Concept of gunshot wound spine

Multi-institutional review of characteristics and management of gunshot wounds to the spine

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.

Timing of surgical intervention after firearm-related spinal cord injury

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.

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.

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.

An incidental migrating intra-spinal bullet: the silent victim of celebratory gunfire

BACKGROUND

Incidentally found intra-spinal bullets are extremely rare, and have never been reported in the literature. The aim of this study is to report a rare case of an asymptomatic migrating intra-spinal bullet, emphasizing the role of cultural context in history taking, and describing its surgical retrieval technique.

CASE PRESENTATION

We discuss a case of a 10-years old boy with an incidentally discovered intra-spinal bullet opposite to the L5 vertebral level, who presented 3 months after the suspected initial insult. Following its migration to the L3/L4 level intraoperatively, the bullet was forced to spontaneously return to its preoperative position by reverse Trendelenburg Position, Valsalva maneuver and Intrathecal saline infusion, thus avoiding extending the previously performed laminectomy.

CONCLUSION

The authors remind the readers that history is the cornerstone of the clinical practice, even in the most obscure cases. Many convoluted intra-operative situations could be resolved by utilizing basic anatomical and physiological principles.

Retained lumbar intradural bullet fragment with neurological recovery after delayed removal of bullet: Case report and literature review

Civilian gunshot wound (GSW) to the spine is expected to increase in our environment due to the recent surge in violence and firearm attacks in the society either by herdsmen, bandits, unknown gunmen, or from exchange of gun fire with security personnel in response to insecurity issues. The management of GSW in the spine remains controversial, with no clear recommendations for surgical intervention by spine surgeons. In light of this, we report a case of civilian GSW to the lumbar spine in a 47-year-old female with resultant immediate paraplegia. Neuroradiological studies revealed a large bullet lodged in the left L2/3 spinal canal. There was a 4-week wait for consent for surgery to be obtained, with no improvement in motor function during the period. She underwent laminectomy and duratomy with removal of the bullet. Motor function returned 3 weeks after the surgery, and she was discharged home 8 weeks after the surgery, actively mobilizing on a Zimmer frame. The case report demonstrates the beneficial role of surgical intervention in properly selected patients, with resultant satisfactory functional neurological recovery.

Gunshot Wound to the Spine With Delayed Radiculopathy: A Case Report

Gunshot wounds (GSWs) to any part of the body can leave a trail of insidious complications. When the spinal cord is the injured organ, these sequelae can be debilitating to the patient and often exhaust all known therapeutic approaches available to the providers. The management of pain associated with GSWs to the spine is often a clinical challenge and there is often a question as to whether or not surgical intervention can help with pain relief in these cases. Here, we present a 45-year-old woman who experienced delayed radicular pain following a GSW to the spine with a retained bullet at the level of the lumbosacral canal. After an unsuccessful comprehensive multimodal analgesia, the patient underwent surgical removal of the bullet, which did not successfully provide a substantial lasting analgesic effect. This case demonstrates the potential for surgical failure and supports the general recommendation of more conservative management in this population.

Successful Removal of a Bullet from the Spinal Canal of a GSW Victim in the Level of L5: Case Report

INTRODUCTION AND IMPORTANCE

Gunshot wounds (GSWs), for increasing violence in urban areas globally and especially among the young population, have been significant causes of morbidity and mortality. These are the most common cause of spinal cord injuries, followed by traffic accidents. The priority of the therapeutic team is to save the victim and then minimise the permanent neural deficits. The indications for lumbosacral decompressive spinal surgery have remained challenging.

CASE PRESENTATION

A 25-year-old man victim of a gunshot in his left flank presented to the emergency department in hemodynamic shock and lethargy status. Resuscitating with fluids, he underwent damage control surgery (DCS). Sources of 2.5 l of intra-abdominal blood were detected of multiple intestinal and mesentery perforations beside the left ureter complete cut. The left psoas muscle was through and through perforated, too, and the bullet was stuck between the vertebrae. On the fifth day after DCS, the bullet surgical removal of the bullet was done in which L2-S1 laminectomy approaching the crushed Conus terminalis was completed. After the operation, his left foot drop and walking ability were improved.

