Penetrating spinal injuries and their management

Abstract

Penetrating spinal trauma due to missile/gunshot injuries has been well reported in the literature and has remained the domain of military warfare more often. Civic society's recent upsurge in gunshot injuries has created a dilemma for the treating neurosurgeon in many ways as their management has always involved certain debatable and controversial issues. Both conservative and surgical management of penetrating spinal injuries (PSI) have been practiced widely. The chief neurosurgical concern in these types of firearm injuries is the degree of damage sustained during the bullet traversing through the neural tissue and the after-effects of the same in long term. We had an interesting case of a penetrating bullet injury to cervical spine at C2 vertebral level. He was operated and the bullets were removed from posterior midline approach. Usually, the management of such cases differs from region to region depending on the preference of the surgeon but still certain common principles are followed world over. Thus, we realized the need to review the literature regarding spinal injuries with special emphasis on PSI and to study the recent guidelines for their treatment in light of our case.

Pediatric arrowshot injury to cervical spinal cord-sagittal cord transection with no neurological deficit and good outcome: case report and review of literature

“…Remaining cases usually undergo conservative treatment with the use of antibiotics of large spectrum [31]. Early operative treatment of missile PSCI is debatable until migrating bullet provokes progression of neurological deficit.…”

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

“…A trend was noted toward surgical management of lumbar or cauda equina injuries and nonsurgical/ observation of complete injuries. 7,14,17,18 CONCLUSION CCS is a common presentation in patients with spinal cord injury, although not commonly seen in patients who suffered GSW to the spine. Some suggested algorithms exist regarding the management of these patients, but still cases should be individualized depending on the specific nature of their presentation.…”

Gunshot injuries in the spine

“…10,11,17,65 The only absolute indication for surgery in spinal GSW is the presence of cutaneous or pleural liquor fistula or the presence of documented progression of the neurological deficit associated with compression of neural elements in imaging examinations. 5 Laminectomy should be considered in patients with partial neurological deficit, especially those with cauda equina, with imaging showing involvement of the spinal canal by bone or metal fragments. The surgery should be performed in the first 24-48 h, provided that the potentially fatal injuries have been treated and the patient is clinically stable.…”

“…The recent literature supports decompression and removal of the projectile in cases of incomplete or progressive deficit. 5 Another indication for surgery is spinal instability caused by associated fractures, observed in 10% of the cases. 70 In contrast to blunt trauma, which has well-established criteria for instability, in penetrating trauma to the spine, any degree of curvature may represent an abnormal or translational instability.…”

“…Because of the increasing violence in urban areas, gunshot wounds (GSWs) are an important cause of morbidity and mortality in the population, especially among young people (Table 1). [1][2][3][4] The incidence of penetrating injuries to the spine has increased lately, 5 and they cause 13-17% of all spine injuries. [6][7][8][9][10][11] The incidence of spinal cord lesions caused by gunshots varies considerably, depending on the country, ranging from 13 to 44%.…”