Management of civilian ballistic injuries to the spine: practice patterns and recovery outcomes at a level 1 trauma center

Introduction

Firearm violence results in substantial morbidity and mortality with gunshot wounds (GSWs) leading to ~1,500–2,000 new spinal cord injury (SCI) cases annually in the U.S. and accounting for approximately 13–21% of all traumatic spinal injuries making it the third leading cause of SCI (1-3). The management of GSWs to the spine in the civilian population is particularly controversial, as there is a lack of robust data guiding the optimal approach to treatment (4). Clinicians often debate whether to adopt surgical interventions or to opt for conservative management strategies, each with its own set of risks and potential benefits (5-7). While tools exist to guide treatment strategies, there is no current standard of care or ways of tracking recovery.

The American Spinal Injury Association Impairment Scale (AIS) serves as a standardized measure for assessing neurological function in patients with SCIs (8). However, the broad categorization within the AIS can sometimes obscure subtle yet clinically significant variations in patient recovery, particularly in those classified under AIS category D (9). In this study, we provide a detailed review of spinal injury cases secondary to GSWs treated at a major urban academic level 1 trauma center. Additionally, we comment upon the variability in outcomes and recovery trajectories within this group with emphasis on those who maintained AIS D status throughout their injury course. Through the collection and analysis of granular data, we hope to contribute valuable insights into the nuances of recovery and management strategies for civilian patients with GSWs to the spine. We present this article in accordance with the STROBE reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-25-66/rc).

Methods

Study design

A retrospective study was conducted on all patients who suffered spinal injuries due to GSW between 2011 and 2023 at Boston Medical Center (BMC), a large urban level 1 safety-net hospital. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional review board of Boston Medical Center (No. H-44609) and the need for patient consent was waived due to the study’s retrospective nature.

Variables and outcomes

Medical charts and neuroimaging were reviewed to collect all relevant variables for analysis. Patient demographics, medical history, AIS score, and Injury Severity Score (ISS) at the time of presentation (10,11). Additionally, the presence of radiological findings (vertebral column fractures, spinal cord and/or nerve root involvement, bullet entry, and exit site, location of retained bullet fragments, perforation of abdominal viscera, presence of associated vascular injuries, and AO grade), type of surgery if performed, detailed neurological exams, Medical Research Council Scale (MRCS) scores for major muscle groups at presentation discharge and follow up, presence of cerebrospinal fluid (CSF) leak, use of tranexamic acid (TXA), MAP goal if specified, presence of infection, presence/type of brace if ordered, as well as antibiotic regimen and duration. Additional information related to hospital course and recovery was collected, including length of hospital stay, discharge location, modified Rankin scale (mRS) at discharge, AIS score at discharge and last follow-up.

Literature review

A review of the literature was also performed to assess studies reporting granular data on spinal GSWs as a reference and supplement to our data. Three large databases (Medline, Ovid, Web of Science) were searched using the following keywords: (gunshot or “gunshot wound”) AND (spine OR lumbar OR cervical OR thoracic). Search results up to January 1, 2024 were included. Data was collected on patient demographics, AIS scores at presentation, involvement of other structures, medications, surgical vs. conservative management, discharge disposition, AIS scores at discharge, and AIS scores at the latest follow-up. The supplementary table (https://cdn.amegroups.cn/static/public/jss-25-66-1.xlsx) reports these findings.

Statistical analysis

Descriptive analytical statistics were utilized to summarize clinical characteristics, management strategies, and neurological outcomes in patients with GSWs. Continuous variables such as age, ISS, number of bullet wounds, and duration of follow-up were assessed for normality and reported as means with standard deviations or medians with interquartile ranges, as appropriate. Categorical variables—including sex, race, AIS scores, bullet location, operative intervention, infection status, and bracing or antibiotic use—were summarized using counts and percentages.

Neurological outcomes were primarily described through changes in the AIS scale, mRS, and MRCS from presentation to discharge and at last follow-up. A Sankey plot was used to visualize transitions in AIS scores over time, and bar graphs were employed to highlight MRCS point improvements among patients who remained in AIS category D. AO spinal fracture grades were categorized and reported by anatomical region. All analyses were performed using Microsoft Excel and R (version 4.5.0).