CLINICAL DISCUSSION

Surgical treatment for gunshot wounds in the spinal column is controversial, but the emphasis is on providing advanced trauma life support. Definite treatment of such lesions mainly focuses on maintaining spinal stability, decreasing neurologic deficits as much as possible, and preventing complications.

CONCLUSION

A patient indicates neurological surgery who is young with incomplete or progressive neurology deficits, unstable spine, or complete injury with persistent neural compression.

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.

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

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

A through-and-through abdominal gunshot wound without intra-abdominal damage: A case report

Abdominal gunshot trauma is the third leading cause of death and is responsible for more than 90% of deaths among people ages 15 to 24 years old. It can cause multi-system organ damage, shock, and infection. We present a case of a through-and-through abdominal bullet wound where laparotomy exploration has found nothing as damage inside the abdomen.

Thoracolumbar Spine Trauma

Thoracolumbar spine trauma can result in potentially life-threatening consequences and requires careful management to ensure good outcomes. The purpose of this chapter is to discuss the anatomy, diagnostic tools, non-operative, and operative treatments important when addressing thoracolumbar trauma.

MANAGEMENT OF SPINAL GUNSHOT WOUND INJURIES

ABSTRACT Objectives Elaborate a care protocol for spinal gunshot wounds (GSWs), based on the experience of more than fifteen years of treating this type of injury. Methods A retrospective cross-sectional analysis of the electronic medical record data of a tertiary hospital related to the treatment of spinal GSWs between January 2002 and January 2018. Results The management proposed was applied to 700 patients. Epidemiological data collected describes the population served. Conclusions An easy-to-use treatment flowchart was developed that, according to factors related to the neurological condition, projectile location, lesion stability and additional criteria, allows the objective determination of the best treatment option for each case. Level of evidence II; Retrospective Study.

Gunshot injury to spine: An institutional experience of management and complications from a developing country

PURPOSE

Gunshot wounds are the second leading cause of spinal cord injuries. Surgical intervention for gunshot injury to the spine carries a high rate of complications. There is a scarcity of data on civilian gunshot injuries to the spine in Pakistan. Approximately 60 cases over the last 10 years have been recoded, with unusual presentation and neurological recovery. Thus it is imperative to fill this gap in data, by reviewing cases of civilian gunshot injuries to spine presenting at a tertiary care hospital (Aga Khan University Hospital, Karachi).

METHODS

This is a retrospective cohort study. Patients of all ages who presented to the emergency department of Aga Khan University Hospital, with gunshot injuries to spine between January 2005 and December 2016 were included in the study. Data were collected on neurological status (American Spinal Injury Association score was used for the initial and follow-up neurological assessment), extent of cord transection, motor and sensory deficits. The patients were further grouped into those with cord transection, and those with fractures of the bony spine but an intact spinal cord. These patients were then followed and the outcomes were recorded.

RESULTS

A total of 40 patients were identified. The mean ± SD of patients age was (30.9 ± 9.5) years. Of the 40 patients with gunshot wounds, 31 had the medical imaging performed at the facility, and hence they were included in this categorization. The remaining 9 patients were excluded from this additional grouping. Thirteen patients were managed surgically and 27 patients underwent the conservative management. The mean ± SD of follow-up was (8.7 ± 7.2) months. In our study, the thoracic spine was the most commonly injured region in gunshot injuries. Of the 31 patients with medical imaging performed at our institute, 17 (54.8%) had cord transection, of whom 8 (47%) ultimately developed paraplegia.

CONCLUSION

The prognosis of gunshot injuries to the spine can be varied depending on whether the spinal cord is intact or transected. This will help healthcare providers to plan the further management of the patient and counsel them accordingly.

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.

The effect of surgically implanted metallic bullet fragments on the intervertebral disc using a canine model☆

PURPOSE

To characterize the gross, histologic, and systemic changes caused by implantation of metal fragments commonly used in commercial bullets into the intervertebral disc.

BACKGROUND CONTEXT

Long-term complications of retained bullet fragments in the spine have been documented in the literature; however, the impact of different metal projectiles on the intervertebral disc has not been described. This study was performed to assess the local effects of the metallic bullet fragments on the intervertebral disc and their systemic effects regarding metal ion concentrations in serum and solid organs.

STUDY DESIGN

Animal Model Study.

