Civilian Gunshot Injuries of the Spinal Cord: A Systematic Review of the Current Literature

Background

The principles that guide management of spinal cord injury (SCI) derive from injury resulting from blunt trauma, not gunshot wounds. Civilian gunshot-induced spinal cord injury (CGSWSCI) is a common, potentially serious cause of neurological deficit; there is disagreement about whether the same approaches used for SCI caused by blunt-force trauma should apply to gunshot-induced SCI.

Questions/purposes

We reviewed the literature to answer the following questions regarding presentation and outcome of gunshot wound-induced SCI: (1) Are there differences in recovery prognosis between complete SCI and other patterns of SCI in CGSWSCI. (2) Does the use of steroids improve neurological recovery? (3) Does surgery to remove the bullet affect neurological recovery in CGSWSCI? (4) Does surgery result in an increased risk of complications of treatment?

Methods

We performed a systematic literature review of articles related to civilian gunshot injuries to the spine. Information relating to incidence, pattern of neurological injury, associated injuries, treatment, neurological outcome, and associated complications was extracted. Three independent reviewers assessed the strength of evidence present in the literature by examining quality, quantity, and consistency of results.

Results

A total of 15 articles met the predetermined inclusion criteria. Complete SCIs are associated with the worst functional recovery regardless of treatment. Steroids do not appear to have any added benefit in terms of restoring sensory and motor function. There appears to be some neurologic benefit to surgical decompression with intracanalicular bullet retrieval in patients with an incomplete lesion and a cauda equina syndrome. Complication rates are greater in operated patients.

Conclusions

These findings should be interpreted with caution because of considerable heterogeneity among the studies in the literature on gunshot-induced SCI and because of generally poor-quality study design and a high associated risk of selection bias. Supportive management should be the primary method of care, whereas surgery should be an option in case of radiographic evidence of a static compression on the spinal cord. Future studies are necessary to develop better treatment guidelines for patients with gunshot wound-associated SCI.     

Adrenal gunshot wound: Laparoscopic approach. Report of a case

INTRODUCTION

Although there is no debate that patients with peritonitis or hemodynamic instability should undergo urgent laparotomy after penetrating abdominal injury, it is also clear that certain stable patients may be managed without operation. Controversy persists regarding use of laparoscopy.

PRESENTATION OF CASE

We report a case of gunshot wounds with bullet in left adrenal gland and perirenal subcapsular hematoma. The patients had no signs of peritonitis but in the observation period we noted a significative blood loss, so we performed an exploratory laparoscopy.

DISCUSSION

We found the bullet in adrenal parenchyma. The postoperative period was regular and the patient was discharged without any local or general complication.

CONCLUSION

Although the data are still controversial, the importance of the laparoscopic approach is rapidly increasing also in case of penetrating trauma of the abdomen. This technique assumes both a diagnostic and therapeutic role by reducing the number of negative laparotomies.     

Retained Bullet Removal in Civilian Pelvis and Extremity Gunshot Injuries: A Systematic Review

Background

Although gunshot injuries are relatively common, there is little consensus about whether retained bullets or bullet fragments should be removed routinely or only in selected circumstances.

Questions/purposes

We performed a systematic review of the literature to answer the following questions: (1) Is bullet and/or bullet fragment removal from gunshot injuries to the pelvis or extremities routinely indicated? And, if not, (2) what are the selected indications for removal of bullets and/or bullet fragments?

Methods

A search of the English-language literature on the topic of gunshot injury and bullet removal was performed using the National Library of Medicine and MEDLINE^® and supplemented by hand searching of bibliographies of included references. Studies were included if they provided clinical data on one or both of our study questions; included studies were evaluated using the levels of evidence rubric. Most studies on the subject were expert opinion (Level V evidence), and these were excluded; one Level III study and seven Level IV studies were included.

Results

No studies provided a rationale for routine bullet removal in all cases. The studies identified bullet fragment removal as indicated acutely for those located within a joint, the palm, or the sole. Chronic infection, persistent pain at the bullet site, and lead intoxication were reported as late indications for bullet removal.

