Gunshot injuries of the spine – a review of
49 cases managed at the Groote Schuur
Acute Spinal Cord Injury Unit
Registrar, Department of Orthopaedics, Stellenbosch University
R. N. DUNN, M.B. CH.B., M.MED. (ORTH.), F.C.S. (S.A.) (ORTH.)
Head of Spinal Services, Division of Orthopaedics, University of Cape Town
dence of gunshot injuries. The Groote Schuur Trauma Unit
sees between 70 and 120 gunshot injuries a month. Many ofthese involve the musculoskeletal system, and some the
The Acute Spinal Injury Unit, relocated from Conradie
spine. This is in stark contrast to the European experience.
Hospital to Groote Schuur Hospital in mid-2003, admit-
Of 34 903 trauma cases seen in Scotland over 28 years there
ted 162 patients in the first year of its existence. A large
was only 1 case of gunshot injury of the spine.1
number of these injuries were the result of interpersonal
The Acute Spinal Cord Injury Unit (ASCI), previously
violence, particularly gunshot wounds.
based at Conradie Hospital, was relocated to Groote Schuur
. To review patients with gunshot injuries to the
Hospital in 2003 as part of the government’s 2010 plan.
spine, with reference to neurological injury, associated
This unit manages spinal cord injuries from the region on a
injuries, need for surgery and complications.
referral basis. During the first year of opening, 162 patients
. A comprehensive database is maintained to
were admitted with various spinal injuries. A large propor-
collect data on all spinal injury admissions. These data,
tion of these were gunshot injuries of the spine.
as well as case notes and X-rays, were reviewed for all
A review of this subset of patients is presented.
gunshot spine patients admitted to the Acute SpinalInjury Unit over a year.
Forty-nine patients were identified. Thirty-eight were
male and 11 female with an average age of 27.5 years(range 15 - 51 ± 8.53). The average stay in the acute
All admissions to the ASCI unit are entered in a database.
Included in the data recorded is the mode of injury and the
The spinal injury was complete in 38 and
neurological status. The latter is classified according to the
incomplete in 8, with 3 having no neurological deficit.
American Spinal Injury Association (ASIA) scoring system,
The level was cervical in 13, thoracic in 24 and lumbar in
with motor function attributable to C5 - T1 and L2 - S1
12. Only 9 patients improved neurologically. The spine
roots allocated a score between 1 and 5 based on the
was considered stable in 43 cases. Stabilisation was
Medical Research Council (MRC) power. This is done
performed in the 6 unstable cases. The bullets were
bilaterally. In addition sensation is scored in a similar fash-
removed in 11 cases as they were in the canal.
ion on a provided form. The subsequent management, com-
There were 55 significant associated injuries, viz. 14
plications and discharge neurological status are also
haemo-pneumothoraces, 16 abdominal visceral injuries,
3 vascular injuries, 4 injuries of the brachial plexus and 3
Patients with gunshot injuries of the spine were identified
of the oesophagus, 2 tracheal injuries, 1 soft palate
from this database. Their case notes and X-rays were
reviewed retrospectively, with a view to procedures per-
Complications included 3 deaths and discitis in 3
formed, complications and neurological change. The
cases, pneumonia in 6 and pressure sores in 6.
patients referred to the local rehabilitation service were
. Gunshot injuries of the spine are a preva-
reviewed for further change in neurological status.
lent and resource-intensive cause of paralysis. There is
A total of 49 patients with gunshot injuries of the spine
a high incidence of permanent severe neurological
were identified. Of these, 47 were from the ASCI service
deficit, but usually the spine remains mechanically sta-
and 2 from the adjacent private facility (University of Cape
ble. Most of the management revolves around the asso-
ciated injuries and consequences of the neurological
All the injuries were from low-velocity weapons, as is typi-
cal for our population. The most frequent calibre was 9 mm.
Of the 49 patients, 38 were male and 11 female. The aver-
With the high level of crime in the Western Cape, the state
age age was 27.5 (15 - 51 ± 8.53) years. The average in-hos-
hospitals have witnessed a tremendous increase in the inci-
pital stay was 30 (4 - 109 ± 28) days. Once the acute
management was completed patients were discharged orreferred to the rehabilitation service depending on their neu-rological status. The rehabilitation service required patientsto be free of pressure sores before admittance. This led tosome of the prolonged hospital stays.
