Injury Vol. 29, Suppl. No. 1, pp.
SA7-S-A12,1998
ELSEVIER
PII: SOO20-1383(98)00098-9
Gunshot wounds to the spine
Zekeriya U. Isiklar, M.D.* and Ronald W. Lindsey, M.D.**
* Orthopaedic Surgeon, Department of Orthopaedic Surgery, Baskent University Hospital, Ankara, Turkey 06490
** Professor, Baylor College of Medicine, Department of Orthopaedic Surgery, 6560 Fannin, Suite 1900, Houston,
Texas 77030
Summa+
In the USA, low velocity gunshot injuries (GSI) account
for 13% of all urban spinal injuries, and they have
become the second leading cause of all spinal cord
injuries. The initial clinical evaluation should assess vas-
cular, visceral, and/or neurological injury. Early imag-
ing studies are required with computerized tomogra-
phy in addition to plain radiographs to assess accurately
the location and extent of the bone injury.
The role of steroids is unclear, and if given, should be
administered to GSI patients with complete or partial
neurological deficit who present within eight hours of
injury. The indications for prophylactic antibiotics have
not been well established and although recommended,
these are deemed essential only in patients with associ-
ated visceral perforation.
Early surgical exploration is most appropriate to
address associated vascular or visceral injury, while
spinal decompression does not appear to influence neu-
rological recovery. The majority of GSI spine fractures
are stable; instability is usually due to ill-advised
decompression of cervical spine GSI.
Retained bullet fragments are rarely problematic; lead
toxicity can occur due to missile contact with the syn-
ovial fluid, disc space, or contact with a pseudocyst.
Keywords: Spine, gunshot wound, fracture, cord
injury lnju y 1998, Vol. 29, Suppl. 1
1 Abstracts in German, French, Italian, Spanish, Japanese and
Russian are printed at the end of this supplement.
0 1998 Elsevier Science Ltd. All rights reserved
Printed in Great Britain
0020-1383/98 $19.00+0.00
Epidemiology
Gunshot injuries (GSI) are the second most common
cause of injury-related death in the United States where
it occurs over 90 times more frequently than in any other
industrialized country. In 1991, firearms were the lead-
ing cause of traumatic death in California, Nevada, New
York, Virginia, District of Columbia, Texas and
Louisiana (1). Likewise, the incidence of civilian gun-
shot wounds to the spine has been steadily increasing
and, in urban areas, it is at present the second leading
cause of spinal cord injury (SCI) (2).
In the urban setting GSI to the spine accounts for 13
percent of all spinal injuries, only one third of SCIs is
due to falls and motor vehicle accidents. Among 6014
spinal cord injury patients reported to the National
Spinal Cord Injury Data Research Center by the differ-
ent regional spinal cord injury systems, 782 (13%) were
the result of gunshot injuries between 1973 and 1982 (2).
Since 1990 GSI to the spine has become the second lead-
ing cause of SC1 with a reported incidence of 25% (2).
Mechanism of injury
In GSI the bullet wounding capacity is directly propor-
tional to its mass and, to an even greater extent, its veloc-
ity (E, = si MV2). A bullet or a fragment of a projectile
can cause tissue damage without actually coming into
close contact with the tissue. As the bullet pierces the
soft tissues, an ill-defined temporary cavity is formed.
Tissue damage occurs from the concussive effect of the
bullet and the cavitation which correlates with its kinetic
energy. Neurological injury can occur if the bullet passes
in close proximity to the spinal cord or the conus (3-5).
 S-AS

Civilian GSIs are predominantly low velocity injuries
with a muzzle velocity of less than 700 m/second and
differ from the high velocity military GSIs. The greater
kinetic energy of military GSIs produces a greater
wounding effect which can result in neurological injury
even without spinal fracture, penetration or retained
missile fragments. Most civilian GSIs to the spine, how-
ever, must traverse or remain inside the spinal canal to
cause deficit.
