- Email: [email protected]
Gunshot Spinal Injury: Factors Determining Treatment and Outcome
Accepted Manuscript Gunshot Spinal Injury: Factors navigating treatment and outcome. Noorulain Iqbal, Salman Sharif, Mehak Hafiz, Aman Ullah PII:
S1878-8750(18)30540-0
DOI:
10.1016/j.wneu.2018.03.062
Reference:
WNEU 7674
To appear in:
World Neurosurgery
Received Date: 21 August 2017 Revised Date:
4 March 2018
Accepted Date: 7 March 2018
Please cite this article as: Iqbal N, Sharif S, Hafiz M, Ullah A, Gunshot Spinal Injury: Factors navigating treatment and outcome., World Neurosurgery (2018), doi: 10.1016/j.wneu.2018.03.062. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Iqbal. 1
Gunshot Spinal Injury: Factors navigating treatment and outcome. Noorulain Iqbal1, Salman Sharif1, Mehak Hafiz1, Aman Ullah1
1. Noorulain Iqbal, MBBS (Corresponding Author) Department of Neurosurgery, Liaquat National Hospital, National Stadium Road, Karachi - 74800,
M AN U
Pakistan, Email: [email protected]
2. Prof. Salman Sharif, FRCS (SN) Department of Neurosurgery, Liaquat National Hospital,
TE D
National Stadium Road, Karachi - 74800, Pakistan
EP
Email: [email protected]
3. Mehak Hafiz, MBBS
Department of Neurosurgery,
AC C
Liaquat National Hospital, National Stadium Road, Karachi - 74800, Pakistan
Email: [email protected]
SC
Authors:
RI PT
1. Department of Neurosurgery, Liaquat National Hospital
ACCEPTED MANUSCRIPT Iqbal. 2
4. Aman Ullah, FCPS Department of Neurosurgery,
RI PT
Liaquat National Hospital, National Stadium Road, Karachi - 74800, Pakistan
M AN U
SC
Email: [email protected]
Keywords: Gunshot Spine, Spinal Injury, Spine, TLICS, SLIC
Abbreviations:
TE D
TLICS: Thoracolumbar injury classification and severity SLIC: Subaxial cervical spine injury classification
AC C
EP
ASIA: American Spinal Injury Association
ACCEPTED MANUSCRIPT Iqbal. 3
Introduction Gunshot wounds to the spine have a significant rate of morbidity and mortality [1]. Motor vehicle accidents precede spinal gunshot wounds as the only other common cause of spinal
RI PT
injury [2-3]. According to World Health Organization, 7% of spinal cord injuries in Pakistan are caused by violence [7]. Majority of the patients presenting with spinal gunshot wounds with neurological deficits are young males under the age of 30 usually belonging to a lower
SC
socioeconomic background [8-12]. Besides the clinical impact of gunshot injuries, there are
M AN U
significant economic consequences resulting from hospital stays and rehabilitation [13-15]. In gunshot wounds, the spinal cord may be damaged due to contusion, partial or complete transection, vascular injury with subsequent ischemia or percussion. The projectile disrupts the bones, soft tissues, and may compress the neural tissue. The extent of tissue damage depends
TE D
on the distance, trajectory, shape, size, and velocity of the projectile [4-6]. Understanding of the mechanism of gunshot wounds, including mechanical and biological factors have improved in last few decades due to better imaging techniques, management protocols, and well-defined
EP
treatment options. The ideal management of patients with spinal gunshots injuries is
AC C
debatable. The challenge lies between aggressive versus conservative treatment options. The purpose of this study was to compare the neurological presentations and radiological findings with the outcomes post treatment. We applied the thoracolumbar injury classification and severity score (TLICS), as well as subaxial cervical spine injury classification system (SLIC), to compare management of patients with defined treatments given in these classifications. Material and Methods:
ACCEPTED MANUSCRIPT Iqbal. 4
From January 2011 through December 2014, a total of 150 consecutive patients with spinal gunshot injury were admitted and treated at Liaquat National Hospital and Medical College,
RI PT
Karachi. Patients were assessed neurologically using the American Spinal Injury Association (ASIA) Scale. From the time of admission an optimal mean arterial pressure of 90mmHg and above was maintained with appropriate fluid management and ionotropic support in these
SC
patients. None of these patients received steroids. The radiographic studies were performed to classify the severity of injury. The thoracolumbar injury classification and severity score (TLICS)
M AN U
and the subaxial cervical spine injury severity score (SLIC) were applied on thoracic/lumbar and cervical injuries, respectively (16). The patients were conservatively or surgically treated, and ASIA scale was reassessed after 1st, 12th and 24th month post treatment. The criteria for surgery was individualized depending on the patient’s age, severity of symptoms, persistent
TE D
compression, deteriorating neurology. And decision was made after discussion with patient and family. This study has a mixed cohort of patients. The time of presentation varied in most cases. The time of surgery was within 48 hours of injury or as soon as feasible. Most patients with
AC C
conservatively.
EP
ASIA A, delayed presentation or patients with other life-threatening conditions, were managed
Results
One hundred and fifty patients were admitted at our hospital with gunshot injuries to the spine over a 4-year period from 2011 to 2014. Twenty-eight patients were lost to follow up due to
ACCEPTED MANUSCRIPT Iqbal. 5
issues ranging from financial constraints or the patients coming from different cities and countries. There were 117 males, and 5 females with the mean age of 30 years. From these
RI PT
patients, 39% had thoracic gunshot wounds, 31% cervical, 24% thoracolumbar and only 6% in sacral spine. The American Spinal Injury Association (ASIA) Scale was applied on admission, in which 39% were ASIA A, 9.8% B, 15.6% C, 12.3% D, and 28% E. Most patients with thoracic
SC
spine injury were ASIA A and other regions had variable ASIA grades. Figure 1.
Moreover, 17 patients had associated cranial injuries, 30 with chest injuries, and 31 with
M AN U
abdominal injuries. After applying the TLICS and SLIC classification, 36 patients scored under the non-surgical criteria, 79 patients scored in the surgical criteria. Furthermore, of the 46 patients that were surgically managed, only 29 of them scored in the surgical criteria. Of the 76 patients managed conservatively only 15 patients scored in the non-surgical criteria. Severity scale
TE D
outcome could not be analyzed in sacral injuries as they were only 10. The treatment given to
EP
the patients did not follow the management criteria given in the classification. Figure 2.
Of the 48 ASIA A patients, 3 had a fatal outcome, furthermore, 8 of these patients improved to
AC C
B, and 7 to C. Of the 12 patients who were ASIA B, 2 had a fatal outcome, 3 improved 1 ASIA grade, and 4 improved up to 2 ASIA grades. Nineteen patients presented with ASIA C of which 9 patients improved to ASIA D, and 1 patient to ASIA E. Three out of 15 patients with ASIA D improved to ASIA E. One of patients who presented ASIA E had a fatal outcome, while the rest remained neurologically intact. Overall improvement was seen in 31% of the patients.
