Hi, my name is Anthony DiGiorgio. I'm senior author on this case series of penetrating spinal trauma. This was a single center review that were performed during my time at LSU in New Orleans. Penetrating spinal trauma is far less common than blunt spinal trauma. There are significant guidelines and treatment recommendations for blunt spinal cord injury. But because penetrating injury is much more rare, these data are lacking. Our hospital, Charity Hospital in New Orleans, has a relatively high rate of penetrating spinal trauma. And that high rate prompted us to do a retrospective chart review of all our penetrating spinal injuries and compare them to the blunt spinal cord injury by patient population. Here are our results. There are 154 penetrating patients and 976 patients with blunt spinal cord injury. You can see here that the patients with penetrating spinal cord injury are significantly younger by almost 15 years. They have a significantly higher injury severity score. They have a significantly longer hospital length of stay. They have a significantly higher percentage of male. And race is a significantly higher percentage of African-Americans. Fewer penetrating injuries were drunk with an ETOH over the legal limit. Many more patients with penetrating spinal cord injury had Medicaid or were uninsured. Significantly fewer had commercial and Medicare. Medicare is likely secondary to the age difference in the patient population. And for discharge location, significantly more of them were able to go to rehab of the penetrating group. Fewer of them went home, and more of them went to other acute care. Nine patients out of our patient cohort underwent surgical operation for their penetrating injury. As you can see, surgery is rarely needed. But it's probably worth noting why these nine patients had surgery. So I'll go over them individually here. Patient number one initially came in as an Asia E, found to have a declining neuro exam. This was secondary to an epidural hematoma. And unfortunately, laminectomy and lumbar drain placement did not help this patient. And they eventually were in Asia A, complete spinal cord injury. Patient two had an L1 to 4 injury, developed persistent CSF leak and meningitis. This was actually a shotgun injury. This patient underwent laminectomy, dural repair, and lumbar drain placement. Patient eventually went from an Asia A to an Asia C, regaining some function. Patient number three had spinal instability and a delayed neurologic decline, underwent a laminectomy infusion, and remained in Asia E. Patient number four developed spinal instability, underwent an anterior cervical corpectomy infusion. This patient was in Asia A and remained in Asia A. Patient number five had a bullet track that went through the esophagus. Not only did this patient develop spinal instability, it also developed an intramedullary spinal cord abscess. This patient underwent a posterior cervical laminectomy, myelotomy, washout, and diffusion. This patient was unfortunately lost to follow-up, but on discharge was still in Asia A. Patient number six also developed spinal instability, underwent an anterior cervical discectomy infusion. This patient also remained in Asia A. Patient number seven is an interesting case of the bullet in the lumbar spine canal. This patient was removed using a minimally invasive technique. This patient improved and was in Asia C at discharge. Patient number eight had a declining neurologic exam, again due to a bullet in the spinal canal. This bullet was also removed using a minimally invasive technique. This patient was in Asia D at discharge. And lastly, patient nine, I will show some images for in a second. This patient developed a delayed spinal instability. We initially tried to treat him conservatively, he underwent a posterior fusion and remained intact. Here are the images for that patient. Panel A shows his initial CT scan. The bullet gave a comminuted fracture of the lateral mass of C2 on the right. This was initially treated with a cervical collar. He came back, he was developing signs of myelopathy. He was losing function in his hands. He still had full strength, but his repeat imaging there in panel B showed a developing subluxation. And this is also evident on the X-ray in panel C. We determined that due to this subluxation, he was still having motion despite wearing the collar, and this was giving him myelopathic signs and symptoms, he underwent a posterior fusion and recovered well. Some treatment pearls that we've learned in our experience with these penetrating spinal cord injuries. Number one is that MRIs are largely safe and often very necessary. As you can see from our surgical cohort, many patients will have a changing neurologic exam and it's important to figure out if this exam change is due to a mass lesion that could be treated with surgery. It's very important to delineate the damage caused by the bullet and blast injury itself versus the damage that could be caused by a mass lesion such as an epidural hematoma or the bullet itself in the canal. Sometimes if a bullet is in the spinal canal, it can migrate, and this can cause a spinal cord injury. If that's the case, obviously the bullet needs to be removed. Any epidural hematomas should be treated as long as the patient has a salvageable injury. We found that MIS approaches are often useful. Using a two base retractor system decreases our CSF leak rate. We're often able to get the bullets out using the tube. And because it's not a wide open midline laminectomy, the CSF leak rate was essentially zero for these cases. One important tidbit is to measure the size of the bullet and know that you use an appropriately sized tube to remove the bullet. Some surgical indications, as I mentioned, if there's a mass lesion causing a deficit, you certainly want to operate on that. Many of our patients did develop spinal instability. And they underwent fusions for those. And of course, to fix any spinal fluid leaks, those will often require surgery. So in conclusion, the demographics of this patient population differ significantly from blunt injuries. It's a younger, largely publicly funded cohort, be they uninsured or Medicaid patients. And these patients often incur a high lifetime cost. When a young patient is injured with spinal cord injury, they'll develop lifetime needs, including rehab, often be unable to work again. And this is a large cost borne to society. Surgical intervention is rarely needed. But when it is needed, it is very useful. Certainly to keep consider MIS techniques and spinal stability procedures for these patients. Thank you very much for your attention. It was a pleasure giving this talk.

penetrating spinal trauma

retrospective chart review

injury severity scores

surgical intervention

demographics