Christopher M Bono1, Robert F Heary. 1. Department of Orthopaedic Surgery, Boston Medical Center, Boston University School of Medicine, Dowling 2 North, One Boston Medical Center Place, Boston, MA 02118-2393, USA. bonocm@prodigy.net
Abstract
BACKGROUND CONTEXT: The incidence of violent crimes has risen over the past decade. With it, gunshot injuries have become increasingly more common in the civilian population. Among the most devastating injuries are gunshot wounds to the spine. PURPOSE: The purpose of this article is to provide a thorough review of the pathomechanics, diagnosis and treatment of gunshot wounds to the spine. STUDY DESIGN/ SETTING: Literature review article. CONCLUSIONS: Treatment of gunshot spine fractures differs from other mechanisms. Fractures are usually inherently stable and rarely require stabilization. In neurologically intact patients, there are few indications for surgery. Evidence of acute lead intoxication, an intracanal copper bullet or new onset neurologic deficit can justify operative decompression and/or bullet removal. Overzealous laminectomy can destabilize the spine and lead to late postoperative deformity. For complete and incomplete neural deficits at the cervical and thoracic levels, operative decompression is of little benefit and can lead to higher complication rates than nonsurgically managed patients. With gunshots to the T12 to L5 levels, better motor recovery has been reported after intracanal bullet removal versus nonoperative treatment. The use of steroids for gunshot paralysis has not improved the neurologic outcome and has resulted in a greater frequency of nonspinal complications. Although numerous recommendations exist, 7 to 14 days of broad-spectrum antibiosis has lead to the lowest rates of infection after transcolonic gunshots to the spine.
BACKGROUND CONTEXT: The incidence of violent crimes has risen over the past decade. With it, gunshot injuries have become increasingly more common in the civilian population. Among the most devastating injuries are gunshot wounds to the spine. PURPOSE: The purpose of this article is to provide a thorough review of the pathomechanics, diagnosis and treatment of gunshot wounds to the spine. STUDY DESIGN/ SETTING: Literature review article. CONCLUSIONS: Treatment of gunshot spine fractures differs from other mechanisms. Fractures are usually inherently stable and rarely require stabilization. In neurologically intact patients, there are few indications for surgery. Evidence of acute lead intoxication, an intracanal copper bullet or new onset neurologic deficit can justify operative decompression and/or bullet removal. Overzealous laminectomy can destabilize the spine and lead to late postoperative deformity. For complete and incomplete neural deficits at the cervical and thoracic levels, operative decompression is of little benefit and can lead to higher complication rates than nonsurgically managed patients. With gunshots to the T12 to L5 levels, better motor recovery has been reported after intracanal bullet removal versus nonoperative treatment. The use of steroids for gunshot paralysis has not improved the neurologic outcome and has resulted in a greater frequency of nonspinal complications. Although numerous recommendations exist, 7 to 14 days of broad-spectrum antibiosis has lead to the lowest rates of infection after transcolonic gunshots to the spine.
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