ACCEPTED MANUSCRIPT Iqbal. 6
Sixty-two percent of the patients were treated conservatively, and 38% surgically. The management of patients was not subject to the level of spine injury, Figure 3. The outcome of
RI PT
patients was dependent on the presenting ASIA grade regardless of whether they were treated conservatively or surgically, Tables 1-2. Out of the 11 patients with ASIA B and C that underwent surgical decompression, 7 improved. Whereas of the 20 patients conservatively managed, 14 improved. The difference in improvement in these two groups was not statistically significant. The patients with
SC
ASIA C that were managed conservatively showed most improvement (80%), as compared to other
M AN U
ASIA grades. Patients with ASIA B and C, who were surgically treated, had best results. The outcome of patients with different ASIA grades at each site after a mean 12 months follow up, showed that the thoracolumbar region had the best results Table 3. The utmost improvement in patients with cervical spine injury was seen in ASIA C, however, this category
TE D
presented with the most fatal outcomes as well. Thoracic region showed greatest progress with ASIA A changing to grades B and C.
Fifty percent of the patients treated conservatively and 48% patients managed surgically
EP
showed complications Table 4. Six patients had a fatal outcome, out of which 3 had cervical
AC C
spine injuries, the rest had dorsal, lumbar, or sacral spine injuries.
Discussion
Incidence of gunshot injuries to the spine have increased since the ongoing decline in the political climate of Pakistan and its neighboring countries. The dilemma in treating these injuries is to decide whether to take a conservative or surgical approach. Various factors in
ACCEPTED MANUSCRIPT Iqbal. 7
spinal gunshot injury may alter the outcome. The mechanism of injury, the presenting neurology, vitals, the radiological findings, and associated injuries are usually the factors that
RI PT
help in making a treatment decision. The primary approach to gunshot injuries should follow advanced trauma life support principles. Spinal gunshot injuries are usually not instantly life threatening. At least a 24-hour period with close observation and frequent neurological
SC
examinations is necessary (18). CT scan of spine with 3D reconstruction is the key diagnostic tool after clinical evaluation including neurological status. The use of magnetic resonance
M AN U
imaging (MRI) in patients with gunshot wounds at the spine is controversial (31). Bullet migration depends on a number of factors including ferromagnetism, duration of injury, mass and shape of bullet. Copper jacketed bullets used for low velocity shotguns do not have ferromagnetic properties; therefore, MRI can be used. On the other hand, steel encased bullets
TE D
used for high-velocity shotguns are ferromagnetic. Since the bullet is mostly destroyed before entering body in high velocity shotguns, MRI can also be used after confirmation that the steel
Hemodynamics
EP
fragments are absent in the spine via X-rays (32).
AC C
Recent studies have shown that acute traumatic spinal cord injury is frequently associated with systemic hypotension, hypovolemia, direct severe spinal cord trauma, or a combination. Hypotension in animal models of spinal cord injury results in worse neurological outcome. Several clinical series of human spinal cord injuries managed with aggressive attention to blood pressure, oxygenation and hemodynamic performance reported improvement in neurological outcome (19,30). Our patients were monitored routinely with regards hemodynamics and neurology using the American Spinal Injury Association Scale (ASIA). In patients with
ACCEPTED MANUSCRIPT Iqbal. 8
incomplete injury, 58% of ASIA B, 73% of ASIA C, 40% of ASIA D showed improvement up to at least 1 ASIA grade. A study by Heary et al, systematically assessed patients with spinal gunshot
RI PT
injuries with their injury characteristics and neurological recovery. In their series only 23% went under surgery, and 24% of Frankel B, 8% percent of Frankel C, 11% of Frankel D showed
improvement of at least 1 Frankel grade. The outcome of our patients was better than many
SC
series of patients that have been published. This can be due to selection bias or the special attention given to the hemodynamics. The blood pressure was maintained and optimized using
M AN U
intravenous fluids, colloids, and inotropes when required. Hemoglobin concentration or hematocrit were obtained on admission to evaluate hypovolemia or blood loss which is also essential for optimizing the blood pressure. Patients underwent specialized spine nursing care, aggressive physiotherapy, rehabilitation and early mobilization or tilt table standing.
TE D
Surgical Indications
Management of spinal gunshot wound is aimed at restoration of neurological function with prevention and management of complications (19). There is general consensus that there is no
EP
added benefit of surgical intervention in patients with complete spinal injury. However, the
AC C
decision regarding treatment does not solely depend upon the presenting neurology of the patient, as there was no significant pattern in patients who were treated conservatively as compared to surgically with respect to ASIA grades (Table 5). Our indications for surgical intervention were young patient with incomplete or progressive neurology, unstable spine, and complete injury in young patients with persistent neural compression (20-22). A patient with complete injury that presented days after injury, was surgically treated due to CSF leak (Figure 4). The surgical procedure may include a decompressive laminectomy and/or stabilization to
ACCEPTED MANUSCRIPT Iqbal. 9
relieve pressure on the spinal cord and nerve roots. Studies have stated that decompressive laminectomy is ineffective for the neurological recovery and the removal of the bullet may not
RI PT
be capable of reducing infection (23-24). Stauffer et al documented no appreciable return of neurological function for complete lesions but with incomplete injuries, 71% of surgically
treated and 77% of conservatively treated patients had substantial recovery (25). On the other
SC
hand, Duz et al, compared Frankel score with trajectory in 128 patients with spinal missile
injury, 74 patients were treated surgically and 55 patients were treated conservatively. After
M AN U
observation their patients with surgical treatment showed significant improvement (26). During our study 37% of the patients that were treated surgically, 13 patients had complete injury and 19 patients had incomplete injuries. Thirty percent of the patients with complete injury and 52% of the patients with incomplete injury improved at least one grade post-
TE D
operatively at 12 months postoperatively, suggesting that complete injury patients cannot be discarded as lost patients. This study had mixed cohort of patients. The time of presentation varied from few hours to few days. The patients underwent pallet and bone debris removal for
EP
neural compression. The 4 patients of ASIA that improved had thoracolumbar fractures. These patients arrived early to hospital leading to immediate decompression and then were treated
AC C
aggressively with spinal injury protocol (keeping spinal perfusion pressure up) and aggressive postoperative rehabilitation physiotherapy. We did have a surgical bias in our series, as mentioned previously. We have increase number of patients from the neighboring countries that are referred to our institute, solely for surgery, as it is well recognized for spinal trauma management. In our series, young patients with complete injuries were surgically treated with special attention to hemodynamics and perfusion.
