**2.4. Perioperative care**

(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

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

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

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

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

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

its interpretation.

72 Essentials of Spinal Cord Injury Medicine

**2.3. Treatment**

mandatory.

too small to dictate any clear conclusions.

probability of late complications in case of leaving it in place.

in cases with a complete SCI but exist also in incomplete SCI.

Intravenous administration of steroids in penetrating SCI has no role, and, moreover, it may raise the risk of infection [26, 27].

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