The anatomical level and neurological status of the spinalinjuries are tabulated in Table I. The vast majority werecomplete neurological injuries, with no incompletes in thethoracic group. Only 9 patients improved neurologically.
Three cervical completes regained 5 - 7 ASIA motor points.
This represents a single level of improvement, and probably
Fig. 1. CT scan of comminuted body regarded as
indicates root escape rather than true cord recovery. One
complete patient regained 10 motor points and good sensoryrecovery.
Bullets in the canal
Of the 4 cervical incomplete injuries, 1 patient with no
bony fracture recovered spontaneously. This was thought to
The bullet was found to be in the canal in 12 cases – 1 cervi-
be because of cord contusion as the bullet did not violate the
cal, 4 thoracic and 7 lumbar. One patient absconded for
canal or column. Another patient improved from a total of
fear of retribution. The rest underwent surgery to remove
85 motor points to 98 at 3 months. This patient had a body
fracture. None of those who recovered had violation of theircanals.
There was no recovery in the thoracic group.
Three patients improved in the lumbar injury group. One
There were many associated injuries, as listed in Table II.
patient improved from 70 to 88 motor points, then
Of the 4 brachial plexus injuries, 3 were related to the cur-
plateaued. This patient is now ambulatory with crutches.
rent injury and 1 to a previous gunshot wound. The latter
Another had a 5-point improvement. Both of these were
patient’s current injury was thoracic, and the brachial plexus
incomplete injuries. Another patient judged on admission to
injury was only explained when the X-ray revealed a previ-
have a complete lumbar injury had return of distal motor
ous bullet near the plexus. There was a high incidence of
function after removal of the bullet.
associated chest trauma, with 14 cases having haemotho-races, pneumothoraces or lung contusions. These required
intercostal drains to be inserted. There were 2 vertebralarterial injuries, one arteriovenous fistula requiring repair
The injury involved the posterior elements in 25 cases, the
and an axillary artery also requiring repair. Laparotomies
body in 15 cases, and both in 2. There were no fractures in
were performed in 9 patients for visceral injuries (Table III).
Our assessment of stability was based on the three-column
system of Denis,2 as described for thoracolumbar fractures
TABLE II. ASSOCIATED INJURIES (N)
from indirect forces. This was modified by the realisation
that gunshot injuries are different to indirect forces, as they
are not associated with posterior column ligamentous
Soft palate (Fig. 2)
injuries. Six patients were assessed as unstable. This was
usually based on severe comminution of the anterior column
(Fig. 1), where it was felt that progressive kyphosis would
occur. Three patients had cervical and 3 had thoracolumbar
injuries. The cervical injuries were fused anteriorly by
means of an autogenous bone graft and plate, whereas the
Liver, spleen, pancreas
thoracolumbar injury patients underwent posterior pedicle
TABLE I. NEUROLOGICAL STATUS PER
TABLE III. ABDOMINAL SURGERY (N)
*Parentheses indicate number of patients with neurological improvement.
VOL 43, NO. 4, NOVEMBER 2005 SAJS
where if 2 columnsare involved the spineis considered to beunstable. In an indi-rect non-penetratingforce, one can extrap-olate that if there issevere anterior col-umn destruction,there is likely to beposterior ligamentousinjury. One then hasa clear indication formechanical stabilisa-tion. In gunshotinjuries of the spine itis possible for a singlecolumn to be injuredwithout associated lig-amentous injury.
Once there is an iso-lated body fracture itis often difficult todecide whether therewill be progressive
Fig. 2. Gunshot C1 (transoral) with C1 arch fracture,
no neurology. The bullet was spontaneously spewed
out and the patient discharged.
spine, where there issupport from the tho-
Six patients developed pneumonia, and 6 developed pressure
sores. Only one deep-vein thrombosis was diagnosed. Three
patients developed a pyogenic discitis (Fig. 3). Three deaths
occurred and 1 patient developed postoperative sepsis.
Fig. 3. Magnetic resonance
image of subsequent discitis fol-
lowing a gunshot injury of the
Gunshot injuries of the spine are endemic in the Western
Cape. Management protocols have evolved as the incidence
kyphosis is extremely functionally limiting in cases of quadri-
has changed. Civilian low-velocity gunshot injuries are vastly
or paraplegia, and we therefore proceed to anterior instru-
different from the military experience which provided much
mented fusion in these cases. Our conservative stance is
of the earlier experience. As one would expect, survival is far
echoed by others. Cornwell et al
.6 reported on 141 thoracic
likelier in the low-velocity group. Many facets of manage-
spine gunshot fractures. Only 2 required surgical stabilisa-
ment have been adopted from management of spinal injuries
tion. Isiklar and Lindsey7 found that 10% were unstable in
resulting from indirect trauma. Not all of these are appropri-
their series. Three cases were cervical and 1 was lumbar.
