*3.5.1. Indication for surgery*

concluded that evidence exists for antibiotic treatment only for the first 24 h after initial

Most of the evidence exists for low-velocity injuries. There is less evidence guiding treatment recommendation in high-velocity injuries. We normally recommend empirically regimen of 3 days of prophylactic antibiotic which is discontinued if no sign of infection is observed.

The mainstay of imaging for MPSCI is the CT scan. In some cases a retained metal fragment can be found in chest and pelvic X-ray routinely done in the trauma bay; however, these can

CTA is usually available, is relatively quickly obtained, and gives sufficient information on other visceral injuries as well as bleeding. The only disadvantage is its inability to demonstrate neurological tissue with high accuracy. It should be reemphasized that an unstable patient should not be referred to CT prior to resuscitation and hemodynamic stabilization. In case of failure to achieve hemodynamic stability, patient should be taken to OR without any further delay. We routinely use CTA in any penetrating trauma as part of our protocol given

MRI has the ability to demonstrate neurologic tissue including direct and secondary injury. However, this is a time-consuming modality and probably not suitable for initial assessment in these scenarios. Some concern exists regarding retained metal fragment migration and further neurologic damage when performing the MRI. Copper and lead are the most common materials for bullet manufacturing. These materials are non-ferromagnetic and should not affect MRI [75]. The literature shows that MRI (up to 1.5 T) is safe to use in case of retained bullets [76–79]. Nevertheless, we recommend that the decision should be done on a case-to-

As mentioned above, other imaging studies may be used when clinical suspicion for specific

Management of acute missile-penetrating SCI is multidisciplinary. The treatment is guided by many factors, but first and above all, the patient's respiratory and hemodynamic stability are defined by the ATLS guidelines. A hemodynamically unstable patient, whose primary resuscitation has failed, should be transferred immediately to angiography or surgery suite

provide limited information regarding concomitant injuries and spatial orientation.

the advantage of demonstrating major vessel injury and extravasation.

case basis, especially if the penetrating missile is not a bullet.

debridement [74].

78 Essentials of Spinal Cord Injury Medicine

**3.4. Imaging**

*3.4.1. CTA*

*3.4.2. MRI*

*3.4.3. Others*

collateral organ damage is raised.

**3.5. Definitive treatment**

There are no clear clinical guidelines to direct the treatment pathway in MPSCI, and hence each case should be treated individually. Some issues, however, should be considered:

Wound care: in high-velocity GSW, an extensive wound debridement and lavage should be performed in the OR given the expected large infected cavity and "wound suction effect" inserting debris into the wound [8, 45, 80]. A low-velocity, civilian-inflicted GSW (gunshot wound) can be treated locally in the ER and observed.

Loss of neurologic function: progressive loss of neurologic function with radiographic evidence of neural tissue compression either by hematoma, bone fragment, or foreign body is an absolute indication for surgery [81–85]. There is no doubt that the initial neurological status will dictate the fate of the patient's neurological function [84]. There is only minor evidence that demonstrate neurological improvement following early (24–48 h) intervention. This is especially true if the insult occurs in the cauda equine area [82, 83, 86]. However, there is more evidence to show that there is no improvement following surgery, especially if the injury occurs between the levels of T1–T11 and definitely in complete injuries due to high-velocity GSW [49, 62]. In low-velocity civilian injuries, these types of injuries might have better prognosis, depending on what was the initial clinical presentation.

Despite the above details, some subgroups of patients may benefit from surgical intervention, even in the presence of a complete or nonprogressing injury. This includes complete injuries of the cervical spine where a potential recovery of an affected level is anticipated or when the injury raises a mechanical issue that might be solved with surgery (**Figure 2**). When intervention is considered, one should remember that it has been shown to result in about 20% of complications compared to 7% for nonsurgical treatment [87]. Clinical discretion should be used in all cases.

Foreign body removal: foreign body, e.g., bullet fragments, shrapnel, and intact bullets, is considered an absolute indication for removal in cases of incomplete SCI, definitely when it is progressive. When there is imaging evidence of cord compression, early intervention has been shown to be beneficial in many studies [47, 51, 88].

Removal of bullets in cases of complete and static SCI is not efficient and will not restore any neurological function [47, 62, 86].

Another possible indication for bullet removal from the spinal canal is the concern of fragment migration (**Figure 2**). This might happen early [89] or late [90, 91] in the course of injury, as shown in some sporadic cases. In both cases, neurologic deterioration had resolved following the surgery. That is why some surgeons suggest preventing this complication by surgically removing the foreign body, especially in cases with easy access and expectedly low complications.

surgery in order to prevent potential infection. Metal toxicity is usually not a concern since most materials used to manufacture bullets and shotgun pellets today are often made of cop-

Penetrating Spinal Cord Injury

81

http://dx.doi.org/10.5772/intechopen.76857

Lead toxicity or plumbism was shown to happen in cases of retained bullets in joint spaces and intervertebral disks [94, 95]. The symptoms can include anemia, abdominal pain, anorexia, nephropathy, lethargy, encephalopathy, and motor neuropathy, all of which can appear intermittently or continuously. Symptoms develop insidiously and can appear even 40 years after the exposure [96], making the diagnosis often challenging. Missiles retained in