Results

Sample characteristics

A total of 39 patients were included in the analysis. The average age in the study was 25 (range, 20–28) years and it was mostly male (92.3%). Patients were predominantly Black (78.4%), Hispanic (18.9%), or Caucasian (2.7%). English was the most common primary language (92.3%). There was a low incidence of common comorbidities such as hypertension (5.1%), diabetes mellitus (5.1%), and cardiovascular disease (0.0%). Of the patients, 34.2% were current smokers, and 15.8% were former smokers. The median annual income across the sample was $72,045 ($61,189–94,823) (Table 1).

Injury characteristics

Prior to injury, no patient had functional impairments. Most patients presented with multiple bullet impacts (71.8%), with the number of additional bullets being 2.5 on average (range, 1–4). On presentation, the distribution of AIS scores was: 31.6% A, 0.0% B, 5.3% C, 18.4% D, 44.7% E. Bullet entry sites were mostly posterior (48.7%) and traversed the abdomen (30.8%) or thorax (41.0%). There was a roughly equal incidence of left (38.5%), right (30.8%), and midline (28.2%) bullet entry locations. When retained, the primary location of the lodged bullet was the lumbar spine (45.5%), followed by thoracic (27.3%) and cervical (21.2%), with the canal involved in 56.4% of cases. The bullet remained inside the intervertebral space in 12.8%, while in 10.3% of cases, the bullet remained inside the vertebral canal. Of the patients, 48.7% had bullet fragments left inside of the canal. Vertebral artery injury occurred in 4 (10.3%) patients overall and 37.5% of those with cervical fractures. Abdominal viscera was compromised in 16 (41.0%) patients, with spinal canal violation (defined as bullet or fragment passing through canal at any point, as opposed to lodged in canal as final destination) in 22 (56.4%) cases, and 17 (43.6%) underwent emergent exploratory laparotomy. Abdominal wound infections occurred in 5 (12.8%) patients. The overall median ISS at admission among the cohort was 27 (range, 24–41) (Table 1).

AO grades

The most common AO fracture grade in the upper cervical spine was Type II, A (50.0%), and Type III, C (50.0%). A0 (83.3%) was the most common fracture in the lower cervical spine, followed by B2 (16.7%). In the thoracic spine, the most common fracture type was A0 (65.0%), A3 (20.0%), followed by A1 (5.0%), A2 (5.0%), and A4 (5.0%). For the lumbar spine, the most common were A0 (55.0%), A3 (35.0%), followed by A1 (5.0%) and A4 (5.0%). All sacral fractures were AO grade B3 fractures. Table S1 shows a detailed breakdown of the injuries and corresponding AIS grades of the patients.

Management

Prophylactic antibiotics were used in 79.5% of patients and were managed by the primary trauma service. All patients with perforated abdominal viscera were given antibiotics. Of those receiving antibiotics, 51.6 % received a regimen and 48.4% a single dose. Among patients receiving antibiotics, cefazolin was the most commonly used agent (51.3%), followed by the combination of ceftriaxone with metronidazole (15.4%). Additionally, 5.1% of patients received cefazolin in combination with either vancomycin, or cefazolin with amoxicillin or Unasyn, while 2.6% received a multi-drug regimen including ceftriaxone, clindamycin, levofloxacin, and metronidazole. For supportive care, external bracing was provided to 76.9% of patients for comfort. Four patients underwent surgery (10.3%). One patient received a laminectomy alone, and three received a laminectomy with instrumentation and fusion. The remaining five patients (12.8%) were managed pharmacologically. TXA was used in 30.8% of cases, with 25.6% of patients receiving a single dose and 5.1% being placed on a regimen. Increased MAP goals (represented in mmHg) were established for 25.6% of patients. Most commonly >85 mmHg (15.4%), vs. >90 mmHg (7.7%), vs. >70 mmHg (2.6%). The increased MAP goals were continued for a median length of 6.5 days (2.5–7.0 days). Additionally, vasopressor therapy was required in 2.6% of patients to maintain goal MAP (Table 2).

Outcomes

mRS scores upon discharge included: 0–2 (47.4%), 3–4 (44.7%), 5 (5.3%), and 6 (2.6%). The distribution of AIS scores included A (23.7%), C (7.9%), D (23.7%) and E (44.7%), with 44.0% sensation intact. Motor status was unchanged in 40%, worsened in 10%, and improved in 10% of our sample. Regarding sensory function, full sensation was retained in 44.1% of patients, while 53.0% reported decreased or absent sensation. Severe allodynia was experienced by 2.9% of patients. Motor function improvement was observed in 8.1% of patients who showed improvement in MRCS scores from presentation to discharge. Among these 8.1% of patients, specific improvements included: 8.1% of the cohort improved their MRCS score by 1 point in any muscle group, 5.4% improved by 2 points, 5.4% improved by greater than 2 points, and 5.4% improved movement from below antigravity to antigravity in at least one muscle group during this time period.

