Gunshot wounds to the spine. (NM) - Department of Neurosurgery

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C.M. Bono and R.F. Heary / The Spine Journal 4 (2004) 230–240 235characterized. If, after appropriate measures, cervical stabilityremains in question, surgical stabilization may be consideredto prevent untoward neurologic injury, particularlyif an intracanal bullet or bone fragment is in close proximity tothe spinal cord or nerve roots.In contrast to blunt traumatic injuries, which have moredefined radiographic criteria for instability, any degree ofabnormal angulation or translation may represent instabilityafter gunshot wounds to the cervical spine. In cases of instability,the affected segments can be stabilized with a varietyof instrumentation and fusion constructs. In the patient withneurologic deficit, spinal stability is deduced from imagingfindings. Severe comminution of both anterior and posteriorelements with evidence of segmental deformity is indicativeof instability.The majority of cases of instability after gunshot woundshave been associated with overly aggressive decompression[34]. Fortunately, there are few indications for decompressionin a neurologically intact patient. New onset orprogressive neurological deficit associated with an intramedullarybullet, bone fragment or expanding epidural hematomais an indication for urgent decompression. Importantly,neurologic progression is most accurately detected by meansof serial examinations performed by a single experiencedobserver and documented in the chart so that follow-upexaminations can be compared with baseline. Less frequentlycited indications are for the treatment of lead intoxicationfrom the bullet or contact of a copper jacketed missilewith the neural elements [11,31,35]. Routine removal ofthe bullet is not warranted for transcolonic injury and isassociated with a high rate of complications.Gunshot injury: neurologic deficitSpinal cord injuries are devastating to the patient, familyand society. In a study by Roye et al. [2] in 1988, the averageinitial admission hospital costs for survivors of cervicallevel injury can be greater than $50,000. High-level completeinjuries frequently leave patients ventilator dependent,requiring highly specialized units for prolonged care. Gunshotwounds more frequently result in complete injuriescompared with blunt trauma, which may be paraplegic orquadriplegic depending on the level. Approximately 59%of penetrating cervical spine injuries result in completespinal cord injury, compared with 49% for blunt trauma [36].In contrast to the predominance of cervical level injuriesafter blunt trauma, the majority of spinal cord injuries aftergunshot wounds occur at the thoracic level [36]. Incompleteinjuries can present in a variety of manners, includingBrown-Sequard, central cord, anterior cord or in rare casescruciate hemiplegic syndromes [37].Decompression/bullet removalThe first rule of medicine is primum non nocere, or “donor harm.” This must be kept in mind in managementof neurologic deficit after gunshot wounds to the spine (Fig.3). It is our tendency as surgeons to be compelled to removebullets and decompress the spinal canal. However, the clinicalbenefit of these actions is inconsistent and is not withoutcomplications.In both complete and incomplete spinal cord injuries, therole of decompression has been studied. Stauffer et al. [34]reviewed 185 cases of gunshot paralysis, half of which weretreated with laminectomy and half with observation only.The authors documented no appreciable return of neurologicalfunction after both surgery and nonoperative managementfor complete lesions. With incomplete injuries, 71%of decompressed spines and 77% of nonsurgically treatedspines demonstrated neural improvement. Incomplete lesionsto the lumbar spine and thoracolumbar junction hadbetter neurologic recovery than more cranial levels regardlessif surgery was performed. Although antibiotic regimenwas not documented, four wound infections and sixspinal fistulae were reported in the operative group as wellas six cases of late spinal instability. There were no casesof infection, cerebrospinal fluid fistula or spinal instabilityin the nonsurgically treated patients. Both groups had ahigh incidence of causalgia (19% and 15% for operative andnonoperative groups, respectively). In support of a nonoperativeapproach, Robertson and Simpson [38] reported no neurologicimprovements with lumbar laminectomy versusnonsurgical treatment in 30 patients with gunshot wounds tothe cauda equina region. A high rate of postoperative complicationswas reported. In no case did the authors report anintracanal bullet.In a more recent prospective study of lesions associatedwith intracanal bullets, Waters and Adkins [39] demonstratedstatistically significant motor improvement after surgicaldecompression from the T12 to L4 levels comparedwith nonoperatively treated spines (Fig. 4). At more cranialsites in the thoracic and cervical regions, surgical removal anddecompression had no significant effect on neurologic outcome.No case of infection was reported in either group.Surgical decompression is indicated for progressive neurologicdeficits associated with compressive intracanalblood, bullet or bone fragments. In these situations, thesurgeon is lead to conclude that neural damage is activelyadvancing secondary to spinal cord compression and immediateoperation is indicated. Intracanal bullets in the lumbarspine should also be removed to improve the rate of motor recoveryin cauda equina level injuries. The role of decompressionand bullet removal in the cervical and thoracic levelsremains unclear, with the complications of surgery a forebodingdetractor. Because of the possible potential benefits ofdecompression, the authors sometimes elect to removecervical-level intracanal fragments, especially in incompletespinal cord injuries. In the current authors’ opinion,the possibility of even one or two levels of recovery justifiesthe risk of cerebrospinal leak, fistula or infection in thecervical region. This, however, would be difficult to justify inthe thoracic spine, where little functional return is sacrificed.
236C.M. Bono and R.F. Heary / The Spine Journal 4 (2004) 230–240Fig. 3. Management of neurologic deficit after gunshot wounds to the spine.SteroidsThe use of corticosteroids in spinal-cord-injured patientsafter gunshot wounds has recently been examined [40,41].Levy et al. [41] retrospectively studied 252 cases of bothcomplete and incomplete gunshot spinal cord injuries. Administrationof methylprednisolone according to NationalAcute Spinal Cord Injury Study (NASCIS-II) protocol didnot significantly affect neurological prognosis. Similarly,Heary et al. [40] demonstrated that administration of eithermethylprednisolone or dexamethasone regimens did not significantlyimprove the neurologic recovery of patients witheither complete or incomplete injuries compared with thosereceiving no steroids. Interestingly, the incidence of pancreatitiswas statistically greatest in patients who receivedmethylprednisolone, while gastrointestinal complicationswere highest in those who received dexamethasone. Althoughthese data were not randomized prospective analyses,they offer compelling evidence that emergent corticosteroidinfusion has no role in the treatment of spinal cord injuryafter gunshot wound. In a recent editorial of the literature,Fehlings [42] reinforced recommendations that steroidsshould not be administered after penetrating spinal cordinjuries.Surgical timingTiming of decompressive surgery may be an importantconsideration. Although there is some support for earlydecompression to improve neurologic outcome after blunttrauma, it has not been similarly supported for gunshotwounds. In a retrospective review of 88 patients, Cybulskiet al. [43] found equivalent rates of neurologic recovery inpatients undergoing decompressive laminectomy for conusor cauda equina level lesions within 72 hours (47.5% improved)versus those operated more than 72 hours after injury(48.1% improved). Similar studies of thoracic or cervicalinjuries have not been performed.Although early surgery does not appear to improve neurologicrecovery rates, surgical timing does appear to affectthe incidence of other complications. Higher rates of infectionand arachnoiditis have been documented when surgerywas performed more than 2 weeks from injury [43]. Incontrast, it has been suggested that cerebrospinal-cutaneousfistulae may be more common after early or immediate laminectomy[14,34].For these reasons, some surgeons recommend delayingbullet removal, if warranted, until 5 to 10 days after injury[14]. However, it should be highlighted that others think
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