while median FIM motor scores were similar at 1-year follow-up (74 vs 75; p = .4). The percentage of patients with complete PSCI remained similar between groups at discharge from SCI rehabilitation (88% vs 88%; p = 0.5). For patients with incomplete PSCIs, acute hospital LOS was similar between groups (13 vs 11; p = .3) and no difference was observed in ASIA Impairment Scale improvement at discharge from rehabilitation (38% vs 37%; p = .9) or in FIM scores at 1 year (84 vs 85; p = .6). Conclusion: Surgery for patients with complete PSCI is associated with increased acute hospital LOS for complete PSCI and is not associated with improvement in neurological or functional outcomes in patients with either complete or incomplete PSCI.
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Affiliation(s)
- Michael Liam Kelly
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio
| | - Mary Joan Roach
- Center for Healthcare Research and Policy, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio
| | - Gregory Nemunaitis
- Department of Physical Medicine and Rehabilitation, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio
| | - Yuying Chen
- Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Birmingham, Alabama
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Escamilla JAC, Ross JÁG, Atanasio JMP, Martínez GC, Cisneros AG, Avila JJ. Spinal Gunshot Wounds: Pattern and Associated Lesions in Civilians. Asian Spine J 2018; 12:648-655. [PMID: 30060372 PMCID: PMC6068414 DOI: 10.31616/asj.2018.12.4.648] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 12/05/2017] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN Retrospective, descriptive case series study. PURPOSE To investigate the frequency, bone pattern, and associated lesions to the spine of gunshot wounds. OVERVIEW OF LITERATURE Gunshot wounds are penetrating in nature and are caused by a bullet or projectile. These are becoming more common and are associated with significant sequelae, requiring long and costly multidisciplinary treatment. Associated spinal cord injuries (SCIs) in the civilian population represent 13%-17% of all spinal traumas. Spinal gunshot wounds are commonly thought to be stable; however, there is potential acute and chronic spinal instability if the bullet passes transversely, fracturing either both pedicles or both facet joints. METHODS We obtained data from the clinical files of patients with spinal gunshot wounds treated by spine surgeons. We performed a statistical analysis to obtain the pattern and frequency of the injuries. RESULTS We included 54 patients (48 men [89%] and six women [11%]). Eight patterns of spinal gunshot wounds were identified; 61% (33 patients) had complete SCI. The thoracic spine was most frequently affected, with 88% of patients having SCI; 75%, hemopneumothorax; 28%, pulmonary lesions; and 16%, hepatic lesions. The presence of pedicle fractures had an odds ratio of 3.64 for SCI. CONCLUSIONS The two main bone patterns are the vertebral body and posterior arch with pedicle fractures as modifiers, given that they are at a high risk for SCI. The spinal pattern and associated lesions were related to the bullet's path, with the vertebral body having the highest frequency of associated lesions. Vertebral body burst fracture was the main indication for instrumentation.
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Affiliation(s)
- Jorge Arturo Cabrera Escamilla
- Instituto Mexicano del Seguro Social, Unidad Médica de Alta Especialidad "Dr. Victorio de la Fuente Narváez", Mexico City, Mexico
| | - Jorge Álvaro González Ross
- Instituto Mexicano del Seguro Social, Unidad Médica de Alta Especialidad "Dr. Victorio de la Fuente Narváez", Mexico City, Mexico
| | - José Manuel Pérez Atanasio
- Instituto Mexicano del Seguro Social, Unidad Médica de Alta Especialidad "Dr. Victorio de la Fuente Narváez", Mexico City, Mexico
| | - Gustavo Casas Martínez
- Instituto Mexicano del Seguro Social, Unidad Médica de Alta Especialidad "Dr. Victorio de la Fuente Narváez", Mexico City, Mexico
| | - Arelhi González Cisneros
- Instituto Mexicano del Seguro Social, Unidad Médica de Alta Especialidad "Dr. Victorio de la Fuente Narváez", Mexico City, Mexico
| | - Jose Jimenez Avila
- Instituto Mexicano del Seguro Social, Unidad Médica de Alta Especialidad "Dr. Victorio de la Fuente Narváez", Mexico City, Mexico
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Todnem N, Hardigan T, Banerjee C, Alleyne CH. Cephalad Migration of Intradural Bullet from Thoracic Spine to Cervical Spine. World Neurosurg 2018; 119:6-9. [PMID: 30036715 DOI: 10.1016/j.wneu.2018.06.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 06/21/2018] [Accepted: 06/22/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND There are few reported instances of intraspinal migration of a bullet fragment. The majority of these migrations occur caudally, typically below the level of T10. Even fewer cases demonstrate cephalad migration from the sacral spine to the lumbar spine. We report here for the first time a case of a cephalad migration intradurally from the thoracic spine to cervical spine. CASE DESCRIPTION A 31-year old man presented to the emergency department with a suspected spinal cord injury following a GSW sustained to the left shoulder. A penetrating gunshot injury to the thoracic spine at the level of T2 was observed, and CT angiography revealed a cephalad migration of the bullet fragment to the level of C6. The patient had marked weakness of the bilateral upper extremities, with paraplegia of the lower extremities. There was a sensory deficit beginning at a level 1 cm below the clavicle, as well as a decrease in rectal tone. We performed a laminectomy at C6 with dural incision and removal of the main bullet fragment. Following the surgery, significant improvement in strength and sensation in the bilateral upper extremities was noted, but paraplegia and sensory loss below the level of T2 persisted. CONCLUSIONS In this report, we review the previously reported cases in which intraspinal migration of bullets have occurred, and discuss the unique finding in this study of cephalad migration of a bullet within the dura. In addition, we detail considerations in the management of such injuries.