Conclusions

The evidence base for making clinical recommendations on the topic of bullet and bullet fragment removal after gunshot injury is weak. Level I and II evidence is needed to determine the indications for bullet removal after gunshot injury.     

Thoracic Myelopathy Secondary to Intradural Extramedullary Bronchogenic Cyst

Background/Objective:

To report a case of thoracic myelopathy secondary to intradural extramedullary bronchogenic cyst.

Study Design:

Case report.

Methods/Findings:

A 20-year-old man presented to the emergency department with increasing back pain and lower-extremity weakness. Magnetic resonance imaging demonstrated a cystic lesion at the T4 level with mass effect on the spinal cord.

Results:

The lesion was resected, and histopathologic evaluation showed a cyst lined by respiratory-type epithelium consistent with a bronchogenic cyst.

Conclusions:

Intradural extramedullary bronchogenic cysts of the thoracic spine have been reported previously but are extremely rare. The treatment of choice is surgical resection.     

Simultaneously diagnosed pulmonary thromboembolism and hemopericardium in a man with thoracic spinal cord injury

Background

Simultaneous pulmonary thromboembolism (PTE) and hemopericardium is a rare but life-threatening condition. As hemopericardium is a contraindication to anticoagulation treatment, it is challenging to handle both conditions together.

Objective

The objective of the study was to report a rare case of a man with thoracic spinal cord injury presenting with simultaneous PTE and hemopericardium.

Design

Case report.

Subject

A 43-year-old man with incomplete T9 paraplegia (American Spinal Injury Association Impairment Scale D) complained of fever one and a half months after spinal cord injury sustained in a fall.

Findings

During evaluation of fever origin, chest computed tomography and transthoracic echocardiogram revealed simultaneous PTE and hemopericardium. After serial echocardiograms over 2 days demonstrated stability, intravenous heparin, and oral warfarin were administered and his medical status was observed closely. Ultimately, both conditions improved without significant complications.

Conclusion

We report successful treatment of man with acute spinal cord injury who presented with simultaneously diagnosed PTE and hemopericardium, a rare complication involving two distinct and opposing pathological mechanisms and conflicting treatments.     

Lead toxicity and management of gunshot wounds in the lumbar spine

Introduction

Gunshot wounds are one of the commonest causes of spinal injury. Management of these patients differs from other blunt trauma injuries to the spine. We present a case of a gunshot wound to the lumbar spine that occurred in 1985 which was treated non-operatively.

Methods

In the last 10 years, the patient was admitted multiple times for confusion and lead toxicity with blood levels over 100 μg/dl. Inpatient chelation therapy was implemented. After multiple recommendations for surgery, the patient agreed to have as much of the bullet removed as possible. The patient successfully underwent decompression and fusion from both anterior and posterior approaches. Lead levels subsequently declined.

Conclusion

The purpose of this paper is to show a case of a gunshot wound to the spine that ultimately caused plumbism and required surgery. Technical aspects of the surgery are described as well as pre- and post-procedural imaging. Recommendations for the general management of spine gunshot wounds are also described.     

Civilian abdominal gunshot wounds in Durban, South Africa: a prospective study of 78 cases

INTRODUCTION

Violence has become part and parcel of the daily routine of living in South Africa. This prospective study of 78 patients who sustained abdominal gunshot wounds was undertaken to evaluate the pattern of injuries, treatment outcome and the role of selective conservative management.

PATIENTS AND METHODS

All patients with abdominal gunshot wounds admitted into the accident and emergency department of Prince Mshyeni Memorial Hospital (PMMH) between January 2005 and June 2005 were included in this prospective study. Case notes were reviewed and data entered on a standard proforma by a single observer (IC).

