Evaluation of spinal missile injuries with respect to bullet trajectory, surgical indications and timing of surgical intervention: a new guideline.
METHODS
Analysis of the patients with spinal missile injury (SMI).


OBJECTIVE
Choosing the optimum treatment for SMI with respect to bullet trajectory, evaluation of surgical indications, and timing of surgical intervention.


BACKGROUND
A few guidelines were reported for the management of SMI. But there is still no consensus about the indication and timing of the surgery. The relationship between the surgery and bullet trajectory was not reported previously.


METHODS
One hundred twenty-nine patients with spinal missile injury were admitted to our department from 1994 to 2006 and 122 of them could be functionally monitored. Functional recovery and complications in surgical and conservative treatment groups were evaluated. Surgical indications were discussed. The injuries were classified with respect to the bullet's trajectory. Seventy-four patients were treated surgically, of whom 60 (81%) had incomplete injuries. All 17 patients whose vertebral column was injured with side-to-side trajectory were operated on because of instability.


RESULTS
In the surgical group, 33 (56.9%) showed improvement, 20 (34.5%) showed no change, and 5 (8.6%) worsened. The best results were obtained by the patients who received operations because of rapid neurologic decline, compression, and instability in the spinal canal (P < 0.0001). Twenty-three (31%) complications and associated injuries were seen in the surgically treated patients and 18 (34.6%) were seen in the conservatively treated patients.


CONCLUSIONS
Anteroposterior and oblique trajectories [Gulhane Military Medical Academy (GATA)-SMI I and GATA-SMI II] of SMI must be recognized as highly infective in the lumbar region. A side-to-side trajectory (GATA-SMI III) missile causing spinal cord injury is unstable and needs further stabilization. The spinal cord is not injured by the GATA-SMI IV trajectory, and thus, the best approach in this case is conservative. The best results from neurosurgical interventions may be achieved after rapid neurologic deteriorations because of spinal compression and/or instability.
Duz
Bulent
B
Gulhane Military Medical Academy, Department of Neurological Surgery, Etlik, Ankara, Turkey. bulentduz@gmail.com
Cansever
Tufan
T
Secer
Halil Ibrahim
HI
Kahraman
Serdar
S
Daneyemez
Mehmet Kadri
MK
Gonul
Engin
E
D000328:Adult; D006801:Humans; D008297:Male; D017410:Practice Guidelines as Topic; D011859:Radiography; D013119:Spinal Cord Injuries / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D013997:Time Factors; D015599:Trauma Severity Indices; D016896:Treatment Outcome; D014950:Wounds, Penetrating / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*