Combat Associated

Penetrating Spine Injury

Ravanno Fanizza Harahap

 Introduction
• Combat-related penetrating spine injuries (PSIs) are due to firearms and explosive devices,
most notably improvised explosive devices (IEDs).

• PSIs account for up to 25% of all spinal cord injuries, of which approximately half present with
complete paraplegia and more than one-quarter are associated with other injuries.

• The thoracic spine accounts for the majority of injuries, with the lumbosacral and cervical
spine following in second and third, respectively.

• Given the relationship of kinetic energy (KE), mass (m), and velocity (v) (KE 5 1/2mv2), the
most critical factor affecting the destructiveness of a projectile is its velocity, making the
high-velocity PSIs seen in combat settings particularly devastating. Therefore, it is not
surprising that patients with military PSI in general have a worse neurologic injury on
presentation and have less potential for neurologic recovery than those with closed spinal cord
trauma.
 Indications
• Incomplete spinal cord injury with mass lesion in the spinal canal, with or without progressive
neurologic deficit
-While the literature is mixed regarding the exact benefit of decompressive surgery (usually in the form of
multilevel laminectomies), most still favor operative intervention in a medically stable patient with an
incomplete spinal cord injury and evidence of persistent cord compression such as bone or metallic fragments within
24–48 hours of the initial injury. An incomplete spinal cord injury may exist without impingement on the spinal canal due
to the energy released to the surrounding structures by the passage of the projectile
(i.e., “shock wave”). In this scenario, surgery is not recommended.
• CSF—cutaneous/pleural fistula
• Prolonged CSF leakage and its concomitant infectious risks constitute a definitive surgical
indication in PSI (Fig. 24.2).
• Fragment-induced nerve root compression
-Patients with both clinical and radiographic evidence of either bony or foreign body induced nerve root
compression should have the involved roots decompressed, ideally in the first 24–48 hours after injury.
 Indications
• Spinal instability
-Since the majority of civilian PSIs are from low-muzzle velocity handguns and knife wounds, biomechanical
instability is not, in general, an issue. As such, these patients require no instrumentation and/or fusion during
operative intervention. In combat PSI, however, the projectiles involved (bullets or fragments from an
explosive device) have a greater energy that can be dissipated to the surrounding anatomic structures, thus
increasing the likelihood of spinal instability. With high-velocity ballistic trauma, the rate of instability can approach 20%
and is most common in injuries with a side-to-side trajectory involving the facet joints bilaterally; however, the
concept of spinal stability remains nebulous and ultimately rests on a case-by-case consideration of multiple
clinical and radiographic findings with clinical intuition playing an equally strong role (Fig. 24.3).
-If the patient has a transgastrointestinal and unstable spinal injury, we recommend that instrumentation be
postponed until the patient has completed a full course of intravenous antibiotic therapy and, if necessary, the
abdomen has been thoroughly debrided and washed out by a general surgeon.
• Recent literature has established that the following clinical scenarios are not indications (in
and of them selves) for operative intervention:
-Complete spinal cord injury (in the absence of spinal instability or CSF leakage) (Fig. 24.4)
-Wound debridement/closure (in the absence of gross wound contamination)
-Copper- and/or lead-based fragments
*Given how rare heavy metal toxicity is with PSI, the composition of a fragment should not dictate
operative intervention based on current evidence.
 Preprocedure Considerations
Initial Evaluation

• Full evaluation/resuscitation protocol in accordance with the Advanced Trauma Life Support
(ATLS) guidelines.

• Detailed neurologic assessment to include motor function in all key muscle groups, sensory
status, reflexes, and sphincter tone as detailed by the American Spinal Injury Association
(ASIA) examination protocol.

• Examination of entrance/exit wounds for evidence of cerebrospinal fluid (CSF) leakage.

• Thorough evaluation and assessment of any associated soft tissue or visceral injuries.
 Preprocedure Considerations
Radiographic Imaging

Plain X-ray
• Demonstrates anatomic alignment, the presence or absence of overt bony injury, and the location of most retained
foreign bodies.

Computed Tomography (CT)

• Provides superior imaging of the bony anatomy and injury patterns. In addition, it also provides information regarding
the location of retained foreign bodies. Metallic streak artifact from retained foreign bodies may degrade the imaging.
• For cervical spine injury, CT angiography (CTA) should be performed on all patients to evaluate for carotid or vertebral
artery injury: disruption, dissection, thrombosis, or pseudoaneurysm formation. For thoracic or lumbar involvement, CTA
and CT venography should be done to evaluate for large vessel injury (e.g., thoracic and abdominal aorta, common iliac
arteries, inferior vena cava).
• CT myelography is rarely indicated in the acute setting; it may be valuable in a patient in whom magnetic resonance
imaging (MRI) is contraindicated but in whom concern exists for a compressive dural lesion not apparent on bone
windows such as an epidural or subdural hematoma.