ACCEPTED MANUSCRIPT Iqbal. 10
Spine Stability Interpreting the stability in patients with gunshot wound is subjective. Thus, there is a need for
RI PT
a replicable classification for spinal stability in these patients. Spinal injury in gunshot could be in the form of compression, burst, tunnel and fracture dislocation. We applied the TLICS and SLIC to correlate the extent of injury to the treatment (16,17). From our group of patients, we
SC
conclude the scores did not correlate with the treatment offered. Neway et al concluded that TLICS is difficult to apply on gunshot patients, as this score did not implicate the need for
M AN U
surgery or debridement. In 1987, Benzel et al divided the patients with spinal gunshot injuries into three groups, group 1 with complete neurological injury, group 2 with incomplete injury, and group 3 with cauda equina injuries (17). Duz et al, applied Gulhane military medical academy – SMI (GATA-SMI) classification that included the bullet’s trajectory along with soft
TE D
tissue damage (26). However, we did not apply these classifications as the patients presented at a varied time past injury. A universal injury severity scale for gunshot wound in the spine is necessary to implement an outline for treatment. The suggested parameters of the scale that
EP
can be collaborated are, ASIA grade, fracture morphology, the vitals on admission, type of
AC C
weapon used, mechanism of injury, distance from the weapon, bullet velocity, trajectory of the bullet, time since injury and associated injury. Outcomes and Complications Aryan et al contends that the initial level of injury and severity of deficits, rather than the method of treatment, determine ultimate neurological outcome (27). There was a significant pattern seen in our patients between the different sites of injury and the presenting ASIA grade
ACCEPTED MANUSCRIPT Iqbal. 11
with their outcomes (Figure 1). Most of the ASIA A had thoracic spine injury, which is the same as all other series. Thoracolumbar injuries showed best results, with patients improving to ASIA
RI PT
E. In anterior lumbar gunshot wounds, a significant factor considering patient outcome is gut perforation which is associated with increased rate of meningitis, spinal infection, and CSF fistula (32). Our patients with anterior abdominal injuries, were managed conservatively. We
SC
encountered six fatalities and majority occurred in patients with cervical injury who required ventilator support and presented with a fatal outcome due to pneumonia or pulmonary
M AN U
embolism. Benzel et al in his series of patients with gunshot wound, showed most deaths in patient occurring in high cervical injuries due to prolonged ventilator support (17). Bertullo performed a comparative cohort study, emphasized the role of respiratory tract infection causing death in patients with cervical spine injury (28). The cervical spine due to its anatomical
TE D
relations to vital structures is prone towards variable outcome. However, complications such as respiratory infections may be avoided by early diagnosis and aggressive treatment. The complications encountered in this study varied from csf leak, recurrent urinary tract
EP
infections, decubitus ulcers, pneumonia, deep vein thrombosis, sepsis, wound infection, and
AC C
meningitis. Our complication rates in surgically managed patient correlated with other studies and the complication rate of our conservatively managed patient was equal to surgically treated patients, (26-29). Most of the complications were not due the treatment option chosen, but due to the consequences of gunshot wound to the spine. This study had its limitations. Follow up was difficult because many patients came from different regions and countries; this was the reason why 28 patients were lost to follow up. Moreover, in these patients we were not able to evaluate many factors that predict the
ACCEPTED MANUSCRIPT Iqbal. 12
management and outcome of the patients such as the type of firearm(s) used, the path and size of projectile, and the distance between firearm(s) and target.
RI PT
Conclusion This study from a third world country showed that 60% of surgically treated gunshot wounds to the spine with ASIA B and C, had at least one ASIA grade improvement at a year follow up.
SC
Gunshot injury patients should be considered for surgery when there is potential for improvement, if there is persistent cord compression, deteriorating, or incomplete neurology.
M AN U
Lumbar gunshot wounds had a better outcome compared to thoracic, followed by cervical
AC C
EP
TE D
injury. Using TLICS and SLIC scales in our series of patients was statistically insignificant.
ACCEPTED MANUSCRIPT Iqbal. 13
References: 1. Jakoi A, Iorio J, Howell R, Zampini J.M. Gunshot injuries of the spine. Spine Journal. 2015;15:2077–2085
RI PT
2. Waters RL, Sie IH. Spinal cord injuries from gunshot wounds to the spine. Clin Orthop Relat Res. 2003;408:120–125.
3. Kitchel SH, Current treatment of gunshot wounds to the spine. Clin Orthop Relat Res.
SC
2003;408:115–119.
M AN U
4. Bumbasirević M, Lesić A, Bumbasirević V, Rakocević Z, Djurić M. Gunshot injury to the face with a missile lodged in the upper cervical spine without neurological deficit. Dentomaxillofac Radiol. 2006;35:38–42.
5. Brohi SR, Brohi AR, Brohi QR. Brown–Sequard syndrome following firearm injury with a bullet lodged in the upper cervical canal. J Coll Physicians Surg Pak. 2008;8:312–313.
2001;94:830–832.
TE D
6. Tender GC, Ratliff J, Awasthi D, Buechter K. Gunshot wounds to the neck. South Med J.
EP
7. Lee BB, Cripps RA, Fitzharris M, Wing PC. The global map for traumatic spinal cord injury epidemiology: update 2011, global incidence rate. Spinal Cord. 2014;52(2):110-6
AC C
8. Sidhu GS, Ghag A, Prokuski V, Vaccaro AR, Radcliff KE. Civilian gunshot injuries of the spinal cord: a systematic review of the current literature. Clin Orthop Relat Res. 2013;
471: 3945–3955.
9. Marcon RM, Cristante AF, Teixeira WJ, Narasaki DK, Oliveira RP, De Barros Filho TEP. Fractures of the cervical spine. Clinics (Sao Paulo). 2013; 68: 1455-1461. 10. Le Roux JC, Dunn RN. Gunshot injuries of the spine–a review of 49 cases
ACCEPTED MANUSCRIPT Iqbal. 14
managed at the Groote Schuur Acute Spinal Cord Injury Unity. S Afr J Surg. 2005; 43: 165–168.
RI PT
11. Heary RF, Vaccaro AR, Mesa JJ, Northrup BE, Albert TJ, Balderston RA et al. Steroids and gunshot wounds to the spine. Neurosurgery. 1997; 41: 576–583
12. Levy ML, Gans W, Wijesinghe HS, SooHoo WE, Adkins RH, Stillerman CB. Use of
SC
methylprednisolone as an adjunct in the management of patients with penetrating spinal cord injury: outcome analysis. Neurosurgery. 1996; 39: 1141–1148
M AN U
13. Bartlett CS. Clinical update: gunshot wound ballistics. Clin Orthop Relat Res. 2003;28-57.
14. Davis JH. The Violence Prevention Task Force of the Eastern Association for the Surgery of Trauma: Violence in America: a public health crisis--The role
TE D
of firearms. The Violence Prevention Task Force of the Eastern Association for the Surgery of Trauma. J Trauma. 1995;38:163-168. 15. Volgas DA, Stannard JP, Alonso JE: Current orthopaedic treatment of
EP
ballistic injuries. Injury. 2005;36:380-386. 16. Joaquim AF et al. Clinical results of patients with thoracolumbar spine trauma treated
AC C
according to the thoracolumbar injury classification and severity score. Journal of
Neurosurg Spine. 2014;20:562-567
17. Vaccaro AR, et al. The subaxial cervical spine injury classification system: a novel approach to recognize the importance of morphology, neurology, and integrity of the disco-ligamentous complex. Spine. 2007;32(21):2365-74.
