A Review Paper Gunshot Wounds to the Spine: Literature Review and Report on a Migratory Intrathecal Bullet Edward Moon, MD, Dimitriy Kondrashov, MD, Matthew Hannibal, MD, Ken Hsu, MD, and Jim Zucherman, MD more likely than blunt trauma to cause complete spinal Abstract cord damage, and have their highest incidence in young Treatment of the complex injury to the spine pro- minority males.2-4 Initial management of a patient with duced by a gunshot wound remains controversial. a gunshot wound must include following standard Treatment depends on the physician’s ability to under- trauma protocols, with maintenance of airway, breath- stand mechanism of injury, principles of medical man- ing, and circulation taking precedence. Evaluation agement, diagnostic imaging, and surgical options. should be guided by area of injury: Gunshot wounds to Antibiotics are an important component of treatment and should be continued for a minimum of 7 days in the neck may be complicated by injuries to the airway cases of wounds that both perforate the colon and or esophagus; wounds to the thoracic region are at risk injure the spine. Corticosteroids do not affect neu- for damaging major organs, including the heart, lungs, rologic outcome and therefore should not be used. and bowel; and sacral injuries are most often compli- Decompression and removal of intracanal bullets cated by hemorrhage.5,6 at T12 and below may improve motor function. In select cases of cervical injuries, removal of intraca- nal bullet fragments may be justified, particularly with incomplete lesions. Regardless of injury level, new- “Periodic examination, onset or progressive neurologic deterioration is an indication for urgent decompression. Optimal surgi- preferably by the same cal timing remains a controversial issue, and more physician, is needed to assess study is needed to develop treatment guidelines. Intrathecal migratory missiles represent a very rare sub- any deterioration in neuro- set of the gunshot wounds to the spine, and their treat- ment should be individualized. In this article, we review logic function...” the literature and then describe the case of a migratory intrathecal bullet in the lumbar spine of a patient who After the patient is stabilized, the spinal injury should presented with cauda equina–type symptoms. be thoroughly evaluated. Important history may include information about type of weapon used, number of shots INITIAL EVALUATION AND MANAGEMENT fired, and proximity of shot(s). This information provides Gunshot wounds to the spine are potentially devastat- important clues regarding extent of injury and will guide ing injuries that account for approximately 13% to treatment decisions. The physical examination is equally 17% of all spinal cord injuries every year.1 Gunshot important in assessing gunshot patients. A complete wounds are most common in the thoracic region, are neurologic examination must be performed to document motor function, reflexes, and sensation at time of injury. Periodic examination, preferably by the same physician, Dr. Moon is Orthopaedic Surgery Resident, University of is needed to assess any deterioration in neurologic func- Washington, Seattle, Washington. tion because it may affect treatment decisions. A rectal Dr. Kondrashov is Orthopaedic Spine Surgeon, Dr. Hannibal is Orthopaedic Spine Surgeon, Dr. Hsu is Orthopaedic Spine examination should also be performed. Entrance and Surgeon, and Dr. Zucherman is Orthopaedic Spine Surgeon, St. exit wounds should be inspected and radiopaque markers Mary’s Spine Center, San Francisco, California. placed over all wounds to help identify the gunshot path in radiographic studies. Address correspondence to: Dimitriy Kondrashov, MD, San Initially, 2 orthogonal plain radiographic views of the Francisco Orthopaedics, One Shrader Street, Suite 650, San Francisco, CA 94117 (tel, 415-513-5865; fax, 415-221-0687; e- spine must be obtained to locate fragments of the bullet mail, [email protected]). and detect fractures. This should be followed by computed tomography (CT), which is the study of choice, as it allows Am J Orthop. 