SPINAL AND SPINAL CORD GUNSHOT INJURIES

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Autors:

Kostiantyn DEINICHENKO

Major of the Medical Service

Head of the Neurosurgical Department of Zaporizhzhia Military Hospital

Iurii MIKHEIEV

Major of the Medical Service, DrSci(Med),

Leading Surgeon of Zaporizhzhia Military Hospital

Roman KUZIV

Lieutenant Colonel of the Medical Service

Commander of the Military Medical Clinical Center of the Eastern Region

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INTRODUCTION

The modern concept of providing care for gunshot wounds of the spine is based on the principles of staged medical evacuation, objective assessment of neurological status, and a rational choice of surgical tactics. At the same time, a differentiated approach to determining the indications for surgical intervention, taking into account the extent of spinal cord injury, is of key importance.

The modern nature of warfare, particularly the widespread use of unmanned aerial vehicles (UAVs), has significantly altered the structure of combat trauma. Clinical practice shows an increasing incidence of gunshot fragmentation wounds to the spine and spinal cord. These materials summarize our own clinical experience and practical approaches to providing care for such injuries. In our practice, we are observing a rise in spinal gunshot fragmentation wounds. These materials outline our experience and perspectives on the concept of care for spinal gunshot wounds, based on both our personal experience and that of our colleagues.

ROLE 1 / 2: Primary care, emergency care, and basic diagnostics

• According to standardized ABCDE or MARCH algorithms;

• In cases of suspected gunshot wounds to the spine and spinal cord: transport on a spine board; cervical stabilization with a semi-rigid collar if potential injury to the cervical spine is suspected (although most spinal gunshot wounds are stable).

In cases of spinal gunshot wounds, the choice of surgical tactics is usually based on the degree of spinal cord injury. However, an adequate neurological assessment is impossible if the patient remains under sedation and on mechanical ventilation (MV) initiated at the pre-hospital stage.

Recommendations for ROLE 1 / 2:

Neurological deficit: It is crucial to emphasize the necessity of documenting the neurological status at the earliest stages of medical care. In the referral form, we recommend recording responses to the following key questions:

• Presence of limb movement and muscle strength.

• Presence of sensation in the lower limbs. (Mark the level of sensory loss on the body with a marker); this is vital for assessing the dynamics of neurological impairment at subsequent stages.

Sedation Control: Deepening medical sedation should be avoided until a neurosurgeon’s assessment is performed at a specialized center, unless the clinical situation dictates otherwise.

Postoperative Monitoring: Following surgery, aim to reduce the level of analgosedation as soon as possible to assess neurological status.

Where and when to operate?

Spinal surgeries must be performed in operating theaters equipped with full material and technical support for spinal interventions. Operations performed within a specialized department with a consistent surgical team significantly reduce the risk of postoperative complications compared to those performed in non-specialized settings lacking appropriate resources and proper planning.

Spinal surgeries must be performed in operating rooms fully equipped for spinal interventions. Operations conducted in a specialized department with a consistent surgical team significantly reduce the risk of postoperative complications compared to those performed in non-specialized settings without appropriate resources or proper planning.

Furthermore, performing surgeries in a rush within the first 24 hours does not provide advantages for neurological recovery. It is preferable to perform such operations as a single-stage procedure in "full" volume, as managing cerebrospinal fluid (CSF) leaks during repeat surgeries is extremely difficult.

Required equipment: CT, C-arm, radiolucent operating table, surgical microscope, electrocoagulation (bipolar and monopolar), aspirator, a set of microinstruments, and a "clean" operating room.

Key practical aspects we emphasize:

Surgical tactics. When to operate, and is a "major" surgery necessary, or is primary surgical debridement (PSD) sufficient? Operations are performed:

a. Urgently – in case of signs of progressive neurological deficit. (This is why assessing neurological status at pre-hospital stages is so crucial, for example, in cases of an expanding intraspinal hematoma, which occurs quite rarely).

b. Within 24 hours – in the presence of a cerebrospinal fluid (CSF) leak or bone fragments in the spinal canal with partial impairment of spinal cord function.

c. Delayed – when indicated for unstable patients after their condition has been stabilized.

In cases of severe penetrating spinal injuries presenting with clinical signs of complete spinal cord injury (Frankel Grade A) and no signs of cerebrospinal fluid (CSF) leakage, we perform only primary surgical debridement (PSD) of the gunshot wound. In such instances, a "radical operation"—the removal of foreign bodies or bone fragments from the spinal canal—will not improve the neurological deficit but will increase the risk of a CSF leak.