ACCEPTED MANUSCRIPT Iqbal. 15
18. Benzel EC, Hadden TA, Coleman JE. Civilian Gunshot Wounds to the Spinal Cord and Causa Equina. Neurosurgery. 1987; 20:2
RI PT
19. Hadley M. Blood pressure management after acute spinal cord injury. Neurosurgery, vol. 50, issue 3 suppl. 2002;58-62
20. Kahraman S, Gonul E, Kayali H, Sirin S, Duz B, Beduk A. Retrospective analysis of spinal
SC
missile injuries. Neurosurg Rev. 2004;27:42–45.
21. Heary R.F, Vaccaro A.R, Mesa J.J, Balderston R.A. Thoracolumbar infections in
M AN U
penetrating injuries to the spine. Orthop Clin N Am. 1996;27:69–81.
22. Yoshida G.M, Garland D, Waters R.L. Gunshot wounds to the spine. Orthop Clin N Am. 1995;26:109–116
23. Sidhu GS, Ghag A, Prokuski V, Vaccaro AR, Radcliff KE. Civilian gunshot injuries of the
471: 3945–3955.
TE D
spinal cord: a systematic review of the current literature. Clin Orthop Relat Res. 2013;
24. Klimo Jr P, Ragel BT, Rosner M, Gluf W, McCafferty R. Can surgery improve neurological
EP
function in penetrating spinal injury? A review of the military and civilian literature and treatment recommendations for military neurosurgeons. Neurosurg Focus. 2010; 28: E4.
AC C
25. Stauffer ES, Wood RW, Kelly EG. Gunshot wounds of the spine: the effects of laminectomy. J Bone Joint Surg Am. 1979;61:389–92.
26. Duz et al, Evaluation of Spinal Missile Injuries with respect to bullet trajectory, surgical indications and timing of surgical intervention. Spine. 2008;33(20): 746-753 27. Aryan HE, Amar AP, Ozgur BM, Levy ML, Gunshot wounds to the spine in adolescents. Neurosurgery. 2005;57: 748-752
ACCEPTED MANUSCRIPT Iqbal. 16
28. Bertullo G et al, Gunshot wounds to the spine: comparative analysis of two retrospective chorts. American Journal of Biomedicine. 2015; 3(8):504-522
RI PT
29. Bumpass et al., An update on civilian spinal gunshot wounds. Spine, 2015; 40(7):450-461 30. Hadley M, Blood pressure management after acute spinal cord injury. Neurosurgery. 2002; 50(3):S58-S62
SC
31. Martinez-del-Campo E, Rangel-Castilla L, Soriano-Baron H, Theodore N. Magnetic resonance imaging in lumbar gunshot wounds: an absolute contraindication?
M AN U
Neurosurgical Focus. 2014;37(1), E13.
32. Kafadar a M, Kemerdere R, Isler C, Hanci M. Intradural migration of a bullet following
AC C
EP
TE D
spinal gunshot injury. Spinal Cord. 2006;44(5), 326–329.
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
Figure 1: A bar graph illustrating the number of patients with each ASIA grade for each site of injury.
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
Figure 2: A bar graph illustrating the number of patients that were managed conservatively or surgically in each TLICS/SLIC category. (p=0.500)
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
Figure 3: A bar graph illustrating the number of patients managed conservatively or surgically for different regions of the spine. (p= 0.490).
ACCEPTED MANUSCRIPT
RIP
A
B
C
D
E
A
3
21
6
5
0
0
B
2
0
2
3
1
0
C
0
0
0
2
SC
RI PT
ASIA
9
1
D
0
0
0
0
4
3
E
0
0
0
0
0
14
M AN U
ASIA Grade on Admission
ASIA Grade After 12 Months
AC C
EP
TE D
Tables 1: The table shows the outcome of each ASIA grade, of patients treated conservatively, after 12 months. (p=0.000)
RI PT
ACCEPTED MANUSCRIPT
A
B
C
D
E
A
0
9
2
2
0
0
B
0
0
1
0
3
C
0
0
0
D
0
0
0
E
1
0
0
SC
RIP
0
M AN U
ASIA Grade on Admission
ASIA Grade After 12 months (Surgical)
3
4
0
0
5
3
0
0
13
AC C
EP
TE D
Table 2: The table shows the outcome of each ASIA grade, of patients treated surgically, after 12 months. (p=0.000).
ACCEPTED MANUSCRIPT
B
C
D
E
10 3
2
5
1
6
9
Thoracic 25
16 6
6
5
11
3
5
Thoraco- 10 Lumbar
4
3
3
8
3
5
10
0
0
0
1
0
1
0
7
M AN U
Sacral
11
13
9
9
3
8
SC
13
Cervical
RI PT
A
5
4
AC C
EP
TE D
Table 3: The table shows the outcome of patients with different sites of spine injury after mean 12 months follow up. (Outcome given in BOLD numbers)
ACCEPTED MANUSCRIPT
3
Wound infection
3
Meningitis
14
Recurrent UTI
14
Decubitus Ulcers
12
Pneumonia
12
Deep vein thrombosis Mortality
M AN U
CSF leak
RI PT
No. of Patients
SC
Complications
6 6
AC C
EP
TE D
Table 4: The table shows complications encountered in our series of patients.
Conservative 35 8 12 7 14 76
Surgery 13 4 7 8 14 46
SC
Pre ASIA A B C D E Total
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
Table 5: Table shows the number of patients with different ASIA grade treated conservatively or surgically.
ACCEPTED MANUSCRIPT
Figure 4A
M AN U
SC
RI PT
Figure 4B
EP
TE D
Figure 4C
AC C
Figure 4A-C: A 21 year old male, with gunshot injury of cervicodorsal spine, presented with ASIA A. Figure 4A and 4B show his CT scan of cervical spine, with bullet lodged at the canal at D1 with tunnel injury and debris on the right side. Figure 4C shows, the intraoperative picture of the bullet removal and CSF leak repair.
ACCEPTED MANUSCRIPT
Highlights
RI PT
SC M AN U TE D EP
•
The TLICS and SCLIS scales do not predict the management of spinal injury due to gunshot. Patients with ASIA B and C after gunshot spinal injury, can improve if treated surgically. Optimizing blood pressure, can affect the patient’s outcome Patients who had lumbar gunshot injury had a better outcome compared to thoracic followed by cervical Gunshot injury patients should be considered for surgery when there is potential for improvement, if there is persistent cord compression, or deteriorating or incomplete neurology.