Discharge locations included home (44.7%), home with nursing care (42.1%), rehab (7.9%), another acute care center (2.6%), or psych hospital (2.6%). The median time until last follow-up was 2.1 months (0.9–11.6 months). AIS scores at last follow-up were 19.2% A, 7.7% C, 26.9% D, and 46.2% E. At last follow-up, 46.2% had a 1-point improvement in MRCS in any effected muscle. An improvement of 2 MRCS points in any muscle was observed in 19.2% of patients, while an improvement of greater than 2 MRCS points in any muscle was seen in 7.7% of patients. Finally, 19.2% reported MRCS improvement that went from below antigravity to antigravity function (Table 2). The breakdown of AIS scores over time from preinjury to the latest follow-up in surviving patients is shown in Figure 1. One patient was excluded from the figure due to severe hemodynamic instability that precluded a reliable examination and also resulted in mortality.

Figure 1 Sankey plot demonstrating the change in AIS scores in patients from preinjury to the latest follow-up. One patient was excluded from the figure due to severe hemodynamic instability that precluded a reliable examination and also resulted in mortality. AIS, American Spinal Injury Association Impairment Scale.

Sub-group analysis of patients with AIS D scores from discharge to follow-up

There were 6 patients who remained AIS D from discharge to latest follow-up. However, only 5 patients were included in this analysis because one patient lacked detailed enough documentation to be included. Three or more muscle groups showed improvement from below antigravity to antigravity movement in 40.0% of patients, while 60.0% demonstrated improvement in muscle groups that did not result in antigravity movement. One patient had no improvement in muscle strength. Figure 2 shows the total improvements in MRCS scores among these 5 patients.

Figure 2 Bar graph showing the overall MRC score point improvements from patients that remained AIS category D from discharge to latest follow-up. AIS, American Spinal Injury Association Impairment Scale; MRC, Medical Research Council.

Literature results

We found a total of 48 studies reporting data on spinal GSWs, representing a total of 8,283 patients. Approximately 78% of patients were male and the mean age was around 29±8.3 years. Only 28 of the studies reported AIS scores for patients, with 41.9% of patients having an AIS score of A at presentation, 8.6% having score B, 19.5% having score C, 13.9% having score D, and 16.1% having score E. Surgical intervention types were reported in 83.3% of studies. Among the procedures performed, laminectomy and decompression was the most common, making up 92.5% of the reported procedures. Fusion procedures accounted for 7.5% of reported interventions, while discectomies comprised 5.0%. Of those reported, outcomes varied significantly in terms of patient improvement among studies, with 25 studies showing patient improvement at last follow-up with their employed intervention strategy, and 7 reporting no improvement at last follow-up. Data from the literature review has been detailed in Table 3.

Discussion

The immediate treatment and long-term management of gun-related spinal injuries in the civilian population remains an understudied topic. High-velocity weapons can damage tissue through pressure waves and cavitation (56). Notably, experimental and computational studies have shown that these pressure waves can propagate through the spinal canal, potentially causing neuronal stretching, axonal shearing, microvascular compromise, and secondary ischemic injury, even without direct contact with the bullet. This phenomenon highlights that ballistic injury is not solely confined to the visible bullet path; rather, the biomechanical forces and energy transfer surrounding the projectile may contribute to spinal cord dysfunction. In addition, wave-induced cerebrospinal fluid displacement has been postulated to exacerbate spinal cord strain in enclosed spaces like the vertebral canal (57). Congruent with current data from the CDC, our sample was 92.3% male, 78.4% black, and had a median income of $72,045, further illustrating the disproportionate burden of injury in this patient population (58).

The bullet causing SCI most often entered posteriorly in the patient’s left thorax. The most common primary location of the lodged bullet was the lumbar spine (45.5%), followed by thoracic (27.3%) and cervical (21.2%). However, there was an almost equal number of individuals without a lodged bullet, who experienced injuries to the lumbar (16 individuals, 41.0%) and thoracic spine (15 individuals, 38.5%), with one individual in the sacral spine. This incongruence between bullet entry site, final bullet location and level of injury demonstrates the unpredictability of ballistic injuries and underscores the importance of critically evaluating more than just the immediate adjacent levels to the lodged bullet, or bullet entry point. Similarly the high prevalence of vertebral artery injury (37.5%) in patients with cervical fractures highlights the importance of vascular imaging in patients with cervical injuries from GSW.