Removal of bullets remains controversial. Concerns
High-dose steroid administration for indirect, non-pene-
regarding lead toxicity (plumbism) have been reported.8,9 The
trating trauma has been promoted by Bracken and Shephad3
incidence is rare and should probably not be used as a reason
in the first 8 hours following indirect spinal cord injury.
to remove all bullets. Bullets in disc spaces and joints are
Despite this being of doubtful clinical benefit in this non-
more likely to release heavy metals. Scuderi et al
penetrating trauma group, some still administer steroids to
only 12 cases of bullets in disc spaces over a 24-year period
patients with gunshot wound injuries of the spine. Heary et
among 238 gunshot injuries of the spine. Only 1 of these 12
4 and Levy et al
.5 have shown that there is no benefit in
developed clinical signs of lead toxicity. They recommend
terms of neurological recovery in penetrating injuries. If one
that rather than imperative bullet removal, signs of lead toxi-
considers the risks of infection and immune compromise, it
is illogical to administer steroids if there is no evidence of
Bullets in the canal are more of a concern. Basic science
neurological benefit. We therefore regard administration of
research has shown that of the heavy metals likely to be in
steroids in the gunshot spine scenario as inappropriate.
bullets, copper is the most toxic to the cord in the animal
The issue of spinal stability in mechanical terms is a diffi-
model.11 Bono and Heary12 reviewed the topic well and com-
cult one, as there is no good classification for gunshot
mented that firstly one should ‘do no harm’. Removal of the
injuries, making interpretation somewhat subjective. Much
bullet did appear to alter the rate and incidence of neurologi-
of our knowledge and experience are based on indirect
cal recovery, but there was an increased incidence of infec-
injuries. Many base this on the 3-column system of Denis,2
Waters and Adkins13 reported that bullet removal did not
Generally the spine is mechanically stable and the neurologi-
alter infection rates or sensory recovery. However, in the
cal status static. Management revolves largely around the
cauda equina region they found that removal may increase
associated injuries and supportive care of the paraplegia.
the neurological recovery. This was also observed in our
Steroid administration is not indicated in these injuries.
cohort. Of course one cannot be sure this was not simply a
Although bullets should not be removed routinely, there is a
matter of passage of time rather than the actual intervention.
case for removal if they are in the canal, especially if the
The current policy of our unit is to remove the round after
a few days, to allow the dura to seal and inflammation to
Because of the high incidence of associated injuries and
resolve. When retrieving bullets from the canal it is impor-
permanent neurological deficit, gunshot injuries of the spine
tant to have recent X-rays available and imaging in theatre.
The bullet may move. In our series there was a case of entryat L3, but the bullet was removed from S1 posteriorly.
There are case reports that confirm this ‘wandering’ of thebullet.14,15 This tends to be in a caudal direction because of
Connell RA, Graham CA, Munro PT. Is spinal immobilisation neces-sary for all patients sustaining isolated penetrating trauma? Injury
widening of the canal from T10 downwards.
Decompression has frequently been performed in an
Denis F. The three columns of the spine and its significance in the clas-
attempt to improve neurological outcome. The results of
sification of acute thoracolumbar spine injuries. Spine
intervention must be seen against natural history, where
Bracken M, Shephad M. Administration of methylprednisolone for 24or 48 hours or tirilazad mesylate for 48 hours in the treatment of ASCI.
spontaneous improvement may occur. This may be an addi-
Results of the 3rd National Acute Spinal Cord Injury Randomized
tional root level, as seen in our study, or more significant
Controlled Trial, NASCIS. JAMA
recovery in incomplete injuries where a degree of spinal cord
Heary RF, Vaccaro AR, Mesa JJ, et al
. Steroids and gunshot wounds to
the spine. Neurosurgery
contusion may have occurred. In our study no patient with
Levy ML, Gans W, Wijesinghe HS, SooHoo WE, Adkins RH,
cervical or thoracic canal violation showed recovery. In
Stillerman CB. Use of methylprednisolone as an adjunct in the manage-
those who recovered, it would appear that the recovery was
ment of patients with penetrating spinal cord injury: outcome analysis.Neurosurgery
because of resolving cord contusion. These cases were body
Cornwell EE 3rd, Chang DC, Bonar JP, et al.
fractures and probably cord injuries owing to the local energy
lization for trauma patients with torso gunshot wounds: is it necessary?