RESULTS

A total of 78 patients who sustained abdominal gunshot wounds were included in the study. There were 68 males and 10 females with an age range of 16–60 years (median age, 25 years). Of these, 59 (76%) underwent emergency laparotomy and 19 (24%) were initially observed. Two patients in the observed group needed a delayed laparotomy, both with positive findings. Fifty-five (71%) patients had one entrance wound each and 23 (29%) had multiple entrance wounds. Forty-one (53%) patients had exit wounds and in 37 (47%) the bullet remained lodged in the body. The entrance wounds were in anterior abdominal wall in 50 patients, posterior trunk in 13, gluteal region in 11 and thorax in 4 patients, respectively. Twelve patients died, all from the emergency laparotomy group. There were two negative laparotomies from the laparotomy group.

CONCLUSIONS

Management of gunshot wounds is expensive and requires a variety of surgical skills. We recommend that a national database to which all gunshot wounds must be reported is required in order to assess the magnitude of the problem nationally as well as funding of research in injury control. This study along with many others shows that selective conservative management is feasible without the use of expensive investigations.     

Cervical instability presenting as thoracic pain: case report and literature review

Study design

Case report.

Objective

To report a case of cervical instability from an os odontoideum that presented as posterior thoracic pain and to present a review of the literature.

Background

Thoracic posterior paraspinal spasms and pain are common chief complaints in individuals with spinal abnormalities.

Methods

A 19-year-old man presented with posterior thoracic pain for nearly 1 year following a college sports-related injury (lacrosse). Computed tomography and magnetic resonance imaging did not reveal any significant thoracic or lumbar spinal cord or nerve root pathology, but did reveal an incidental finding of an os odontoideum.

Results

Surgical stabilization of the atlantoaxial instability resulting from the os odontoideum resulted in complete resolution of the patient''s thoracic pain.

Conclusions

Thoracic back pain without a clear thoracic spine etiology warrants further workup to rule out the possibility of spinal instability.     

Hemorrhagic intramedullary hemangioblastoma of the cervical spinal cord presenting with acute-onset quadriparesis: Case report and review of the literature

Context

Hemangioblastomas of the spinal cord are uncommon vascular tumors. Patients commonly present with subtle neurologic findings that are thought to represent growth of the lesion over time. Hemorrhage of an intramedullary hemangioblastoma presenting as acute neurologic deficit is an extremely rare occurrence. Although the cervical spine is the most common location for hemangioblastoma of the spinal cord, there have been no previously published cases in the literature of intramedullary hemorrhage from such a lesion.

Findings

A 22-year-old woman with a previously undiagnosed spinal cord hemangioblastoma presented with sudden-onset dense quadriparesis due to intramedullary hemorrhage in the cervical spinal cord. The patient did not have any clinical findings of von-Hippel Lindau disease. Laminoplasty from C5 to T2 and posterior midline myelotomy for resection of the intramedullary tumor with hematoma evacuation were completed without complication.

Conclusion

Intramedullary hemangioblastoma of the spinal cord is uncommon, and hemorrhage from a cervical spinal cord lesion has not previously been reported. Symptoms from these usually indolent lesions are commonly associated with tumor growth, edema, or associated syrinx, whereas devastating acute neurologic deficit from hemorrhage is exceedingly rare. Microsurgical resection should be done in cases of symptomatic lesions and considered in isolated symptomatic lesions without the known diagnosis of von Hippel-Lindau disease.     

Short report of an unusual ballistic trauma

INTRODUCTION

Portable firearms have a relevant medico-legal interest, being a major cause of injury. Bullet entry wounds generally have a particular appearance, including contusion, skin introflection, and simple or excoriated ecchymosis. The skin wound is typically a hole with frayed margins, whose diameter is smaller than that of the bullet.

PRESENTATION OF CASE

We report the case of a 19-year-old man with ballistic trauma. Examination of the patient''s lesions indicated that the bullet had entered from the left mandibular parasymphysis, creating a small hole without the typical bullet wipe and blackening. Subsequently, the bullet seemed to have fractured the left chin region immediately below the lower alveolar process, and it finally stopped in the submandibular area in the suprahyoid region of the neck.

DISCUSSION

This case is peculiar because the distinctive features of a firearm injury were absent; the lack of bleeding and edema made the case difficult to interpret without additional diagnostic investigations.