Spinal instability: low-velocity spinal GSW involving the vertebral column are normally stable and do not mandate surgical stabilization. Risk of instability is higher with high-velocity injuries. Preventive stabilization should be considered if instability is anticipated following the surgery. There are reports claiming that stabilization may improve neurology [44], and

CSF leak: should bullet or other foreign bodies enter the spinal canal, durotomy is suspected. If a clinical presentation of post-LP syndrome (positional headaches, diplopia, photophobia, nausea, and neck stiffness) presents, surgical exploration should be considered. The preferable treatment is direct repair of the dural defect. This might prevent fistula formation, secondary meningitis, cord herniation, and neurologic impairment. If primary repair is not feasible, like in the ventral cervical and thoracic cord, fibrin glue combined with synthetic or local graft should be used. Submuscular drains are controversial. Position restrictions (upright for cervical injuries or reclining for lumbar) are not mandatory and case specific. Subarachnoid continuous drainage is optional as primary treatment for minor tears or as an adjuvant to surgical

The optimal timing of surgery for any indication is debatable [97–99]. Early surgical intervention has been reported to have less complication, while late intervention (more than 2 weeks)

No significant benefit of steroids has been shown [3]. A Cochrane review that shows some neurologic improvement in SCI following steroid administration (up to 8 h of injury) excluded

Empiric Intravenous antibiotic should be given for a minimum of 3 days and up to 2 weeks, in most cases. The covered spectrum should be wide in order to treat Gram-positive, Gramnegative, and anaerobic bacteria. This treatment was shown to prevent most infections includ-

This chapter is an overview of two relatively rare-penetrating spinal cord injuries, their epidemiology, mechanism of injury, initial evaluation, and emergency primary and late definitive

treatment. We also reviewed the complication and prognosis of each injury.

was associated with a high rate of arachnoiditis and spinal abscess [83].

per or lead.

repair.

penetrating injuries [100].

**4. Summary**

ing trans-colonic and trans-oral injuries [41, 81].

bone and soft tissues are usually asymptomatic.

other reports state that it may facilitate rehabilitation [37].

**Figure 2.** A 30-year-old patient, who sustained a low-velocity gunshot wound. He had a few entry wounds in his head and neck. He was conscious, alert, and hemodynamically stable with normal neurological status. The following images describe the evolution of events. (a) Plain radiograph showing the patient's skull with a bullet located at the center; (b) axial CT scan showing the broken arc of C1 with the bullet located next to the dens; (c) trans-oral approach to C1 vertebra with the bullet at the base of the surgical dissection. The smiley gives the orientation of the patient's face; (d) the bullet is shown outside of the patient's spine; (e) C1 ring following osteosynthesis.

The presence of foreign body inside the spinal canal was not shown to be associated with increased risk of infection, regardless of the previous path of the bullet, prior to its final location in the spinal canal [92, 93]. Thus, we do not consider bullet removal as an indication for surgery in order to prevent potential infection. Metal toxicity is usually not a concern since most materials used to manufacture bullets and shotgun pellets today are often made of copper or lead.

Lead toxicity or plumbism was shown to happen in cases of retained bullets in joint spaces and intervertebral disks [94, 95]. The symptoms can include anemia, abdominal pain, anorexia, nephropathy, lethargy, encephalopathy, and motor neuropathy, all of which can appear intermittently or continuously. Symptoms develop insidiously and can appear even 40 years after the exposure [96], making the diagnosis often challenging. Missiles retained in bone and soft tissues are usually asymptomatic.

Spinal instability: low-velocity spinal GSW involving the vertebral column are normally stable and do not mandate surgical stabilization. Risk of instability is higher with high-velocity injuries. Preventive stabilization should be considered if instability is anticipated following the surgery. There are reports claiming that stabilization may improve neurology [44], and other reports state that it may facilitate rehabilitation [37].

CSF leak: should bullet or other foreign bodies enter the spinal canal, durotomy is suspected. If a clinical presentation of post-LP syndrome (positional headaches, diplopia, photophobia, nausea, and neck stiffness) presents, surgical exploration should be considered. The preferable treatment is direct repair of the dural defect. This might prevent fistula formation, secondary meningitis, cord herniation, and neurologic impairment. If primary repair is not feasible, like in the ventral cervical and thoracic cord, fibrin glue combined with synthetic or local graft should be used. Submuscular drains are controversial. Position restrictions (upright for cervical injuries or reclining for lumbar) are not mandatory and case specific. Subarachnoid continuous drainage is optional as primary treatment for minor tears or as an adjuvant to surgical repair.

The optimal timing of surgery for any indication is debatable [97–99]. Early surgical intervention has been reported to have less complication, while late intervention (more than 2 weeks) was associated with a high rate of arachnoiditis and spinal abscess [83].

No significant benefit of steroids has been shown [3]. A Cochrane review that shows some neurologic improvement in SCI following steroid administration (up to 8 h of injury) excluded penetrating injuries [100].

Empiric Intravenous antibiotic should be given for a minimum of 3 days and up to 2 weeks, in most cases. The covered spectrum should be wide in order to treat Gram-positive, Gramnegative, and anaerobic bacteria. This treatment was shown to prevent most infections including trans-colonic and trans-oral injuries [41, 81].
