Surgery Linked to Better Odds of Neurologic Improvement in Gunshot-induced Spinal Injuries
Key findings
- This study of 961 patients identified from the National Spinal Cord Injury Statistical Center database assessed the role of surgical intervention in gunshot-induced spinal injuries (GSIs)
- Improvement of at least one grade on the American Spinal Injury Association (ASIA) Impairment Scale from admission to one-year follow-up was noted in 34% of surgical patients versus 21% of those in the nonoperative group (P<0.01)
- In multivariable analysis, surgical intervention was the only factor significantly associated with improvement on the ASIA scale (OR, 1.7; P<0.01)
- At one year, the odds of improvement with surgery, compared with nonoperative interventions, were 2.5 times greater for thoracic GSIs and 1.7 times greater for lumbar GSIs, but not significantly different for cervical GSIs
- These retrospective data are not conclusive, so for now the care of GSIs should continue to be individualized
Spinal injuries from penetrating trauma, mostly gunshot-induced, are increasing more in the U.S. than those from blunt trauma. Brian C. Goh, MD, PhD, a senior resident in the Harvard Combined Orthopaedic Residency Program (HCORP), Stuart H. Hershman, MD, director of Adult Spinal Deformity & Spinal Reconstruction in the Orthopaedic Spine Center, and colleagues recently reviewed 40 years of data on the effects of surgical intervention in gunshot-induced spinal injuries (GSIs).
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Reporting in Clinical Spine Surgery, they conclude surgery was associated with a greater likelihood of neurologic recovery than nonoperative interventions were, especially for injuries to the thoracic or lumbar spine.
Methods
An analysis of 32,159 patients in the National Spinal Cord Injury Statistical Center database (1975–2015) showed 4,920 with a GSI. Of those, 961 had information available on the region of spinal injury, surgical intervention (yes/no), and American Spinal Injury Association (ASIA) Impairment Scale rating at presentation and one-year follow-up.
Patient Characteristics
Most of the patients were male (90%), Black/African American (56%), and 15 to 29 years old at the time of GSI (74%). The thoracic spine was most frequently affected (52% of injuries) while the cervical and lumbar spine were injured comparably often (25% and 23%).
20% of patients were treated surgically. At presentation, 46% of patients in the operative cohort, and 68% of the nonoperative group were rated ASIA A (complete loss of motor and sensory function).
Improvement in the Overall Cohort
Improvement of at least one grade on the ASIA Impairment Scale from admission to one-year follow-up was noted in 34% of surgical patients versus 21% of those in the nonoperative group (P<0.01).
In multivariable analysis, surgical intervention was the only factor significantly associated with improvement on the ASIA scale (OR, 1.7; P<0.01).
Improvement by Spinal Region
Contrary to conventional wisdom, surgery was associated with neurological recovery among patients who had GSIs in the thoracic and lumbar regions. At one year, the odds of improvement with surgery, compared with nonoperative interventions, were:
- Thoracic GSI—2.5 (95% CI, 1.4–4.6)
- Lumbar GSI—1.7 (95% CI, 1.1–3.1)
- Cervical GSI—No significant difference
Improvement in the ASIA A Subgroup
Since the nonoperative cohort had significantly more ASIA A injuries than the surgically treated group, the researchers performed a post hoc subgroup analysis of only the 681 patients who were rated ASIA A at presentation.
The main result remained unchanged: 21% of surgical patients experienced improvement on the ASIA scale compared with only 11% of the nonoperative group (P<0.01). Patients who had surgery were 2.2 times more likely to have improvement at the one-year follow-up.
These data are only associative and therefore not entirely conclusive, so for now, the decision to pursue surgery should still be individualized.
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