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Affiliation(s)
- Nathan Todnem
- Department of Neurosurgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Trevor Hardigan
- Department of Neurosurgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA.
| | - Chris Banerjee
- Department of Neurosurgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Cargill H Alleyne
- Department of Neurosurgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
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Retained Glass Fragment in the Cervical Spinal Canal in a Patient with Acute Transverse Myelitis: A Case Report and Literature Review. Case Rep Neurol Med 2018; 2018:5129513. [PMID: 30009065 PMCID: PMC6000836 DOI: 10.1155/2018/5129513] [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: 12/20/2017] [Revised: 04/16/2018] [Accepted: 05/03/2018] [Indexed: 12/03/2022] Open
Abstract
A 50-year-old male presented with a one-day history of right leg weakness, numbness, and urinary retention. Weakness was present for two weeks but worsened significantly during the last 24 hours. On the right there was sensory loss in the leg and below the Th8 dermatome. On the left there was sensory loss below the Th10 dermatome and distal loss of temperature sensation. Past medical history revealed a cervical trauma 30 years ago when a glass chip lodged into the left side of the neck. The patient did not seek medical attention after removing it himself. No neurological symptoms followed the incident. No cervical manipulation or other physical trauma occurred before current symptom onset. Magnetic resonance (MR) imaging showed features consistent with myelitis at the level of C4–Th3. At the level of C6–C7, a T1 and T2 hypointense lesion was noted. On computed tomography, this lesion was hyperdense and occupied the spinal canal and the left intervertebral foramen. It was deemed to be a glass fragment. Surgical removal was withheld because the fragment was clinically silent for 30 years, the risk of surgical removal would outweigh the benefits and the patient did not prefer surgical treatment. Acute demyelinating transverse myelitis was diagnosed and treated with methylprednisolone. 10 months later MR features of myelitis resolved and the patient's neurological condition improved. Our case shows that foreign bodies in the cervical spinal canal can remain asymptomatic for up to 30 years. In the case of a long asymptomatic retention period the need for surgical removal of a foreign body must be carefully evaluated, taking into account the probability that a foreign body is the cause of current symptoms, risk of a foreign body causing damage in the future, risk of damage to the spinal cord during removal, and probability of therapeutic success.
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Galloza J, Valentin J, Ramos E. Central cord syndrome from blast injury after gunshot wound to the spine: a case report and a review of the literature. Spinal Cord Ser Cases 2017; 3:17003. [PMID: 28382215 DOI: 10.1038/scsandc.2017.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 09/27/2016] [Accepted: 01/03/2017] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Central Cord Syndrome (CCS) is the most common of the spinal cord injury syndromes. Few cases have been presented with gunshot wound (GSW) as a cause of a central cord syndrome, and none, to our knowledge, has been presented without any evidence of central canal bullet/bone fragments. CASE PRESENTATION A 27-year-old male suffered two close-range gunshot wounds, one to the left neck and one to the left shoulder. CT scan showed C5 spinous process fracture and paraspinal muscle hemorrhage without evidence of central canal stenosis or bullet/bone fragments. Physical examination showed severe weakness and dysesthesias in bilateral upper extremities and mild weakness in bilateral lower extremities. Diagnosis of central cord syndrome was made. He was treated conservatively and started inpatient rehabilitation. Four months post injury, the patient had almost full recovery with only left proximal arm and bilateral distal hand weakness. DISCUSSION Only four cases of CCS caused by GSW have been reported in the literature. Some suggested algorithms exist regarding the management of these patients, but still cases should be individualized depending on the specific nature of their presentation. The prognosis for patients with CCS tends to be favorable in regaining sensory, bladder, bowel, gross motor function and ambulation, but fine motor skills may remain impaired.
