**3. Missile-penetrating spinal cord injury**

Missile-penetrating spinal cord injury (MPSCI) can be a devastating event and may cause severe and long-term morbidity and mortality. As in other SCI, these injuries have a substantial economic and psychosocial burden to patient, their family, and society.

MPSCI was first described in 1762 by a surgeon named Andre Louis that removed a bullet from the lumbar spine of a patient, who later on regained motion in his lower extremities [9].

Many famous fatalities of MPSCI are known throughout the history. Among them was Lord H. Nelson who was shot by a French sniper in the Trafalgar battle. The injury was to his shoulder, and he was described as experiencing immediate paraplegia. He died shortly after. Other known cases were the American presidents, J.A. Garfield and A. Lincoln. As a general rule, these injuries have a high rate of mortality and hence discouraged any treatment for many centuries [31]. Only at the end of World War II, surgeons started to treat it aggressively. Pool had reported [32] 57% marked neurological improvement with laminectomy compared with only 4.5% spontaneous improvement with previously untreated patients. Later, studies that were published following the Korea and Vietnam wars had shown no benefit of laminectomies in cases of complete and incomplete SCI. They concluded that surgery should be considered only in grossly contaminated wounds and for patients with progressive neurological deterioration [33–35].

MPSCI can be divided by the kind of the penetrating missile, that is to say, bullet vs. shrapnel or any other foreign body that penetrates, by blast, the patient body. Another way to classify these injuries is by the muzzle velocity of the shouting firearm: high versus low. The third option would be to classify them by the amount of penetrating particles—a solitary missile penetration versus multiple, usually combined with a blast injury. Segregation can also be done for civilian versus military injuries.