Patient evaluation and treatment
All patients with suspected GSI to the spine should be
thoroughly evaluated according to a routine trauma
protocol (Fig. 1). The patient’s general medical condi-
tion should be stabilized prior to addressing specific
organ injuries. The patient’s neurological condition
should be documented using the Frankel (6) or the
detailed American Spinal Injury Association (ASIA) (7)
scales. GSI to the neck warrants routine angiography
and panendoscopy (Fig. 2). In the absence of an expand-
ing haematoma or vascular abnormality, surgical explo-
ration of the wound tract is not recommended as it may
increase morbidity (8). Thoracic spine GSIs are fre-
quently associated with pulmonary and cardiac injuries.
In the lumbar spine GSI the abdominal viscera, genito-
urinary system, and major vascular structures can also
be damaged. Bullets that traverse the colon and lodge

Fig. 1:
Management algorithm for gunshot
injuries to the spine.
lsiklar: Gunshot wounds to the spine
in the bony spine or the spinal canal are a special con-
cern since they may be complicated by infection if not
treated with early operative debridement and par-
enteral antibiotics.
Radiographic assessment of the spine includes con-
ventional radiographs and computed tomography to
determine best the extent of the injury and the location
of retained bullet or bone fragments (9) (Fig. 3). Mag-
netic resonance imaging of the spine is contraindicated
as the missile ferromagnetism produces artifacts and
image obscurity, and can cause significant deflection of
the bullet and threaten further injury (10). In the con-
scious, cooperative patient with suspected instability,
voluntary flexion/extension views can be obtained.
Although spinal stability is often thought to be guaran-
teed following GSI, the authors’ clinical experience has
identified 3 cases of cervical instability. Also cervical
spine GSI was associated with a high incidence of vas-
cular injury and required routine angiography (11).
The benefit of steroids in the management of acute
spinal cord injury resulting from indirect trauma to the
spinal cord column has been documented, however, the
role of steroids in the presence of GSI to the spine is not
Fig. 2: C6 gunshot injury with severe comminution of
the vertebral body and pedicle warranting angiography
to rule out vascular injury. The patient had a White-
Panjabi score of 6.
Injury 1998, Vol. 29, Suppl. 1
S-A9
known. If the spine GSI causes neurological deficit and
the patient presents within the first 8 hours, 30 mg/kg
methylprednisolone followed by a continuous infusion
of 5.4 mg/kg/hour for 23 hours may be initiated (12).
The role of prophylactic antiobiotics in the manage-
ment of spinal GSI is not clear. Kupche et al. proposed
7 days of IV antibiotic prophylaxis in the presence of
cervical GSIs because of the proximity of visceral, vas-
cular, neurological and airway structures and recom-
mended extension of length of administration if a
transpharyngeal path of the bullet could be documented
(13). Romanick reported 20 patients with GSI to the lum-
bar spine of which 12 sustained perforated viscus. Of
eight patients with colon perforation 7 developed infec-
tion, however, patients in this series received prophy-
lactic antibiotics for only 2 to 4 days (14).
Roff reviewed 42 patients with associated perforation
of the alimentary canal. Thirty-five patients had a bul-
let lodged in the spinal structures. Of these, 17 patients
underwent bullet removal and debridement; 18 were
managed without bullet removal and none of these
developed infections. Nine of these 18 patients had asso-
ciated colon injuries (15). The difference in management
from Romanick’s series was the longer use of IV antibi-
otics (7-14 days). Roffi concluded that 2 weeks of IV
antibiotic coverage was sufficient spinal prophylaxis.
Waters reported success with Roffi’s recommended cov-
erage as none of the 19 patients with alimentary tract
perforation developed infection even though 10 of the
bullets were left in the spine (16). In the management of
transperitoneal spinal GSIs, Kihtir et al. advocated irri-
gation of the wound tract and the administration of
short-term antibiotics with routine general surgical
management of associated injuries (17).