CONCLUSION

Ballistic trauma can manifest in different ways; therefore, internal trauma should be suspected even in the absence of clear external signs. This case report shows how an unusual bullet entry hole can mask quite serious injuries.     

American Spinal Injury Association A (sensory and motor complete) is not different from American Spinal Injury Association B (sensory incomplete,motor complete) in gunshot-related spinal cord injury

Background Context

We receive a large number of patients with spinal cord injury (SCI) due to penetrating gunshot wounds (GSW) at our national rehabilitation center. Although many patients are labeled American Spinal Injury Association (ASIA) B sensory incomplete because of sensory sparing, especially deep anal pressure, with purported prognostic value, we have not observed a clinical difference from patients labeled ASIA A complete. We hypothesized that sensory sparing, if meaningful, should reduce the occurrence of pressure ulcers.

Lumbar vertebral hemangioma mimicking lateral spinal canal stenosis: Case report and review of literature

Context

Hemangiomas are the commonest benign tumors of the spine. Most occur in the thoracolumbar spine and the majority are asymptomatic. Rarely, hemangiomas cause symptoms through epidural expansion of the involved vertebra, resulting in spinal canal stenosis, spontaneous epidural hemorrhage, and pathological burst fracture.

Findings

We report a rare case of a 73-year-old woman, who had been treated for two months for degenerative neurogenic claudication. On admission, magnetic resonance imaging and computed tomographic scans revealed a hemangioma of the third lumbar vertebra protruding to the epidural space producing lateral spinal stenosis and ipsilateral nerve root compression. The patient underwent successful right hemilaminectomy for decompression of the nerve root, balloon kyphoplasty with poly-methyl methacrylate (PMMA) and pedicle screw segmental stabilization. Postoperative course was uneventful.

Conclusion

In the elderly, this rare presentation of spinal stenosis due to hemangiomas may be encountered. Decompression and vertebral augmentation by means balloon kyphoplasty with PMMA plus segmental pedicle screw fixation is recommended.     

Flexion Model Simulating Spinal Cord Injury Without Radiographic Abnormality in Patients With Ossification of the Longitudinal Ligament: The Influence of Flexion Speed on the Cervical Spine

Background/Objective:

It is suspected that the speed of the motion of the spinal cord under static compression may be the cause of spinal cord injury (SCI). However, little is known about the relationship between the speed of the motion of the spinal cord and its stress distributions. The objective was to carry out a biomechanical study of SCI in patients with ossification of the longitudinal ligament without radiologic evidence of injury.

Methods:

A 3-dimensional finite element spinal cord model was established. After the application of static compression, the model underwent anterior flexion to simulate SCI in ossification of the longitudinal ligament patients without radiologic abnormality. Flexion of the spine was assumed to occur at 1 motor segment. Flexion angle was 5°, and flexion speeds were 0.5°/s, 5°/s, and 50°/s. Stress distributions inside of the spinal cord were evaluated.

Results:

Stresses on the spinal cord increased slightly after the application of 5° of flexion at a speed of 0.5°/s. Stresses became much higher at a speed of 5°/s and increased further at 50°s.

Conclusions:

The stress distribution of the spinal cord under static compression increased with faster flexion speed of the spinal cord. High-speed motion of the spinal cord under static compression may be one of the causes of SCI in the absence of radiologic abnormality.     

The Relationship between Spinal Stenosis and Neurological Outcome in Traumatic Cervical Spine Injury: An Analysis using Pavlov's Ratio, Spinal Cord Area, and Spinal Canal Area

Background

This study examined the relationship between four radiological parameters (Pavlov''s ratio, sagittal diameter, spinal cord area, and spinal canal area) in patients with a traumatic cervical spine injury, as well as the correlation between these parameters and the neurological outcome.