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Affiliation(s)
- Juan Galloza
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston-McGovern Medical School, Houston, TX, USA
| | - Juan Valentin
- Department of Physical Medicine, Rehabilitation and Sports Health, University of Puerto Rico-School of Medicine, Rico, PR, USA
| | - Edwardo Ramos
- Department of Physical Medicine, Rehabilitation and Sports Health, University of Puerto Rico-School of Medicine, Rico, PR, USA
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Jakoi A, Iorio J, Howell R, Zampini JM. Gunshot injuries of the spine. Spine J 2015; 15:2077-85. [PMID: 26070284 DOI: 10.1016/j.spinee.2015.06.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 05/11/2015] [Accepted: 06/01/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal gunshot injuries (spinal GSIs) are a major cause of morbidity and mortality in both military and civilian populations. These injuries are likely to be encountered by spine care professionals in many treatment settings. A paucity of resources is available to summarize current knowledge of spinal GSI evaluation and management. PURPOSE The aim was to summarize the ballistics, epidemiology, evaluation, treatment, and outcomes of spinal GSI among civilian and military populations. STUDY DESIGN This was a review of the current literature reporting spinal GSI management. METHODS MEDLINE (PubMed) was queried for recent studies and case reports of spinal GSI evaluation and management. RESULTS Spinal GSI now comprise the third most common cause of spinal injury. Firearms that produce spinal GSI can be divided into categories of high- and low-energy depending on the initial velocity of the projectile. Neural and mechanical spinal damage varies with these types and results from several factors including direct impact, concussion waves, tissue cavitation, and thermal energy. Management of spinal GSI also depends on several factors including neurologic function and change over time, spinal stability, missile tract through the body, and concomitant injury. Surgical treatment is typically indicated for progressive neurologic changes, spinal instability, persistent cerebrospinal fluid leak, and infection. Surgical treatment for GSI affecting T12 and caudal often has a better outcome than for those cranial to T12. Surgical exploration and removal of missile fragments in the spinal canal are typically indicated for incomplete or worsening neurologic injury. CONCLUSIONS Treatment of spinal GSI requires a multidisciplinary approach with the goal of maintaining or restoring spinal stability and neurologic function and minimizing complications. Concomitant injuries and complications after spinal GSI can present immediate and ongoing challenges to the medical, surgical and rehabilitative care of the patient.
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Affiliation(s)
- Andre Jakoi
- Department of Orthopaedic Surgery, Drexel University College of Medicine, 245 N 15th St, MS 420, Philadelphia, PA 19102, USA
| | - Justin Iorio
- Department of Orthopaedic Surgery, Temple University, 3401 N Broad Street, Philadelphia, PA 19140, USA
| | - Richard Howell
- Department of Orthopaedic Surgery, Drexel University College of Medicine, 245 N 15th St, MS 420, Philadelphia, PA 19102, USA
| | - Jay M Zampini
- Department of Orthopaedic Surgery, Harvard Medical School, Division of Spine Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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Gunshot injuries in the spine. Spinal Cord 2014; 52:504-10. [DOI: 10.1038/sc.2014.56] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 03/05/2014] [Accepted: 03/18/2014] [Indexed: 12/13/2022]
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Pediatric arrowshot injury to cervical spinal cord-sagittal cord transection with no neurological deficit and good outcome: case report and review of literature. Childs Nerv Syst 2013; 29:1933-9. [PMID: 23579483 PMCID: PMC3771431 DOI: 10.1007/s00381-013-2095-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 03/22/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Penetrating spinal cord injuries (PSCI) in cervical region are extremely rare in children. They mostly occur in a mechanism of a gunshot or a stab injury with the use of sharp objects. Gunshot injuries are usually fatal or end up with tetraplegia. Stab wounds may be less severe and result in partial neurological syndrome. In the management of PSCI in children, reliable diagnostics and history of the patient are the most valuable for further decisions, which include early or delayed exploration either nonsurgical treatment. There exist no clear algorithm for antibiotic use in pediatric population--it depends on the site of an injury, presence of pathological secretion from the wound, and nature of the trauma. The use of steroids is controversial. The most common complications related to surgery include infections, edema, and hemorrhage. They may also be associated with the migration of small residual microtraumatizing agent. The literature lacks algorithms for management in children. DISCUSSION In this paper, an unusual case of almost total sagittal cervical cord transection is reported. The patient had no neurological symptoms and recovered with no complications. Diagnostic imaging on admission included X-ray and computed tomography. The patient underwent early surgical intervention with removal of foreign body from the cord and subsequent dural suturing. In the paper, the role of detailed history taking, adequate imaging, and drugs administration is discussed. The choice of distinct strategies is analyzed, and a revised literature review is presented in order to unify the management algorithm for pediatric PSCI.
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