AC C
• • • •
S1878-8750(18)30540-0
DOI:
10.1016/j.wneu.2018.03.062
Reference:
WNEU 7674
To appear in:
World Neurosurgery
Received Date: 21 August 2017 Revised Date:
4 March 2018
Accepted Date: 7 March 2018
Please cite this article as: Iqbal N, Sharif S, Hafiz M, Ullah A, Gunshot Spinal Injury: Factors navigating treatment and outcome., World Neurosurgery (2018), doi: 10.1016/j.wneu.2018.03.062. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Iqbal. 1
Gunshot Spinal Injury: Factors navigating treatment and outcome. Noorulain Iqbal1, Salman Sharif1, Mehak Hafiz1, Aman Ullah1
1. Noorulain Iqbal, MBBS (Corresponding Author) Department of Neurosurgery, Liaquat National Hospital, National Stadium Road, Karachi - 74800,
M AN U
Pakistan, Email: [email protected]
2. Prof. Salman Sharif, FRCS (SN) Department of Neurosurgery, Liaquat National Hospital,
TE D
National Stadium Road, Karachi - 74800, Pakistan
EP
Email: [email protected]
3. Mehak Hafiz, MBBS
Department of Neurosurgery,
AC C
Liaquat National Hospital, National Stadium Road, Karachi - 74800, Pakistan
Email: [email protected]
SC
Authors:
RI PT
1. Department of Neurosurgery, Liaquat National Hospital
ACCEPTED MANUSCRIPT Iqbal. 2
4. Aman Ullah, FCPS Department of Neurosurgery,
RI PT
Liaquat National Hospital, National Stadium Road, Karachi - 74800, Pakistan
M AN U
SC
Email: [email protected]
Keywords: Gunshot Spine, Spinal Injury, Spine, TLICS, SLIC
Abbreviations:
TE D
TLICS: Thoracolumbar injury classification and severity SLIC: Subaxial cervical spine injury classification
AC C
EP
ASIA: American Spinal Injury Association
ACCEPTED MANUSCRIPT Iqbal. 3
Introduction Gunshot wounds to the spine have a significant rate of morbidity and mortality [1]. Motor vehicle accidents precede spinal gunshot wounds as the only other common cause of spinal
RI PT
injury [2-3]. According to World Health Organization, 7% of spinal cord injuries in Pakistan are caused by violence [7]. Majority of the patients presenting with spinal gunshot wounds with neurological deficits are young males under the age of 30 usually belonging to a lower
SC
socioeconomic background [8-12]. Besides the clinical impact of gunshot injuries, there are
M AN U
significant economic consequences resulting from hospital stays and rehabilitation [13-15]. In gunshot wounds, the spinal cord may be damaged due to contusion, partial or complete transection, vascular injury with subsequent ischemia or percussion. The projectile disrupts the bones, soft tissues, and may compress the neural tissue. The extent of tissue damage depends
TE D
on the distance, trajectory, shape, size, and velocity of the projectile [4-6]. Understanding of the mechanism of gunshot wounds, including mechanical and biological factors have improved in last few decades due to better imaging techniques, management protocols, and well-defined
EP
treatment options. The ideal management of patients with spinal gunshots injuries is
AC C
debatable. The challenge lies between aggressive versus conservative treatment options. The purpose of this study was to compare the neurological presentations and radiological findings with the outcomes post treatment. We applied the thoracolumbar injury classification and severity score (TLICS), as well as subaxial cervical spine injury classification system (SLIC), to compare management of patients with defined treatments given in these classifications. Material and Methods:
ACCEPTED MANUSCRIPT Iqbal. 4
From January 2011 through December 2014, a total of 150 consecutive patients with spinal gunshot injury were admitted and treated at Liaquat National Hospital and Medical College,
RI PT
Karachi. Patients were assessed neurologically using the American Spinal Injury Association (ASIA) Scale. From the time of admission an optimal mean arterial pressure of 90mmHg and above was maintained with appropriate fluid management and ionotropic support in these
SC
patients. None of these patients received steroids. The radiographic studies were performed to classify the severity of injury. The thoracolumbar injury classification and severity score (TLICS)
M AN U
and the subaxial cervical spine injury severity score (SLIC) were applied on thoracic/lumbar and cervical injuries, respectively (16). The patients were conservatively or surgically treated, and ASIA scale was reassessed after 1st, 12th and 24th month post treatment. The criteria for surgery was individualized depending on the patient’s age, severity of symptoms, persistent
TE D
compression, deteriorating neurology. And decision was made after discussion with patient and family. This study has a mixed cohort of patients. The time of presentation varied in most cases. The time of surgery was within 48 hours of injury or as soon as feasible. Most patients with
AC C
conservatively.
EP
ASIA A, delayed presentation or patients with other life-threatening conditions, were managed
Results
One hundred and fifty patients were admitted at our hospital with gunshot injuries to the spine over a 4-year period from 2011 to 2014. Twenty-eight patients were lost to follow up due to
ACCEPTED MANUSCRIPT Iqbal. 5
issues ranging from financial constraints or the patients coming from different cities and countries. There were 117 males, and 5 females with the mean age of 30 years. From these
RI PT
patients, 39% had thoracic gunshot wounds, 31% cervical, 24% thoracolumbar and only 6% in sacral spine. The American Spinal Injury Association (ASIA) Scale was applied on admission, in which 39% were ASIA A, 9.8% B, 15.6% C, 12.3% D, and 28% E. Most patients with thoracic
SC
spine injury were ASIA A and other regions had variable ASIA grades. Figure 1.
Moreover, 17 patients had associated cranial injuries, 30 with chest injuries, and 31 with
M AN U
abdominal injuries. After applying the TLICS and SLIC classification, 36 patients scored under the non-surgical criteria, 79 patients scored in the surgical criteria. Furthermore, of the 46 patients that were surgically managed, only 29 of them scored in the surgical criteria. Of the 76 patients managed conservatively only 15 patients scored in the non-surgical criteria. Severity scale
TE D
outcome could not be analyzed in sacral injuries as they were only 10. The treatment given to
EP
the patients did not follow the management criteria given in the classification. Figure 2.
Of the 48 ASIA A patients, 3 had a fatal outcome, furthermore, 8 of these patients improved to
AC C
B, and 7 to C. Of the 12 patients who were ASIA B, 2 had a fatal outcome, 3 improved 1 ASIA grade, and 4 improved up to 2 ASIA grades. Nineteen patients presented with ASIA C of which 9 patients improved to ASIA D, and 1 patient to ASIA E. Three out of 15 patients with ASIA D improved to ASIA E. One of patients who presented ASIA E had a fatal outcome, while the rest remained neurologically intact. Overall improvement was seen in 31% of the patients.