The most common AIS score at admission was E (44.7%), followed by A (31.6%), D (18.4%), then C (5.3%). As expected, those individuals presenting as AIS A had injuries most often affecting the cervical or thoracic spine (90.0%), with only one individual presenting as AIS A due to an injury at L4–L5. This is in agreement with what has been demonstrated in the literature and seen in our review which is likely because these spinal levels are superior to the conus medullaris and cauda equina (59). Bullets entering the cord below the level of the conus at the cauda equina would result in less severe injury as the nerve roots have more room inside of the thecal sac, and are mobile, rendering them less prone to compression or damage from a penetrating force. This was observed in our cohort in the case of a 20-year-old female that presented status post GSW to the left flank and left upper extremity whose imaging can be seen in. Initial exam showed bilateral lower extremity 0/5 strength with significant allodynia and absent rectal tone. CT showed a large bullet fragment located centrally in the canal at L2/L3. She was taken emergently to the operating room with the trauma team for exploratory laparotomy given penetrating flank/abdominal injury with multiple intra-abdominal ballistic injuries, including spleen and diaphragm injuries. The bullet fragment in the canal was not removed. She spontaneously began to regain function in her lower extremities and 1 month post op was full 5/5 strength in her left lower extremity and 4+/5 in the muscles of the right lower extremity. She retained bowel and bladder function and had no new saddle anesthesia. Additionally, there was another individual who was treated nonoperatively who improved from AIS A to AIS C in the postoperative setting, whose injury was also in the lumbar levels. It is unclear what factors allowed for recovery of function, but cases like this illustrate the importance of granular research on this rare topic so that conclusions can one day be drawn.

Furthermore, indications for surgery in this population is a controversial topic. Factors influencing this decision include the presence of/risk for a CSF leak, infection, deterioration in neurological status, or the presence of an unstable fracture (60). Occasionally, the risk of potential lead poisoning from retained bullet fragments is considered, though it appears low based on a handful of documented case reports (52,53). Despite having 41.8% of patients with retained bullet fragments in our series, there were zero cases of lead poisoning, corroborating this as a low frequency event. Similarly there were zero occurrences of CSF leaks, in our cohort. Recommendations regarding antibiotic indication, usage, and duration are varied in the literature (61,62). Antibiotic prophylaxis was administered to 79.5% of patients, most commonly with cefazolin. Anaerobic and gram-negative coverage was usually added in patients who underwent an exploratory laparotomy due to concern for intraabdominal hemorrhage and/or perforation of the abdominal viscera. The only infections were intrabdominal abscesses/hepatic abscesses (12.8%). Across all patients, there was zero incidence of infection involving any aspect of the spinal column demonstrating both the low likelihood of ballistic fragments causing infection of spinal elements as well as adequate antibiotic choice and duration. The lack of an injury scoring system specifically designed for penetrating spinal injuries is likely contributing to the lack of clarity surrounding management. Based on our use of a combination of the AO thoracolumbar and upper cervical classification system to quantify the stability of the fracture, only 5.1% of our patients had unstable fractures.

In our series, 90.0% of patients were managed conservatively without surgery (with pharmacologic pain control and bracing as needed). Some argue for a higher rate of surgical intervention, showing higher rates of improvement in AIS score among these patients than their non-surgical counterparts (7,63). This may be influenced by consideration of SCI outcomes unrelated to ballistics (64,65). As seen in our study, as well as others, people with SCI due to penetrating GSW tend to improve over time without surgical intervention (54). This suggests that in the absence of new acute neurological deficit following the initial injury seen in GSW wounds to the spine, conservative management may be superior as it avoids the added risks inherent in surgery.

There is extensive variability in the literature highlighting the complexity of decision-making. Our review of the literature showed conflicting evidence in cohorts of operative vs. conservative management of patients. While this is partially expected due to the dynamic nature of GSW related management that is highly dependent on patient-specific cases and risk factors, it further reinforces the lack of and need for widely accepted standards in decision-making.