In our series only 20 of 36 patients (54%) received
intravenous prophylactic antibiotics for 3 to 14 days.
Fig. 3: An Ll injury with fractures of both pedicles; CT
scan clearly depicting the extent of bone injury and vio-
lation of the canal. This patient’s potential for instabil-
ity was not recognized and was treated with immobi-
lization and a brace uneventfully.

One patient with colon perforation developed a lesions did not benefit significantly from multilevel
paraspinal infection despite two weeks of prophylactic
antibiotic administration. We were unable to detect dif-
ferences between patients that received antibiotic pro-
phylaxis and patients that did not. The authors recom-
mend prophylactic antibiotics in the presence of hollow
viscus, airway, or pharyngeal perforations (11).
Decompression and bullet removal
Management guidelines for wartime highvelocity spine
GSI have a clear emphasis on exploration, debridement
and decompression (18,19,16,20,21). Selective decom-
pression and/or bullet removal is most appropriate for
the civilian low velocity spine GSI if there is vascular or
hollow viscus perforation (1,8,14,15,17,22-25). Unless
the patient’s neurological status is not deteriorating,
there are no neurological indications for spinal decom-
pression following civilian GSI to the spine. Stauffer et
al. in an analysis of 185 patients with spine GSI were not
able to demonstrate any benefit of decompression fol-
lowing complete lesions of the spinal cord. Incomplete
Fig. 4a,b: Two views of low velocity GSI to the lumbar spine without
let in the spinal canal.
S-Al0
decompression and decompression attempts were com-
plicated by a higher rate of instability, infection, and
spinal fluid fistula (27).
The author’s experience mirrors that of Stauffer who
reported 94 percent improvement in patients with cauda
equina lesions treated non-operatively. Benzel reported
that nerve root function improved in all patients despite
severity with or without surgery (28). In a collaborative
study by the National Spinal Cord Injury Model Systems,
serial neurological examinations were conducted on 66
of 90 study patients with bullet fragments lodged in the
spinal cord. The results of this prospective series with
objective motor and sensory evaluation criteria identi-
fied at least a subset of patients who may benefit from
bullet removal. Patients who had bullets removed from
T12 to L4 vertebral segments showed significant neuro-
logical recovery (25). Differences in the regional anatomy
of the spinal cord and greater susceptibility of the spinal
cord to injury compared to the cauda equina may explain
the more favourable outcome in regard to functional
recovery in the lumbar area (25,29). In the author’s series
our findings suggest that cauda equina lesions are more
obvious bone injury, but with a retained bul-
lsiklar: Gunshot wounds to the spine
favourable in regards to potential for functional recov-
ery since the percentage in 13 patients with GSI to the
spine improved 1 or 2 Frankel grades (11).
Bullet removal is rarely indicated with spine GSI. Bul-
let or bone fragments lodged in the spinal canal may
cause late neurological deficit and should be removed
if symptoms develop (30,31) (Fig. 4a,b). Bullet removal
has also been advocated when the bullet perforates the
alimentary canal before injuring the spine. Romanick
studied 20 patients with GSI to the lumbar spine of
which 12 patients sustained a perforated viscus. Patients
in this series received prophylactic antibiotics for 2 to 4
days without bullet removal and seven of eight patients
with colon perforations developed infection (14). Roffi
reviewed 42 spine GSI patients with associated perfo-
ration of the alimentary canal of which thirty-five
patients had retained bullet fragments in bone. Among
these, 17 patients were surgically debrided and 18 were
not. However, none of their patients developed infec-
tions although nine of the 18 patients treated non-oper-
atively had associated colon injuries (15). All 35 patients
received intravenous antibiotics for 7-14 days and the
authors concluded that at least 2 weeks of intravenous
antibiotic coverage alone was necessary to prevent
spinal infection.