ACCEPTED MANUSCRIPT Iqbal. 6
Sixty-two percent of the patients were treated conservatively, and 38% surgically. The management of patients was not subject to the level of spine injury, Figure 3. The outcome of
RI PT
patients was dependent on the presenting ASIA grade regardless of whether they were treated conservatively or surgically, Tables 1-2. Out of the 11 patients with ASIA B and C that underwent surgical decompression, 7 improved. Whereas of the 20 patients conservatively managed, 14 improved. The difference in improvement in these two groups was not statistically significant. The patients with
SC
ASIA C that were managed conservatively showed most improvement (80%), as compared to other
M AN U
ASIA grades. Patients with ASIA B and C, who were surgically treated, had best results. The outcome of patients with different ASIA grades at each site after a mean 12 months follow up, showed that the thoracolumbar region had the best results Table 3. The utmost improvement in patients with cervical spine injury was seen in ASIA C, however, this category
TE D
presented with the most fatal outcomes as well. Thoracic region showed greatest progress with ASIA A changing to grades B and C.
Fifty percent of the patients treated conservatively and 48% patients managed surgically
EP
showed complications Table 4. Six patients had a fatal outcome, out of which 3 had cervical
AC C
spine injuries, the rest had dorsal, lumbar, or sacral spine injuries.
Discussion
Incidence of gunshot injuries to the spine have increased since the ongoing decline in the political climate of Pakistan and its neighboring countries. The dilemma in treating these injuries is to decide whether to take a conservative or surgical approach. Various factors in
ACCEPTED MANUSCRIPT Iqbal. 7
spinal gunshot injury may alter the outcome. The mechanism of injury, the presenting neurology, vitals, the radiological findings, and associated injuries are usually the factors that
RI PT
help in making a treatment decision. The primary approach to gunshot injuries should follow advanced trauma life support principles. Spinal gunshot injuries are usually not instantly life threatening. At least a 24-hour period with close observation and frequent neurological
SC
examinations is necessary (18). CT scan of spine with 3D reconstruction is the key diagnostic tool after clinical evaluation including neurological status. The use of magnetic resonance
M AN U
imaging (MRI) in patients with gunshot wounds at the spine is controversial (31). Bullet migration depends on a number of factors including ferromagnetism, duration of injury, mass and shape of bullet. Copper jacketed bullets used for low velocity shotguns do not have ferromagnetic properties; therefore, MRI can be used. On the other hand, steel encased bullets
TE D
used for high-velocity shotguns are ferromagnetic. Since the bullet is mostly destroyed before entering body in high velocity shotguns, MRI can also be used after confirmation that the steel
Hemodynamics
EP
fragments are absent in the spine via X-rays (32).
AC C
Recent studies have shown that acute traumatic spinal cord injury is frequently associated with systemic hypotension, hypovolemia, direct severe spinal cord trauma, or a combination. Hypotension in animal models of spinal cord injury results in worse neurological outcome. Several clinical series of human spinal cord injuries managed with aggressive attention to blood pressure, oxygenation and hemodynamic performance reported improvement in neurological outcome (19,30). Our patients were monitored routinely with regards hemodynamics and neurology using the American Spinal Injury Association Scale (ASIA). In patients with
ACCEPTED MANUSCRIPT Iqbal. 8
incomplete injury, 58% of ASIA B, 73% of ASIA C, 40% of ASIA D showed improvement up to at least 1 ASIA grade. A study by Heary et al, systematically assessed patients with spinal gunshot
RI PT
injuries with their injury characteristics and neurological recovery. In their series only 23% went under surgery, and 24% of Frankel B, 8% percent of Frankel C, 11% of Frankel D showed
improvement of at least 1 Frankel grade. The outcome of our patients was better than many
SC
series of patients that have been published. This can be due to selection bias or the special attention given to the hemodynamics. The blood pressure was maintained and optimized using
M AN U
intravenous fluids, colloids, and inotropes when required. Hemoglobin concentration or hematocrit were obtained on admission to evaluate hypovolemia or blood loss which is also essential for optimizing the blood pressure. Patients underwent specialized spine nursing care, aggressive physiotherapy, rehabilitation and early mobilization or tilt table standing.
TE D
Surgical Indications
Management of spinal gunshot wound is aimed at restoration of neurological function with prevention and management of complications (19). There is general consensus that there is no
EP
added benefit of surgical intervention in patients with complete spinal injury. However, the
AC C
decision regarding treatment does not solely depend upon the presenting neurology of the patient, as there was no significant pattern in patients who were treated conservatively as compared to surgically with respect to ASIA grades (Table 5). Our indications for surgical intervention were young patient with incomplete or progressive neurology, unstable spine, and complete injury in young patients with persistent neural compression (20-22). A patient with complete injury that presented days after injury, was surgically treated due to CSF leak (Figure 4). The surgical procedure may include a decompressive laminectomy and/or stabilization to
ACCEPTED MANUSCRIPT Iqbal. 9
relieve pressure on the spinal cord and nerve roots. Studies have stated that decompressive laminectomy is ineffective for the neurological recovery and the removal of the bullet may not
RI PT
be capable of reducing infection (23-24). Stauffer et al documented no appreciable return of neurological function for complete lesions but with incomplete injuries, 71% of surgically
treated and 77% of conservatively treated patients had substantial recovery (25). On the other
SC
hand, Duz et al, compared Frankel score with trajectory in 128 patients with spinal missile
injury, 74 patients were treated surgically and 55 patients were treated conservatively. After
M AN U
observation their patients with surgical treatment showed significant improvement (26). During our study 37% of the patients that were treated surgically, 13 patients had complete injury and 19 patients had incomplete injuries. Thirty percent of the patients with complete injury and 52% of the patients with incomplete injury improved at least one grade post-
TE D
operatively at 12 months postoperatively, suggesting that complete injury patients cannot be discarded as lost patients. This study had mixed cohort of patients. The time of presentation varied from few hours to few days. The patients underwent pallet and bone debris removal for
EP
neural compression. The 4 patients of ASIA that improved had thoracolumbar fractures. These patients arrived early to hospital leading to immediate decompression and then were treated
AC C
aggressively with spinal injury protocol (keeping spinal perfusion pressure up) and aggressive postoperative rehabilitation physiotherapy. We did have a surgical bias in our series, as mentioned previously. We have increase number of patients from the neighboring countries that are referred to our institute, solely for surgery, as it is well recognized for spinal trauma management. In our series, young patients with complete injuries were surgically treated with special attention to hemodynamics and perfusion.