The development of standardized decision-making may be negatively impacted by the limitations of the AIS scale as a metric to track recovery progress in this patient population, especially considering the broadness of the AIS D category. By definition, AIS D represents an incomplete injury with “at least half of key muscles below the neurological level having muscle grade greater than or equal to three”. There is great variation in functional status of patients with GSWs to the spine who would fit this definition (8). Hypothetically, a patient could exhibit muscle strength of three out of five on one entire side of their body below the affected neurological level and be hemiplegic on the opposite side, yet still be in the same AIS D category as a patient with mostly fours/fives out of five for muscle strength bilaterally below the neurological level. These hypothetical patients would have vastly different levels of function yet be considered the same category. In fact, our subgroup analysis of the five patients who remained in the AIS D category from discharge to follow-up revealed extreme variability in their functional recovery as characterized by the gain in MRCS (Figure 2). Due to the inherent broadness of the AIS D category, these patients all met the criteria to be classified as AIS D, yet these five patients regained vastly different levels of function.

Subcategorization within the AIS D category and/or an altogether different method of documenting neurological status would be of value in facilitating a more accurate representation of meaningful neurological improvement that does not quite reach the AIS E category. The broadness of this category also weakens the ability to extract meaningful data from the reported literature and the evaluation of recovery from different interventions. This is important given that AIS D patients have tangible potential for improvement in muscle strength and overall function, compared to patients in AIS A and B categories. A previous meta-analysis found that 0.0% and 0.3% of patients in the AIS A and B categories, respectively, made a full neurologic recovery, while 46.5% of patients in the AIS D category went on to make a full recovery (66). Further distinction is necessary in order to make meaningful comparisons of outcomes in these patients.

It is also imperative to recognize that spinal ballistic injuries rarely occur in isolation. Many patients present with polytrauma, including thoracoabdominal injuries, long bone fractures, or potential traumatic brain injury (TBI), which can significantly complicate both neurological assessment and overall management. As discussed by Logsdon et al., TBI is frequently underdiagnosed in the polytrauma setting, despite its profound impact on outcomes. The systemic inflammatory response triggered by TBI and other concurrent injuries can exacerbate neuronal injury, delay recovery, and impair decision-making capacity (67). In our cohort, several patients required exploratory laparotomy for visceral injury, and one had a documented TBI. The presence of polytrauma may confound accurate AIS scoring, obscure early neurological deterioration, and influence the appropriateness or timing of surgical interventions. As such, a multidisciplinary approach is critical in managing these complex presentations, ensuring both spinal and extracranial injuries are adequately addressed to optimize functional recovery.

There is also variability and lack of standardization in the literature regarding the overall reporting of AIS scales in patients with GSW to the spine. Only 28 of the 48 studies analyzed in the literature review reported AIS scores for their patients, which makes quantifying patient outcomes on a standard scale difficult. Furthermore detailed injury descriptions such as the location of bullet entry, exact spinal fracture descriptions or classifications, and specific MRC scores at different time points are often not included. This significantly limits the utility of the published data and compromises a clinician’s ability to draw meaningful conclusions about this patient population. Future efforts investigating the treatment and outcomes of GSW to the spine in civilian patients would benefit from collecting and reporting functional and neurological outcomes using a standardized method while working towards the overall goal of defining a standard of care.

Study limitations

This study is limited by its single-center retrospective nature and all the inherent biases of its design. We relied on documented neurological exams in the electronic medical record (EMR) and therefore are unable to account for variations in exam technique, or differences in exam interpretation by individual providers. The sample size is small, which limits the ability to detect differences between groups. It is possible that unknown confounders and clinician-specific bias could impact the results. Lastly, the cohort has a relatively short time between hospitalization and the last follow-up, which limits our study’s ability to comment on long-term outcomes in these patients.

Conclusions

Civilian patients presenting with ballistic injuries to the spine are most commonly young males. Most patients may be managed conservatively and may have neurological improvements throughout their hospital course and subsequent follow-up. AIS grades may be suboptimal in accurately tracking, recording, and reporting the progress of these patients over time. Specifically, AIS category D is broad and lacks the nuance required to distinguish the level of meaningful recovery patients may achieve within that category. Thought should be given to developing metrics to improve the characterization of recovery outcomes. There is significant variation in the literature reporting on civilian ballistic injuries to the spine, making it difficult to draw meaningful conclusions. Overall, there is a need for more granular data on this infrequent pathology to create a clearer understanding of management strategies and patient outcomes.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-25-66/rc

Data Sharing Statement: Available at https://jss.amegroups.com/article/view/10.21037/jss-25-66/dss

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-25-66/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-25-66/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional review board of Boston Medical Center (No. H-44609) and the need for patient consent was waived due to the study’s retrospective nature.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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