2008;37(3):E47-E51. Copyright, Quadrant for more precise localization of the bullet fragments within HealthCom Inc., 2008. All rights reserved. the spinal canal or vertebral segments.7 Although magnetic March 2008 E47 Gunshot Wounds to the Spine resonance imaging (MRI) is better for detecting soft-tissue SURGICAL INDICATIONS damage and produces less artifact, its use remains con- The decision to perform surgery depends on 4 main vari- troversial because of the potential for bullet fragments to ables: neurologic status, spinal stability, bullet location, migrate and cause additional neural injury.7,8 However, a and injury level. Structured algorithms that may facilitate detailed study of morbidity associated with MRI use after treatment decisions for blunt and penetrating chest and gunshot wounds to the spine has not been conducted, and abdominal trauma were described by Bishop and col- numerous investigators have demonstrated that MRI can be leagues.2 However, the mortality rate was not substan- used safely in the appropriate clinical context.7 tially higher for these gunshot patient protocols than for treatments that deviated from the algorithms.2 There is ROLE OF ANTIBIOTICS a continued need for well-studied protocols, specific to AND STEROIDS spinal gunshot injuries, to simplify treatment decisions and Aggressive medical management is indicated for all improve the standard of care. spinal gunshot wound patients. Tetanus prophylaxis is Neurologic Status. Neurologic status is best evaluated required, especially if immunization status is unknown. in thorough serial examinations by a single experienced Moreover, broad-spectrum antibiotics should be started observer who can accurately document findings. Patients immediately, regardless of injury location and without with a progressive or new-onset neurologic deficit with a delaying treatment for wound culture, which has limited radiologically identifiable cause—including patients with utility in this setting.7,9 Recommendations regarding opti- bone fragments, bullet fragments, or compressive epidural mal length of antibiotic treatment vary in the literature. hematoma—should be treated with urgent decompression The decision should be based on clinical assessment of regardless of other factors.2,7 In neurologically intact the wound, injury location, and whether a viscus was patients, there are relatively few indications for surgery, perforated. Antibiotic prophylaxis of gunshot wounds as overly aggressive treatment may result in additional that have not perforated the viscera should continue for a injury.7 Recently, Medzon and colleagues15 retrospec- minimum of 48 to 72 hours. If the injury is complicated tively reviewed 81 patients with cervical spine gunshot by viscus perforation before the bullet enters the spine, injuries and reported a low rate of fracture and instabil- however, antibiotics should be continued for 7 to 14 days, ity in alert, neurologically intact patients. Decompression particularly with colonic wounds.10-12 after complete and incomplete spinal cord injuries was Roffi and colleagues11 retrospectively studied 42 patients studied by Stauffer and colleagues.16 Of the 185 cases of with gunshot wounds to the spine. In each case, the bullet gunshot paralysis, approximately half were treated with perforated the viscus before entering the spine. Various observation; the other half were treated with decompres- combinations of antibiotics were used, including cefoxitin, sion. For complete injuries, there was no statistical dif- gentamicin, clindamycin, and penicillin, for a minimum ference between those treated surgically and those treated of 6 days. There were 3 spinal infections, 2 paraspinal nonsurgically. For incomplete injuries, 77% of nonsurgi- abscesses, and 1 case of meningitis. More recently, Kumar cally treated patients and 71% of surgically treated patients and colleagues10 found, in 13 patients with spinal gunshot showed neural improvement. Surgically treated patients wounds and colonic perforation, no spinal infection after also experienced a higher rate of complications, including treatment with antibiotics for 7 days. Optimal antibiotic wound infections, spinal fistulae, and late spinal instabil- treatment for spinal cord gunshot injuries after esophageal ity. It is important to note that spinal injuries from gunshot and upper airway perforation is unclear. There is a need for wounds are not always accompanied by neurologic impair- controlled studies to demonstrate the effects of antibiotics ment.17 Recently, Klein and colleagues17 reported a sig- in these situations. Regardless of viscus perforation, use of nificant incidence of spinal injury in asymptomatic gunshot diverting colostomies and surgical débridement does not wound patients and recommended complete radiographic appear to affect the rate of spinal infection.7 imaging to ensure that spinal injuries are not missed in this Recent Findings About Steroids. Until recently, the population. role of corticosteroids in the treatment of spinal gunshot Spinal Stability. Criteria for spinal stability after gun- wounds was undetermined. Levy and colleagues13 ret- shot injuries are not well established. Previously, the 3- rospectively reviewed 252 cases of spinal cord gunshot column theory for spinal stability popularized by Denis18 injuries and concluded that use of methylprednisolone did was applied to gunshot injuries of the spine.7 Unlike