MRI (When Available)

• Excellent for showing soft tissue anatomy: the integrity of the spinal cord, nerve roots, ligaments, muscles, joint
capsules,
and intervertebral disks. MRI is usually contraindicated in PSI if there are retained metallic fragments.
 Preprocedure Considerations
Initial Medical Management

• Admission to monitored setting.

• Immobilization until spinal stability established.
• Avoid hypotension (systolic blood pressure , 90 mmHg) and maintain mean arterial pressures
at 85–90 mmHg for the first 7 days if the patient has suffered a spinal cord injury.
-Use careful intravenous hydration with pressors (dopamine) if needed to maintain
mean arterial pressure (MAP) goals.
• Place in-dwelling (Foley) urinary catheter and nasogastric tube (connected to suction) to
prevent urinary retention and vomiting/aspiration, respectively.
• High-dose methylprednisolone is not indicated in the management of PSI.
• Stress ulcer and pharmacologic deep vein thrombosis prophylaxis is encouraged.
• High-dose broad-spectrum intravenous antibiotics given for 7–10 days are indicated,
especially in the case of a transabdominal trajectory with an associated bowel injury.
 Operative Considerations/Techniques
The patient with a PSI is at high risk for a wide range of perioperative complications that the
surgeon must anticipate and try to prevent. In a recent article by Possley et al, complications—
defined as unplanned medical events (surgical or nonsurgical) that require further intervention
occurred in 35% of service members with PSI who underwent surgical intervention.

Tactical Scenario
• Does the current tactical setting allow for operative intervention in a safe, sterile environment?

Associated Injuries
• For transthoracic injuries: Is the patient able to tolerate being prone from a respiratory and
hemodynamic standpoint?
• For transperitoneal injuries: Does the patient require intervention for a possible
intestinal/vascular injury? Can the patient tolerate being prone for the duration of the
operation?
 Operative Field Preparation
Radiographic Imaging
• Plain X-rays: For posterior thoracic approaches to determine the number of ribs for
localization

Equipment/Set-Up
• Headlight, loupes, bipolar/Bovie cautery
• Intraoperative uoroscopy
• Mayfield head holder: For posterior cervical approaches
• Prone table: Open/closed Jackson table with Wilson frame or bolsters depending on surgeon
preference for posterior thoracolumbar approaches
• Basic spine tray with Kerrison rongeurs
• High-speed drill
• Basic spinal instrumentation tray: Should have on stand-by for all cases
• Dural repair materials: Should have appropriate sutures (4-0 braided nylon, etc.) available for
primary dural repair, synthetic dural substitutes, and dural sealants for all cases.
Also, materials for thecal sac ligation if indicated should be available.
• Lumbar drain: Should have available if needed for CSF diversion in lumbosacral
decompressions.
 Operative Field Preparation
Anesthesia Issues
• Consider awake fiberoptic intubation if spinal instability suspected
• Prophylactic intravenous antibiotics 30 minutes prior to incision if not already on
broadspectrum antibiotics
• Foley catheter
• Arterial line to maintain mean arterial pressur, 85 mmHg for the entirety of the case.

Neuromonitoring
• Recommended if available for monitoring of somatosensory evoked potentials (SSEPs) and
electromyography (EMG).

Prepping/Incision
• Shave with electric hair clippers
• Surgical preparation in the standard sterile fashion
Operative Procedure
Instrumentation/Fusion
• If indicated, perform instrumentation and fusion after the primary operative goals of
decompression and dural repair have been accomplished.

Closing
• Suction canister/Jackson-Pratt drains if needed (avoid when dural repair performed).
• Close dorsal fascia in a watertight manner with interrupted 0-0 braided absorbable sutures.
• Close subcutaneous tissue with inverted, interrupted 2-0 braided absorbable sutures.
• Close skin with either staples or running 2-0/3-0 nylon suture.
 Postoperative Management
• Admission to a monitored setting with continued blood pressure goals as specified for up to 7
days after the initial injury.

• Monitor drain output with removal when output is minimal or if any concern exists for CSF
leakage.

• Obtain early postoperative imaging if instrumentation performed.

• Maintain appropriate antimicrobial coverage with intravenous antibiotics for 7 days if visceral
injury is confirmed.

• In the case of a low thoracic or lumbar dural repair, maintain the patient at for 48–72 hours
postoperatively. For cervical or proximal thoracic dural repairs, maintain the patient with the
head of bed at 90 degrees for 48–72 hours in the postoperative setting. In the case of mid-
thoracic dural repairs, the positioning of the patient postoperatively is at the discretion
of the operating surgeon.
 Postoperative Management
• Mechanical deep vein thrombosis (DVT) prophylaxis should be initiated upon admission and
continued throughout surgery and postoperatively. When it is determined to be appropriate,
institute pharmacologic DVT prophylaxis.

• Recommend postoperative scoliosis survey in the sitting or standing position (depending on

the patient’s clinical status) to provide baseline knowledge regarding regional and global
spinal balance. This should be repeated at regular intervals (as determined by the operating
surgeon) to monitor for any deformity progression in the post-surgical setting, particularly in
those patients with complete spinal cord injury and those with incomplete injury but who are
nonambulatory.
Thankyou