METHODS

Funding for this project was provided by the Cervical Spine Research Society in the amount of $10,000. Copper, lead, and aluminum alloys from commercially available bullets were surgically implanted into sequential intervertebral discs in the lumbar spine of six canines. Kirschner wire implantation and a sham operation were performed as controls. Radiographs were performed to confirm the location of the bullets. Animals were sacrificed at 4, 6, and 9 months postimplantation. Whole blood, plasma, cerebrospinal fluid, kidney tissue, and liver tissue samples were analyzed for copper and lead concentrations. Histologic and gross samples were examined at the time of sacrifice.

RESULTS

Significant tissue reactions were noted in the discs exposed to copper and lead. Copper resulted in significantly more severe disc degeneration than either the lead or aluminum alloy. In the short interval follow-up of this study, no statistically significant trend was observed in whole blood, plasma, cerebrospinal fluid, and tissue levels.

CONCLUSION

This study demonstrates that the canine intervertebral disc is differentially susceptible to metallic fragments depending on the composition. Trends were noted for increasing levels of lead and copper in liver tissue samples although statistical significance could not be reached due to short time interval and small sample size. The metallic composition of retained fragments can be a determining factor in deciding on surgical intervention.

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.

Spinal Gunshot Wounds: Pattern and Associated Lesions in Civilians

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.

Delayed diagnosis of traumatic gunshot wound Brown-Sequard-plus syndrome due to associated brachial plexopathy

Introduction

Brown-Séquard Syndrome (BSS) is one of the rarest incomplete spinal cord syndromes. The combination of injuries to peripheral nerves and the central nervous system result in an array of symptoms that can result in overlapping clinical presentations and delayed diagnosis. Early detection of spinal cord injury in patients with peripheral nerve injury has been observed to have a positive effect on outcomes.

Case presentation

This report discusses the case of a 29-year-old male patient with Brown-Sequard-Plus Syndrome (BSPS) and Brachial Plexopathy (BP) secondary to gunshot wound in the left inferior neck. The patient was found initially with left hemibody weakness. A chest CT Scan demonstrated a fracture of the left T2 transverse process. Imaging studies of the spinal cord were not performed in the acute setting. Evaluation in an outpatient setting 3 weeks later showed significant left upper extremity weakness with improvement of left lower extremity strength. Also present were loss of pain and temperature sensation on the right side below the T2 dermatome level. A cervico-thoracic MRI was requested and revealed a T2 level spinal cord contusion. Electrodiagnostic studies confirmed a lower trunk left BP.

Discussion

The patient was diagnosed with BSPS and associated left lower trunk BP. To our knowledge, this is the first reported case of a concomitant BSPS and BP secondary to a gunshot wound. Delayed diagnosis of BSPS may occur in a trauma setting underlying the importance of a detailed history and physical examination for favorable outcomes.

Central cord syndrome from blast injury after gunshot wound to the spine: a case report and a review of the literature

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.

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

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

3.

Enterococcus faecalis causing delayed spondylodiscitis in a case with retained intraspinal bullet

Delayed presentations have been reported following gunshot wounds (GSW) with retained intraspinal bullets due to migration of projectile or lead intoxication. We report on the rare occurrence of delayed pyogenic spondylodiscitis and neurological dysfunction following injury from low velocity GSW to the spine with a retained projectile. A 55-year-old male presented 4 months following GSW to the abdomen which resulted in colonic injury and L5 fracture. The patient was treated initially with ileo-transverse anastomosis, antibiotics, without retrieval of the bullet. He developed low back pain, claudication 4 months following GSW and investigations suggested a pyogenic spondylodiscitis at L5-S1. The patient was treated with surgical debridement of infective focus and stabilisation with definitive fusion being performed after an interval of 14 days. The biopsy of the lesion confirmed findings of spondylodiscitis and the culture isolated Enterococcus faecalis species. The patient was treated with antibiotics as per sensitivity and made an uneventful recovery over 4 weeks. The follow-up radiographs showed satisfactory healing at final follow up of 24 months. GSW with colonic perforation have higher incidence of infective complications however majority to these occur in the early postoperative period. This case report demonstrates the possibility of late onset presentation due to spinal infection occurring following colonic perforation with retained intraspinal bullet.