ACCEPTED MANUSCRIPT Iqbal. 10
Spine Stability Interpreting the stability in patients with gunshot wound is subjective. Thus, there is a need for
RI PT
a replicable classification for spinal stability in these patients. Spinal injury in gunshot could be in the form of compression, burst, tunnel and fracture dislocation. We applied the TLICS and SLIC to correlate the extent of injury to the treatment (16,17). From our group of patients, we
SC
conclude the scores did not correlate with the treatment offered. Neway et al concluded that TLICS is difficult to apply on gunshot patients, as this score did not implicate the need for
M AN U
surgery or debridement. In 1987, Benzel et al divided the patients with spinal gunshot injuries into three groups, group 1 with complete neurological injury, group 2 with incomplete injury, and group 3 with cauda equina injuries (17). Duz et al, applied Gulhane military medical academy – SMI (GATA-SMI) classification that included the bullet’s trajectory along with soft
TE D
tissue damage (26). However, we did not apply these classifications as the patients presented at a varied time past injury. A universal injury severity scale for gunshot wound in the spine is necessary to implement an outline for treatment. The suggested parameters of the scale that
EP
can be collaborated are, ASIA grade, fracture morphology, the vitals on admission, type of
AC C
weapon used, mechanism of injury, distance from the weapon, bullet velocity, trajectory of the bullet, time since injury and associated injury. Outcomes and Complications Aryan et al contends that the initial level of injury and severity of deficits, rather than the method of treatment, determine ultimate neurological outcome (27). There was a significant pattern seen in our patients between the different sites of injury and the presenting ASIA grade
ACCEPTED MANUSCRIPT Iqbal. 11
with their outcomes (Figure 1). Most of the ASIA A had thoracic spine injury, which is the same as all other series. Thoracolumbar injuries showed best results, with patients improving to ASIA
RI PT
E. In anterior lumbar gunshot wounds, a significant factor considering patient outcome is gut perforation which is associated with increased rate of meningitis, spinal infection, and CSF fistula (32). Our patients with anterior abdominal injuries, were managed conservatively. We
SC
encountered six fatalities and majority occurred in patients with cervical injury who required ventilator support and presented with a fatal outcome due to pneumonia or pulmonary
M AN U
embolism. Benzel et al in his series of patients with gunshot wound, showed most deaths in patient occurring in high cervical injuries due to prolonged ventilator support (17). Bertullo performed a comparative cohort study, emphasized the role of respiratory tract infection causing death in patients with cervical spine injury (28). The cervical spine due to its anatomical
TE D
relations to vital structures is prone towards variable outcome. However, complications such as respiratory infections may be avoided by early diagnosis and aggressive treatment. The complications encountered in this study varied from csf leak, recurrent urinary tract
EP
infections, decubitus ulcers, pneumonia, deep vein thrombosis, sepsis, wound infection, and
AC C
meningitis. Our complication rates in surgically managed patient correlated with other studies and the complication rate of our conservatively managed patient was equal to surgically treated patients, (26-29). Most of the complications were not due the treatment option chosen, but due to the consequences of gunshot wound to the spine. This study had its limitations. Follow up was difficult because many patients came from different regions and countries; this was the reason why 28 patients were lost to follow up. Moreover, in these patients we were not able to evaluate many factors that predict the
ACCEPTED MANUSCRIPT Iqbal. 12
management and outcome of the patients such as the type of firearm(s) used, the path and size of projectile, and the distance between firearm(s) and target.
RI PT
Conclusion This study from a third world country showed that 60% of surgically treated gunshot wounds to the spine with ASIA B and C, had at least one ASIA grade improvement at a year follow up.
SC
Gunshot injury patients should be considered for surgery when there is potential for improvement, if there is persistent cord compression, deteriorating, or incomplete neurology.
M AN U
Lumbar gunshot wounds had a better outcome compared to thoracic, followed by cervical
AC C
EP
TE D
injury. Using TLICS and SLIC scales in our series of patients was statistically insignificant.
ACCEPTED MANUSCRIPT Iqbal. 13
References: 1. Jakoi A, Iorio J, Howell R, Zampini J.M. Gunshot injuries of the spine. Spine Journal. 2015;15:2077–2085
RI PT
2. Waters RL, Sie IH. Spinal cord injuries from gunshot wounds to the spine. Clin Orthop Relat Res. 2003;408:120–125.
3. Kitchel SH, Current treatment of gunshot wounds to the spine. Clin Orthop Relat Res.
SC
2003;408:115–119.
M AN U
4. Bumbasirević M, Lesić A, Bumbasirević V, Rakocević Z, Djurić M. Gunshot injury to the face with a missile lodged in the upper cervical spine without neurological deficit. Dentomaxillofac Radiol. 2006;35:38–42.
5. Brohi SR, Brohi AR, Brohi QR. Brown–Sequard syndrome following firearm injury with a bullet lodged in the upper cervical canal. J Coll Physicians Surg Pak. 2008;8:312–313.
2001;94:830–832.
TE D
6. Tender GC, Ratliff J, Awasthi D, Buechter K. Gunshot wounds to the neck. South Med J.
EP
7. Lee BB, Cripps RA, Fitzharris M, Wing PC. The global map for traumatic spinal cord injury epidemiology: update 2011, global incidence rate. Spinal Cord. 2014;52(2):110-6
AC C
8. Sidhu GS, Ghag A, Prokuski V, Vaccaro AR, Radcliff KE. Civilian gunshot injuries of the spinal cord: a systematic review of the current literature. Clin Orthop Relat Res. 2013;
471: 3945–3955.
9. Marcon RM, Cristante AF, Teixeira WJ, Narasaki DK, Oliveira RP, De Barros Filho TEP. Fractures of the cervical spine. Clinics (Sao Paulo). 2013; 68: 1455-1461. 10. Le Roux JC, Dunn RN. Gunshot injuries of the spine–a review of 49 cases
ACCEPTED MANUSCRIPT Iqbal. 14
managed at the Groote Schuur Acute Spinal Cord Injury Unity. S Afr J Surg. 2005; 43: 165–168.
RI PT
11. Heary RF, Vaccaro AR, Mesa JJ, Northrup BE, Albert TJ, Balderston RA et al. Steroids and gunshot wounds to the spine. Neurosurgery. 1997; 41: 576–583
12. Levy ML, Gans W, Wijesinghe HS, SooHoo WE, Adkins RH, Stillerman CB. Use of
SC
methylprednisolone as an adjunct in the management of patients with penetrating spinal cord injury: outcome analysis. Neurosurgery. 1996; 39: 1141–1148
M AN U
13. Bartlett CS. Clinical update: gunshot wound ballistics. Clin Orthop Relat Res. 2003;28-57.
14. Davis JH. The Violence Prevention Task Force of the Eastern Association for the Surgery of Trauma: Violence in America: a public health crisis--The role
TE D
of firearms. The Violence Prevention Task Force of the Eastern Association for the Surgery of Trauma. J Trauma. 1995;38:163-168. 15. Volgas DA, Stannard JP, Alonso JE: Current orthopaedic treatment of
EP
ballistic injuries. Injury. 2005;36:380-386. 16. Joaquim AF et al. Clinical results of patients with thoracolumbar spine trauma treated
AC C
according to the thoracolumbar injury classification and severity score. Journal of
Neurosurg Spine. 2014;20:562-567
17. Vaccaro AR, et al. The subaxial cervical spine injury classification system: a novel approach to recognize the importance of morphology, neurology, and integrity of the disco-ligamentous complex. Spine. 2007;32(21):2365-74.