CEREBROSPINAL FLUID (CSF) LEAK FROM THE WOUND

Eliminating cerebrospinal fluid (CSF) leakage is a key task for a neurosurgeon. The method of closure depends on the size of the dural defect, its location, and the overall possibility of achieving closure.

For small defects, suturing the dura mater with 6-0 Prolene on an atraumatic needle is possible. However, when the dural defect is larger and the edges cannot be approximated, a "patch" made from paravertebral muscle fascia or fascia lata should be sutured into the defect area. Additionally, sealants such as TachoComb, Hemopatch, or Coseal can be used.

The worst-case scenario occurs when the edges of the dura mater (TMO) cannot be fully visualized. In this situation, it is advisable to use the "spinal canal duraplasty" technique developed by our neurosurgical colleagues at the Mechnikov Dnipro Clinical Hospital.

STAGES OF "SPINAL CANAL DURAPLASTY" FOR TRANSVERSE PENETRATING WOUNDS:

1.Transverse penetrating wound.

2.Preservation of the spinous process attached to soft tissues.

3.Ventral bone defect tamponade using muscle tissue.

4.Sealing with fascia lata.

5.Additional sealing with fascia lata.

6.Application of Surgicel or its analogs.

7.Additional sealing with a pedicled muscle flap.

8.Closure of the spinal canal with bone.

9.Alternatively, a pedicled muscle flap can be transposed into the canal, with the entire area sealed from above using a large fascia lata graft.

Important rules to always keep in mind:

• If a patient has a significant dural defect, we must close it using as many layers as possible.

• When suturing the wound, it is mandatory to approximate the paravertebral muscles with sutures to reduce the "dead space" volume.

  

• The aponeurosis should be sutured as airtight (watertight) as possible.

• It is always crucial to isolate the spinal wound from the contaminated wound track.

• Asepsis and Surgical Organization: The neurosurgical stage must be performed in a "clean" operating room and should not be combined with other procedures. Before manipulating the dura mate, it is mandatory to change gloves and instruments. "In neurosurgery, you can never have too much sterility."

• Surgical Site Preparation: Due to the high contamination levels of gunshot wounds, the first step should be a thorough washing of the skin with soap until completely clean. Only after this is antiseptic processing performed, allowing for the standard contact time according to protocols.

• Surgical Approach: An off-axis (extra-projectional) approach to the spine is recommended to avoid passing through the gunshot wound. This reduces the risk of infection and promotes healing. For paravertebral wounds, the skin incision should be shifted 2–3 cm away from the wound; despite some inconvenience, this significantly lowers the risk of infection.

• Avoiding Extensive Approaches: Excessive laminectomy increases the risk of late-stage instability. Preference should be given to hemilaminectomy or access through the existing defect. "A smaller approach is easier to seal."

• Drainage: In cases of wound liquorrhea (CSF leak), the following may be used: Lumbar drainage — indicated for injuries of the lumbosacral region and recommended for postoperative CSF leaks. Subaponeurotic drainage — used only in extreme cases when the dura mater cannot be sealed. The drain temporarily diverts the CSF to allow the "wound to heal." The drain is removed after 5 days, and the counter-aperture is sutured.

• Spinal Stabilization: Usually not required for gunshot wounds, as these fractures are typically stable. However, instability may develop over time if the facet joints are involved. Due to the high risk of infection, stabilization surgeries should be delayed.

• Postoperative Patient Positioning: To avoid ischemia of the wound edges and necrosis, it is crucial to minimize pressure on the surgical site. Whenever possible, the patient should be positioned on their side or abdomen, with their position changed every 2 hours. It is also recommended to extubate the patient as soon as possible to assess their neurological status and facilitate body turning.

• We do not use corticosteroids for spinal gunshot injuries.

GENERAL CONCLUSION:

Gunshot spinal and spinal cord injuries represent a significant challenge for neurosurgeons. No two gunshot wounds are identical; every case is unique and demands meticulous preparation and "creativity" from the neurosurgical team. The scope of intervention must correspond to the specific clinical situation: in some cases, primary surgical debridement (PSD) is sufficient, while others require a full-scale operation involving dural suturing, removal of foreign bodies, sealing of the spinal canal, etc. The quality of spinal surgery often determines not only the patient’s functional outcome but their very survival.