*2.2.5. Others*

Other imaging studies may be used when clinical suspicion for specific collateral organ damage is raised. This may include sonography, Doppler, endoscopy, and barium contrast imaging studies. Those studies are not routinely used, and the need depends on the site of injury (thoracic vs. cervical), clinical examination, and the results of CTA. Sonography is a quick, noninvasive, and readily available tool; however, the technique is highly operator-dependent, and air from the injury, artifacts from retained metallic fragments, and hematoma can limit its interpretation.

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

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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

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

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

Intravenous administration of steroids in penetrating SCI has no role, and, moreover, it may

Preventive antibiotic treatment in the perioperative period is controversial. The incidence of meningitis following NMPSCI is very low [2]. However, the incidence of soft tissue infection around the stab wound is high. There are no evidences as to what is the recommended antibiotic therapy for these injuries; thus, no protocol was published. In the Lipschitz study [6], only 4 out of 252 patients developed meningitis and 2 developed superficial abscess. The authors did not describe whether these patients were treated with antibiotics around the surgery. They mentioned that antibiotics were prescribed to these six patients, only after sepsis was diagnosed. Our policy is to treat these patients empirically, like with open fractures, with a wide range of antibiotic therapies. When canal penetration is evident, we include CSF-

penetrating agents such as third-generation cephalosporin, for 3 days.

Oxidation of metallic fragments and rust deposit were also described [28].

Complications can be related to the spine injury itself or to the surrounding organs.

Spine-associated complications are continuous CSF leak; infection (less than 1% will develop chronic abscess and osteomyelitis) and rarely meningitis; chronic epidural granulation (sometimes will present as progressive myelopathy); and there are reports of arachnoiditis and syringomyelia. Retained foreign body reaction may present as late-onset myelopathy due to foreign body migration. Metal particles such as copper or silver may cause a marked inflammatory reaction, while nickel and lead particles can be a source of an intermediate reaction.

further damage. Fiber optic-assisted intubation is preferable in difficult cases.

is a consensus to proceed with immediate surgical intervention.

injured loci.

sealing material [25].

**2.4. Perioperative care**

**2.5. Complications**

raise the risk of infection [26, 27].