ACCEPTED MANUSCRIPT Iqbal. 15
18. Benzel EC, Hadden TA, Coleman JE. Civilian Gunshot Wounds to the Spinal Cord and Causa Equina. Neurosurgery. 1987; 20:2
RI PT
19. Hadley M. Blood pressure management after acute spinal cord injury. Neurosurgery, vol. 50, issue 3 suppl. 2002;58-62
20. Kahraman S, Gonul E, Kayali H, Sirin S, Duz B, Beduk A. Retrospective analysis of spinal
SC
missile injuries. Neurosurg Rev. 2004;27:42–45.
21. Heary R.F, Vaccaro A.R, Mesa J.J, Balderston R.A. Thoracolumbar infections in
M AN U
penetrating injuries to the spine. Orthop Clin N Am. 1996;27:69–81.
22. Yoshida G.M, Garland D, Waters R.L. Gunshot wounds to the spine. Orthop Clin N Am. 1995;26:109–116
23. Sidhu GS, Ghag A, Prokuski V, Vaccaro AR, Radcliff KE. Civilian gunshot injuries of the
471: 3945–3955.
TE D
spinal cord: a systematic review of the current literature. Clin Orthop Relat Res. 2013;
24. Klimo Jr P, Ragel BT, Rosner M, Gluf W, McCafferty R. Can surgery improve neurological
EP
function in penetrating spinal injury? A review of the military and civilian literature and treatment recommendations for military neurosurgeons. Neurosurg Focus. 2010; 28: E4.
AC C
25. Stauffer ES, Wood RW, Kelly EG. Gunshot wounds of the spine: the effects of laminectomy. J Bone Joint Surg Am. 1979;61:389–92.
26. Duz et al, Evaluation of Spinal Missile Injuries with respect to bullet trajectory, surgical indications and timing of surgical intervention. Spine. 2008;33(20): 746-753 27. Aryan HE, Amar AP, Ozgur BM, Levy ML, Gunshot wounds to the spine in adolescents. Neurosurgery. 2005;57: 748-752
ACCEPTED MANUSCRIPT Iqbal. 16
28. Bertullo G et al, Gunshot wounds to the spine: comparative analysis of two retrospective chorts. American Journal of Biomedicine. 2015; 3(8):504-522
RI PT
29. Bumpass et al., An update on civilian spinal gunshot wounds. Spine, 2015; 40(7):450-461 30. Hadley M, Blood pressure management after acute spinal cord injury. Neurosurgery. 2002; 50(3):S58-S62
SC
31. Martinez-del-Campo E, Rangel-Castilla L, Soriano-Baron H, Theodore N. Magnetic resonance imaging in lumbar gunshot wounds: an absolute contraindication?
M AN U
Neurosurgical Focus. 2014;37(1), E13.
32. Kafadar a M, Kemerdere R, Isler C, Hanci M. Intradural migration of a bullet following
AC C
EP
TE D
spinal gunshot injury. Spinal Cord. 2006;44(5), 326–329.
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
Figure 1: A bar graph illustrating the number of patients with each ASIA grade for each site of injury.
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
Figure 2: A bar graph illustrating the number of patients that were managed conservatively or surgically in each TLICS/SLIC category. (p=0.500)
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
Figure 3: A bar graph illustrating the number of patients managed conservatively or surgically for different regions of the spine. (p= 0.490).
ACCEPTED MANUSCRIPT
RIP
A
B
C
D
E
A
3
21
6
5
0
0
B
2
0
2
3
1
0
C
0
0
0
2
SC
RI PT
ASIA
9
1
D
0
0
0
0
4
3
E
0
0
0
0
0
14
M AN U
ASIA Grade on Admission
ASIA Grade After 12 Months
AC C
EP
TE D
Tables 1: The table shows the outcome of each ASIA grade, of patients treated conservatively, after 12 months. (p=0.000)
RI PT
ACCEPTED MANUSCRIPT
A
B
C
D
E
A
0
9
2
2
0
0
B
0
0
1
0
3
C
0
0
0
D
0
0
0
E
1
0
0
SC
RIP
0
M AN U
ASIA Grade on Admission
ASIA Grade After 12 months (Surgical)
3
4
0
0
5
3
0
0
13
AC C
EP
TE D
Table 2: The table shows the outcome of each ASIA grade, of patients treated surgically, after 12 months. (p=0.000).
ACCEPTED MANUSCRIPT
B
C
D
E
10 3
2
5
1
6
9
Thoracic 25
16 6
6
5
11
3
5
Thoraco- 10 Lumbar
4
3
3
8
3
5
10
0
0
0
1
0
1
0
7
M AN U
Sacral
11
13
9
9
3
8
SC
13
Cervical
RI PT
A
5
4
AC C
EP
TE D
Table 3: The table shows the outcome of patients with different sites of spine injury after mean 12 months follow up. (Outcome given in BOLD numbers)
ACCEPTED MANUSCRIPT
3
Wound infection
3
Meningitis
14
Recurrent UTI
14
Decubitus Ulcers
12
Pneumonia
12
Deep vein thrombosis Mortality
M AN U
CSF leak
RI PT
No. of Patients
SC
Complications
6 6
AC C
EP
TE D
Table 4: The table shows complications encountered in our series of patients.
Conservative 35 8 12 7 14 76
Surgery 13 4 7 8 14 46
SC
Pre ASIA A B C D E Total
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
Table 5: Table shows the number of patients with different ASIA grade treated conservatively or surgically.
ACCEPTED MANUSCRIPT
Figure 4A
M AN U
SC
RI PT
Figure 4B
EP
TE D
Figure 4C
AC C
Figure 4A-C: A 21 year old male, with gunshot injury of cervicodorsal spine, presented with ASIA A. Figure 4A and 4B show his CT scan of cervical spine, with bullet lodged at the canal at D1 with tunnel injury and debris on the right side. Figure 4C shows, the intraoperative picture of the bullet removal and CSF leak repair.
ACCEPTED MANUSCRIPT
Highlights
RI PT
SC M AN U TE D EP
•
The TLICS and SCLIS scales do not predict the management of spinal injury due to gunshot. Patients with ASIA B and C after gunshot spinal injury, can improve if treated surgically. Optimizing blood pressure, can affect the patient’s outcome Patients who had lumbar gunshot injury had a better outcome compared to thoracic followed by cervical Gunshot injury patients should be considered for surgery when there is potential for improvement, if there is persistent cord compression, or deteriorating or incomplete neurology.
AC C
• • • •