title: Evaluation of spinal missile injuries with respect to bullet trajectory, surgical indications and timing of surgical intervention: a new guideline.
abstract: 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.
authors.affiliation: Gulhane Military Medical Academy, Department of Neurological Surgery, Etlik, Ankara, Turkey. bulentduz@gmail.com
authors.forename: Bulent
authors.initials: B
authors.lastname: Duz
authors.forename: Tufan
authors.initials: T
authors.lastname: Cansever
authors.forename: Halil Ibrahim
authors.initials: HI
authors.lastname: Secer
authors.forename: Serdar
authors.initials: S
authors.lastname: Kahraman
authors.forename: Mehmet Kadri
authors.initials: MK
authors.lastname: Daneyemez
authors.forename: Engin
authors.initials: E
authors.lastname: Gonul
mesh_terms: 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*