**2.3. Treatment**

As mentioned above, initial treatment of these injuries should be treated as any other traumatic injury, by the ATLS guidelines. After securing airway breathing and circulation, the spine surgeon can address the NMPSCI. The management of regimen to date is still controversial, which is understandable given the low prevalence of these injuries. To date no guidelines exist as for the proper management plan, and the published series described are too small to dictate any clear conclusions.

Most authors agree that in cases of progressive neurological deficits, radiographic evidence of neural tissue compression, or persistent CSF leak, early intervention should be considered. In case of spinal canal penetration with no neurological deficit or CSF leak, surgery is not mandatory.

There is no clear evidence that removal of the retained foreign body will improve the neurological status. The literature describes conflicting reports where in some, foreign body removal improves neurological status and in others, neurological improvement was seen even with retained small fragments. Unfortunately, no RCT (randomized control trials) are available to guide us which option is better. Therefore, each case should be evaluated independently. One should judge the potential damage of extracting the penetrating object compared with the probability of late complications in case of leaving it in place.

In most cases, decompressive procedures, most commonly laminectomies, hemilaminectomies, and dural exploration, are the procedures of choice, mainly because the injury comes from the back. In other rarer cases, mainly in the cervical spine, anterior decompression is indicated.

Most NMPSCI are considered as stable spine injuries, and in an awake and alert patient without distracting injury, clearance of the spine can be done by clinical examination [11, 13, 14].

The surgical management of NMPSCI is a controversial topic [2, 6, 12, 14, 15]. This is more so in cases with a complete SCI but exist also in incomplete SCI.

The literature supports the fact that early surgical intervention for spinal cord injuries caused by low-velocity missile-penetrating injuries (bullets) does not improve the neurological status [1]. There is no clear-cut evidence regarding NMPSCI given the infrequency of these injuries. Case reports describe improvement of the neurological status following emergent or late surgical removal of the foreign body, in some cases even months after the injury [12, 19]. However, this improvement can occur without intervention as well, as reported by others [2] who recommended observation only, in most of their patients. Surgical intervention in NMPSCI may reduce late complications such as decreasing infection rate, cerebrospinal fluid fistula, and arachnoiditis. Delayed myelopathy has been described years following injury with a retained foreign body up to 36 years after the primary insult [12]. When there is rapid progression of neurological deficit or in case of incomplete SCI with radiographic evidence of cord compression (i.e., expanding hematoma, bony fragments, or a retained foreign body), it is a consensus to proceed with immediate surgical intervention.

Positioning a patient with a retained knife handle protruding from his upper back is a challenge. Intubation in an alert patient must be done on a lateral decubitus position, to avoid further damage. Fiber optic-assisted intubation is preferable in difficult cases.

Essential part of surgery is canal decompression. Ideally, it should be done from an uninjured part of the dura mater to the next uninjured space, one level distal and one proximal to the injured loci.

Direct repair of the dura in the immediate setting is controversial, especially in the thoracic spine. This area of the spine is the narrowest along the spinal column. Moreover, blood supply to this segment has been described as the watershed area. Direct repair of the dura mater in this zone raises concern of cord compression secondary to neural tissue swelling. This is why it was proposed by some authors to apply collagen matrix on the defect instead of primary closure. Others are more concerned with the risk of infection and thus repeal any use of sealing material [25].