Lead toxicity is rarely a problem with bullets retained
in the spinal canal. Lead dissolution usually occurs in
the synovial fluid, in contact with a pseudocyst, or in a
disc space (32-35). Lead poisoning clinically presents
with abdominal pain, anaemia, headaches, memory loss
and muscle weakness. Medical treatment prior to bul-
let removal can improve clinical results and consists of
chelation therapy, with EDTA (ethylenediaminetetra-
acetate), D-Penicillamine or dimercaptol (BAL) (36).
Spinal stability
Spinal instability secondary to low velocity gunshot
injury is generally thought to be rare (37). The majority
of spinal GSI are stable and simple orthotic management
is often sufficient. Usually reported cases of instability
secondary to spinal GSI are iatrogenic, the result of
surgical decompression. Helden et al. reviewed 38
patients with spinal GSI and the one unstable spine
resulted from decompressive laminectomy (22). Stauf-
fer et al. reported six cases of iatrogenic instability in a
series of 185 spinal GSI treated with laminectomy (27).
Although the thoracolumbar spine proved stable fol-
lowing GSI in the authors’ reported series, 4 cases of
spinal instability without surgical decompression were
observed by the instability criteria of White and Panjabi
(38). One case of instability was noted in the lumbar
spine using the Denis criteria (39).
It is evident from the author’s series that instability
should be considered when the patient’s spinal GSI is
being initially assessed. This is especially evident in the
Injury 1998, Vol. 29, Suppl. 2
S-All
cervical spine, even with low velocity GSI. Therefore,
the authors suggest that spinal stability following GSI
is not guaranteed and early immobilization and a thor-
ough assessment of spinal stability is warranted (Figs 2
and 3).
Conclusion
Civilian low velocity spinal GSI has become a prevalent
cause of morbidity and mortality in an urban patient
population. The initial neuroIogica1 presentation is the
best determinant of the ultimate functional outcome.
The surgical removal of missile fragments from the tho-
racolumbar spinal canal may be effective in improving
neurological recovery. In the author’s series, the role of
routine antibiotic prophylaxis could not be established.
However, prophylactic antibiotics are recommended for
patients at increased risk of infection (i.e. associated vis-
ceral perforation). In the cervical spine vascular injury
is common following GSI and requires a high index of
suspicion. Every injury should be examined to rule out
spinal instability especially GSI of the cervical spine.
References
1. Schwab CW. Violence in America: A public health crisis:
the role of firearms. A position paper of the Eastern Asso-
ciation for the Surgery of Trauma, 1994.
2. Yoshida GM, Garland D, Waters RL. Gunshot wounds to
the spine. Orthop. Clin. North Am. 1995;26(1):109-116.
3. Clark RA Jr.Analysis of wounds involving the lumbosacral
canal in the Korean War. In: Meirowsky A, ed. Neurolog-
ical surgery of trauma. Washington D.C.: Office of the Sur-
geon General, 1965:337-344.
4. DeMuth WE Jr. Bullet velocity and design and determi-
nants of wounding capability: An experimental study.
J. Trauma 1966;6:222-232.
5. DeMuth WE Jr. Bullet velocity as applied to military rifle
wounding capacity. J. Trauma 1969;9(1):27.
6. Frankel HL, Hancock DO, Hyslop G et al. The value of pos-
tural reduction in initial management of closed injuries of
the spine with paraplegia and tetraplegia. Paraplegia
1969;7:179.
7. American Spinal Injury Association: Standards for Neu-
rologic Classification of Spinal Injury Patients. Chicago,
1989:1-21.
8. Golueke I’, Sclafari S, Philips T et al. Vertebral artery injury
diagnosis and management. J. Trauma 1987;27:856-865.
9. Plumney TF, Kilcoyne RF, Mack LA. Computed tomogra-
phy in evaluation of gunshot wounds of the spine. J.Com-
put. Assist. Tomogr. 1983;7(2):310.