Methods

A total of 212 cervical spinal levels in 53 patients with a distractive-extension injury were examined. The following four parameters were measured: Pavlov''s ratio on the plain lateral radiographs, the sagittal diameter, the spinal cord area, and the spinal canal area on the MRI scans. The Pearson correlation coefficients between the parameters at each level and between the levels of each parameter were evaluated. The correlation between the radiological parameters and the spinal cord injury status classified into four categories, A (complete), B (incomplete), C (radiculopathy), and D (normal) was assessed.

Results

The mean Pavlov''s ratio, sagittal diameter, spinal cord area and spinal canal area was 0.84, 12.9 mm, 82.8 mm² and 236.8 mm², respectively. An examination of the correlation between the radiological spinal stenosis and clinical spinal cord injury revealed an increase in the values of the four radiological parameters from cohorts A to D. Pavlov''s ratio was the only parameter showing statistically significant correlation with the clinical status (p = 0.006).

Conclusions

There was a correlation between the underlying spinal stenosis and the development of neurological impairment after a traumatic cervical spine injury. In addition, it is believed that Pavlov''s ratio can be used to help determine and predict the neurological outcome.     

Safety and tolerance of the ReWalk™ exoskeleton suit for ambulation by people with complete spinal cord injury: a pilot study

Objectives

The objective of the study was to evaluate the safety and tolerance of use of the ReWalk^™ exoskeleton ambulation system in people with spinal cord injury. Measures of functional ambulation were also assessed and correlated to neurological spinal cord level, age, and duration since injury.

Study design

Case series observational study.

Setting

A national spinal cord injury centre.

Methods

Six volunteer participants were recruited from the follow-up outpatient clinic. Safety was assessed with regard to falls, status of the skin, status of the spine and joints, blood pressure, pulse, and electrocardiography (ECG). Pain and fatigue were graded by the participants using a visual analogue scale pre- and post-training. Participants completed a 10-statement questionnaire regarding safety, comfort, and secondary medical effects. After being able to walk 100 m, timed up and go, distance walked in 6 minutes and 10-m timed walk were measured.

Results

There were no adverse safety events. Use of the system was generally well tolerated, with no increase in pain and a moderate level of fatigue after use. Individuals with lower level of spinal cord injury performed walking more efficiently.

Conclusion

Volunteer participants were able to ambulate with the ReWalk^™ for a distance of 100 m, with no adverse effects during the course of an average of 13–14 training sessions. The participants were generally positive regarding the use of the system.     

Management of fracture-dislocation of the lower cervical spine with the cervical pedicle screw system

INTRODUCTION

Usually, cervical pedicle screw fixation has been considered too risky for neurovascular structures. The purpose of this study was to investigate the method and efficacy of the cervical pedicle screw system for fracture-dislocation of the cervical spine because of its rigid fixation.

PATIENTS AND METHODS

A prospective study was conducted involving 48 patients with cervical spine fracture-dislocation who underwent cervical pedicle screw fixation surgery between January 2003 and January 2007. All patients had various degrees of cord injury, and they were classified according to the American Spinal Cord Injury Association (ASIA) Impairment Scale: 18 cases were grade A, 15 grade B, 10 grade C, and 5 grade D.

RESULTS

Six months after the operation, all patients had achieved solid bony fusion and stable fixation of the related segments. Thirty patients with incomplete spinal cord injury improved their ASIA Impairment Scale classification by 1 to 2 grades after the operation. Eighteen patients with complete spinal cord injury had no improvement in neural function. However, nerve root symptoms such as pain and numbness were alleviated to some extent.

CONCLUSIONS

The cervical pedicle screw system is an effective and reliable method for the restoration of cervical stability. Sufficient pre-operative imaging studies of the pedicles and strict screw insertion technique should be emphasised.     

Acute transverse myelitis associated with dengue viral infection

Background:

Acute transverse myelitis is a rare manifestation of dengue viral infection. Four cases have been previously reported in the literature.

Objective:

To report a case of a 61-year-old woman who developed acute transverse myelitis 6 days after the onset of a dengue viral infection.

Findings:

Magnetic resonance imaging of spinal cord showed hypersignal intensity on T2W at T9-T10. Laboratories studies revealed a high titer of hemagglutination inhibition of dengue virus. Treatment with intravenous pulse methylprednisolone and physiotherapy yielded a partial recovery, followed by complete resolution at 1 year postinfection.

