Can surgery improve neurological function in penetrating spinal injury? A review of the military and civilian literature and treatment recommendations for military neurosurgeons

Abstract

Neurosurg Focus 28 (5):E4, 20101 P atients with PSIs present very complex, multidisciplinary management challenges for military surgeons. Not only can the patient have immediate and delayed life-threatening damage to organs along the path of the projectile, the spinal column and possibly the neurological structures contained within can also, by definition, suffer injury, the severity of which depends on multiple factors. Spinal cord injury from spinal GSWs is more often a complete lesion with a decreased potential for neurological recovery than with closed trauma. 43There are a number of potential surgical indications, the most controversial of which is whether decompressive laminectomy has any effect on neurological recovery. Medical civilian and military literature is replete with opinions for and against the use of surgery.Although missile characteristics such as size, composition and design are important, the major determinant of the destructive ability of a projectile is velocity at impact and thus the kinetic energy imparted to the surrounding tissue.10 Energy is calculated based on mass and velocity as follows: energy = 1/2mv 2 . Therefore, velocity has a significantly greater effect on energy than projectile mass. Object. Penetrating spinal injury (PSI), although an infrequent injury in the civilian population, is not an infrequent injury in military conflicts. Throughout military history, the role of surgery in the treatment of PSI has been controversial. The US is currently involved in 2 military campaigns, the hallmark of both being the widespread use of various explosive devices. The authors reviewed the evidence for or against the use of decompressive laminectomy to treat PSI to provide a triservice (US Army, Navy, and Air Force) consensus and treatment recommendations for military neurosurgeons and spine surgeons.Methods. A US National Library of Medicine PubMed database search that identified all literature dealing with acute management of PSI from military conflicts and civilian urban trauma centers in the post-Vietnam War period was undertaken.Results. Nineteen retrospective case series (11 military and 8 civilian) met the study criteria. Eleven military articles covered a 20-year time span that included 782 patients who suffered either gunshot or blast-related projectile wounds. Four papers included sufficient data that analyzed the effectiveness of surgery compared with nonoperative management, 6 papers concluded that surgery was of no benefit, 2 papers indicated that surgery did have a role, and 3 papers made no comment. Eight civilian articles covered a 9-year time span that included 653 patients with spinal gunshot wounds. Two articles lacked any comparative data because of treatment bias. Two papers concluded that decompressive laminectomy had a beneficial role, 1 paper favored the removal of intracanal bullets between T-12 and L-4, and 5 papers indicated that surgery was of no benefit.Conclusions. Based on the authors' military and civilian PubMed literature search, most of the evidence s...

An Update on Civilian Spinal Gunshot Wounds

“…[5][6][7] Most studies have failed to demonstrate a clear benefi t of decompression for neurological outcome, instead frequently fi nding increased complication rates with operative intervention. [8][9][10][11][12][13] However, a large longitudinal clinical series evaluating the effectiveness of this shift toward nonoperative treatment has not been published.…”

How bullet trajectory affects outcomes of civilian gunshot injury to the spine

“…Pressure or shock waves created by the bullet impacting on adjacent tissue and temporary cavitation may be responsible for this kind of injury in the battlefields. 7,8 Unlike military gunshot injuries, blast effect may have a limited role in neurological injury in civilian GSIS. 9 This is supported by our findings.…”

“…The routine use of a cervical collar could cause detrimental side effects, such as airway obstruction or masking life-threatening wounds on patients with penetrating injury to the neck. 6,7 In our series, the use of external bracing was influenced by individual surgeon preference. However, in retrospect, we found that the factors having a statistically significant association with physician's recommendation to brace were the same factors that were significant on the incidence of paralysis (that is, multiple vertebral levels of damage and presence of a fragment in the canal).…”

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.…”

“…14 Spinal instability can be present in any abnormal angulation or translation and in cases where the bullet traverses the pedicle or the facet. 7,14,17 Progressive neurological deficit, cerebrospinal fluid leak and evidence of lead toxicity are also complications in which surgical intervention is strongly recommended. Level of lesion (cervical, thoracic and lumbar), severity of injury, or the presence Figure 2.…”