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 wound causing complete spinal cord injury without mechanical violation of spinal axis: Case report with review of literature

Penetrating spine injury (PSI) forms the third most common cause of spine injury, only next to road traffic accidents and fall. Gunshot wound (GSW) forms the major bulk of PSI. Due to easy availability of firearms and antisocial behavior, GSW which were predominant in military population is now increasingly seen in civilized society. Here, we present a detail case review of unique case of civilian GSW indirectly causing complete spinal cord injury due to shock wave generated by the bullet, along with its systematic management.

Current concepts in penetrating and blast injury to the central nervous system

Aim

To review the current management, prognostic factors and outcomes of penetrating and blast injuries to the central nervous system and highlight the differences between gunshot wound, blast injury and stabbing.

Methods

A review of the current literature was performed.

Results

Of patients with craniocerebral GSW, 66–90 % die before reaching hospital. Of those who are admitted to hospital, up to 51 % survive. The patient age, GCS, pupil size and reaction, ballistics and CT features are important factors in the decision to operate and in prognostication. Blast injury to the brain is a component of multisystem polytrauma and has become a common injury encountered in war zones and following urban terrorist events. GSW to the spine account for 13–17 % of all gunshot injuries.

Conclusions

Urgent resuscitation, correction of coagulopathy and early surgery with wide cranial decompression may improve the outcome in selected patients with severe craniocerebral GSW. More limited surgery is undertaken for focal brain injury due to GSW. A non-operative approach may be taken if the clinical status is very poor (GCS 3, fixed dilated pupils) or GCS 4–5 with adverse CT findings or where there is a high likelihood of death or poor outcome. Civilian spinal GSWs are usually stable neurologically and biomechanically and do not require exploration. The indications for exploration are as follows: (1) compressive lesions with partial spinal cord or cauda equina injury, (2) mechanical instability and (3) complications. The principles of management of blast injury to the head and spine are the same as for GSW. Multidisciplinary specialist management is required for these complex injuries.

Radiculopathy as Delayed Presentations of Retained Spinal Bullet

Bullet injuries to the spine may cause injury to the anatomical structures with or without neurologic deterioration. Most bullet injuries are acute, resulting from direct injury. However, in rare cases, delayed injury may occur, resulting in claudication. We report a case of intradural bullet at the L3-4 level with radiculopathy in a 30-year-old male. After surgical removal, radicular and claudicating pain were improved significantly, and motor power of the right leg also improved. We report the case of intradural bullet, which resulted in delayed radiculopathy.

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.

An update on civilian spinal gunshot wounds: treatment, neurological recovery, and complications

STUDY DESIGN

Retrospective analysis of inpatient and outpatient data from a single academic trauma center.

OBJECTIVE

To test the effectiveness of a conservative treatment algorithm for civilian spinal gunshot wounds (CSGSWs) by comprehensively evaluating neurological status and recovery, fracture type, concomitant injuries, indications for surgery, and complications.

SUMMARY OF BACKGROUND DATA

Few large studies exist to guide treatment of CSGSWs, and none have been published in nearly 20 years.

METHODS

A search of International Classification of Diseases, Ninth Revision (ICD-9) codes was performed for all hospital patients treated from 2003 to 2011 by either neurosurgery or orthopedic surgery to identify 159 consecutive patients who sustained CSGSWs. Mean follow-up was 13.6 months. American Spinal Injury Association grading was used to assess neurological injury.

RESULTS

Fifty percent of patients had neurological deficits from CSGSW. Complete spinal injury was the most common injury grade; thoracic injuries had the most risk of complete injury (P < 0.001). Nearly 80% of patients had concomitant injuries to other organs. Operative treatment was more likely in patients with severe neurological injuries (P = 0.008) but was not associated with improved neurological outcomes (P = 1.00). Nonoperative treatment did not lead to any cases of late spinal instability or neurological deterioration. Overall, 31% of patients had an improvement of at least 1 American Spinal Injury Association grade by final follow-up. Nearly half of patients experienced at least 1 GSW-related complication; risk of complications was associated with neurological injury grade (P < 0.001) and operative treatment (P = 0.04).

CONCLUSION

The vast majority of CSGSWs should be managed nonoperatively, regardless of neurological grade or number of spinal columns injured. Indications for surgery include spinal infection and persistent cerebrospinal fluid leaks.

LEVEL OF EVIDENCE

3.