Conclusion:

Acute transverse myelitis is a rare manifestation of dengue infection that can occur in either the peri-infectious or postinfectious phases.     

Biomechanical study of the spinal cord in thoracic ossification of the posterior longitudinal ligament

Background

Ossification of the posterior longitudinal ligament (OPLL) in the thoracic spine produces myelopathy. This is often progressive and is not affected by conservative treatment. Therefore, decompressive surgery is usually chosen.

Objective

To conduct a stress analysis of the thoracic OPLL.

Methods

The three-dimensional finite element spinal cord model was established. We used local ossification angle (LOA) for the degree of compression of spinal cord. LOA was the medial angle at the intersection between a line from the superior posterior margin at the cranial vertebral body of maximum OPLL to the top of OPLL with beak type, and a line from the lower posterior margin at the caudal vertebral body of the maximum OPLL to the top of OPLL with beak type. LOA 20°, LOA 25°, and LOA 30° compression was applied to the spinal cord in a preoperative model, the posterior decompressive model, and a model for the development of kyphosis.

Results

In a preoperative model, at more than LOA 20° compression, high stress distributions in the spinal cord were observed. In a posterior decompressive model, the stresses were lower than in the preoperative model. In the model for development of kyphosis, high-stress distributions were observed in the spinal cord at more than LOA 20° compression.

Conclusions

Posterior decompression was an effective operative method. However, when the preoperative LOA is more than 20°, it is very likely that symptoms will worsen. If operation is performed at greater than LOA 20°, then correction of kyphosis by fixation of instruments or by forward decompression should be considered.     

Epidemiology of traumatic spinal cord injury in Asia: a systematic review

Study design

A systematic review.

Background

The number of traumatic spinal cord injury (TSCI) reports grows annually, especially in China and Korea. The epidemiological characteristics of TSCI in Asia differ from those in other countries. Thus, we compiled epidemiological factors from Asia to compare with those from other countries.

Method

We searched articles published in any language between January 1980 to December 2011 using the terms “spinal cord injury”, “traumatic spinal cord injury”, “epidemiology”, and “Asia”. The articles were reviewed for information regarding TSCI incidence, total cases, case criteria, case source, causes of injury, male/female ratio, mean age, prospective or retrospective, neurological level of injury, extent of injury, and America Spinal Injury Association Impairment Scale (AIS)/grade.

Results

Epidemiological data were extracted from 39 reports in the published literature that met the inclusion criteria. Only two studies reported prevalence rates. Incidence rates ranged from 12.06 to 61.6 per million. The average age ranged from 26.8 to 56.6 years old. Men were at higher risk than women. Motor vehicle collisions (MVCs) and falls were the main causes of TSCI. However, several countries reported war wounds as the major cause. The neurological level and extent of injury were mixed, and most patients were categorized as AIS/Frankel grade A.

Conclusion

TSCI is an important public health problem and a major cause of paralysis. We must understand the epidemiology to implement appropriate preventative measures. Asian epidemiology is different from that in other regions, so intervention measures must be established according to population-specific characteristics.     

Spinal epidural abscess with myelitis and meningitis caused by Streptococcus pneumoniae in a young child

Background

Spinal epidural abscess (SEA) in children is a rare infectious emergency warranting prompt intervention. Predisposing factors include immunosuppression, spinal procedures, and local site infections such as vertebral osteomyelitis and paraspinal abscess. Staphylococcus aureus is the most common isolate.

Design

Case report and literature review.

Findings

A 2.5-year-old boy with tetraparesis was found to have an SEA in the posterior lumbar epidural space with evidence of meningitis and myelitis on MRI spine in the absence of any local or systemic predisposing factors or spinal procedures. Streptococcus pneumoniae was isolated from the evacuated pus.

Conclusions

Definitive treatment of SEA is a combination of surgical decompression and iv antibiotics. Timely management limits the extent of neurological deficit.