Penetrating Injury

Treatment goals are the same for penetrating and blunt spinal injury. There are, however, additional considerations in penetrating trauma ( Fig. 248-9). Optimal treatment of these injuries has been the subject of debate. One concern is that of infectious complications related to the presence of foreign bodies. Additional contamination is associated with transperitoneal and transintestinal trajectories of gunshot wounds to the spine. Intravenous antibiotics should be given in the ED. Surgical debridement with laminectomy has not proven effective in reducing the incidence of infectious complications, as most are managed nonoperatively. If the patient requires laparotomy for abdominal trauma, irrigation and debridement of the spinal injury through the missile tract may be appropriate. 14

As with blunt trauma, there is general agreement that progressive neurologic deficits warrant surgical decompression. The indication for removal of bullet and bone fragments in those patients with nonprogressive neurologic deficits is less clear. Wound location may determine the need for surgical intervention. Bullet removal has not been shown to significantly improve the neurologic status of patients with stable cervical and thoracic spinal cord lesions. In contrast, a collaborative study by the National Spinal Cord Injury Model Systems demonstrated that bullet removal from the thoracolumbar spine significantly improved motor recovery in both complete and incomplete injuries.26 Most vertebral injuries to the spine following penetrating trauma are stable and require only symptomatic treatment with a supportive orthosis and analgesics.

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