Various authors have reported on decompression in this
Isiklar ZU, Lindsey RW. Low-velocity civilian gunshot wounds of the
scenario. Kahraman et al
.16 reported on 106 patients, where
Linden MA, Manton WI, Stewart RM, Thal ER, Feit H. Lead poison-
60% were operated on. There was similar recovery in both
ing from retained bullets. Pathogenesis, diagnosis, and management.
the surgically managed group and the conservatively man-
Grogan DP, Bucholz RW. Acute lead intoxication from a bullet in an
aged group. The study by Benzel et al
.17 showed root
intervertebral disc space. A case report. J Bone Joint Surg Am
improvement in complete injuries as opposed to conserva-
tively managed cases. The incomplete cord injury and cauda
Scuderi GJ, Vaccaro AR, Fitzhenry LN, Greenberg S, Eismont F. Long-term clinical manifestations of retained bullet fragments within the inter-
equina injury groups showed improvement irrespective of
vertebral disk space. J Spinal Disord Tech
decompression. This has been echoed by other authors.18,19
Tindel NL, Marcillo AE, Tay BK, Bunge RP, Eismont FJ. The effect of
Stauffer et al
.20 reported 19% iatrogenic instability in their
surgically implanted bullet fragments on the spinal cord in a rabbitmodel. J Bone Joint Surg Am
2001; 83-A: 884-890.
laminectomy group, which highlights a risk associated with
Bono CM, Heary RF. Gunshot wounds of the spine. Spine J
posterior decompression. Our policy is not to decompress
unless there is neurological deterioration subsequent to
Waters RL, Adkins RH. The effects of removal of bullet fragments
injury, with compression demonstrated on imaging.
retained in the spinal canal. A collaborative study by the National Spinal
Cord Injury Model Systems. Spine
The associated injuries are a major factor in the manage-
Gupta S, Senger RL. Wandering intraspinal bullet. Br J Neurosurg
ment of these patients. Transvisceral injuries are a particular
concern because of possible infection of the spine. This
Oktem IS, Selcuklu A, Kurtsoy A, Kavuncu IA, Pasaoglu A. Migration
seems to be a less frequent problem than expected. Kumar
of bullet in the spinal canal: a case report. Surg Neurol
.21 reported on 31 cases (13 transcolonic injuries) treated
Kahraman S, Gonul E, Kayali H, et al.
Retrospective analysis of spinal
with antibiotics for 2 - 43 days. None of their cases devel-
missile injuries. Neurosurg Rev
oped a vertebral osteitis, and they recommend conservative
Benzel EC, Hadden TA, Coleman JE. Civilian gunshot wounds to the
spinal cord and cauda equina. Neurosurgery
treatment of the spine. Kihtir et al
.22 reviewed 21 transperi-
Hammoud MA, Haddad FS, Moufarrij NA. Spinal cord missile injuries
toneal gunshot injuries, including 5 transcolonic injuries.
during the Lebanese civil war. Surg Neurol
There were no vertebral infections. Roffi et al
.23 followed up
Kupcha PC, An HS, Cotler JM. Gunshot wounds to the cervical spine.
42 patients with 51 visceral perforations. These included 14
Stauffer ES, Wood RW, Kelly EG. Gunshot wounds of the spine: the
colonic and 15 small-bowel injuries. They used antibiotic
effects of laminectomy. J Bone Joint Surg Am
cover and reported 3 spinal infections. They concluded that
Kumar A, Wood GW 2nd, Whittle AP. Low-velocity gunshot injuries of
early bullet removal did not seem to be helpful.
the spine with abdominal viscus trauma. J Orthop Trauma
Kihtir T, Ivatury RR, Simon R, Stahl WM. Management of transperi-
toneal gunshot wounds of the spine. J Trauma
Roffi RP, Waters RL, Adkins RH. Gunshot wounds to the spine associ-
Gunshot injuries of the spine are devastating to the individu-
ated with a perforated viscus. Spine
al in terms of the severe neurological consequences.
VOL 43, NO. 4, NOVEMBER 2005 SAJS
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