10. Teitelbaum GE, Yee CA, Van Horn DD, Kim HS, Colletti
PM. Metallic ballistic fragments: MR imaging safety and
artifacts. Radiology 1990;175(3):855-859.
11. Isiklar ZU, Lindsey RW. Low velocity civilian gunshot
wounds of the spine. Orthopedics 1997;20(10):967-972.
 S-Al2

12. Bracken MB, Shepard MJ, Collins WF et al. A randomised, 31. Conway JE, Crofford TW, Terry AF, Protzman RR. Cauda
controlled trial of methylprednisolone or naloxone in treat- equina syndrome occurring nine years after a gunshot
ment of acute spinal cord injury: Results of the Second injury to the spine. J. Bone Joint Surg. 1993;75A:760-763.
National Acute Spinal Cord Injury Study. N. Eng. J. Med.
32. Dillman RO, Crumb CK, Lidsky MJ. Lead poisoning from
1990;322:1405.
a gunshot wound. Report of a case and review of the lit-
13. Kupcha PC, An HC, Cotler JM. Gunshot wounds to the erature. Am. J. Med. 1979;66:509.
cervical spine. Spine 1990;15(10):1058-1063.
33. Grogan DP, Bucholz RW. Acute lead intoxication from a
14. Romanick PC, Smith TK, Kopariky DR, Oldfield D. Injec- bullet in an intervertebral disc space: A case report. J. Bone
tion about the spine associated with low velocity injury to Joint Surg. 1981;63A:1180.
the abdomen. J. Bone Joint Surg. 1985;67A:1195-1201.
34. Leonard MH. Solution of the lead by synovial fluid. Clin.
15. Roffl RF’, Waters RL, Adkins RH. Gunshot wounds to the Orthop. 1969;64:255-261.
spine associated with a perforated viscus. Spine
35. LindenMA, Manton WI, Stewart RM, Thal ER, Feit H. Lead
1989;14:808-811.
poisoning from retained bullets. Pathogenesis, diagnosis
16. McCravey A. War wounds of the spinal cord: A plea for and management. Ann. Surg. 1969;195(30):305-313.
exploration of spinal cord and cauda equina injuries. 36. Graef JW, Lovejoy FH. Heavy metal poisoning. In: Braun-
JAMA 1945;129:152-153. wald E, Isselbacher KJ, Petersdorf RG et al, ed. Harrison’s
17. Kihtir T, Ivatury RR, Simon R, Stahl WM. Management of principles of internal medicine. 11th Ed. New York:
transperitoneal gunshot wounds of the spine. J. Trauma McGraw Hill, 1987:852.
1991;31(12):1579-1583. 37. Waters RL, Hu SS. Penetrating injuries of the spinal canal.
18. Haynes WG. Acute war wounds of the spinal cord. Am. J. Stab and gunshot injuries. In: Frymoyer JW, ed. The adult
Surg. 1948;72:424-433. spine. Vol. 1. New York: Raven Press, 1991:815-826.
19. Jacobs GB, Berg RA. The treatment of acute spinal cord 38. White AA, Johnson RM, Panjabi MM et al. Biomechanical
injuries in a war zone. J. Neurosurg. 1971;34:164-167. analysis of clinical stability in the cervical spine. Clin.
Orthop. 1975;109:85-95.
20. Pool JL. Gunshot wounds of the spine. Observations from
an evacuation hospital. Surg. Gynecol. Obstet. 1945;81:617- 39. Denis F. The three column spine and its significance in the
622. classification of acute thoracolumbar spinal injuries. Spine
1983;8(8):817-831.
21. Wannamaker GT. Spinal cord injuries: Areview of the early
treatment in 300 consecutive cases during the Korean con-
flict. J. Neurosurg. 1954;11:517-524. Address for correspondence:
22. Heiden JS, Weiss MH, Rosenbery AW, Kurz T. Apuzzo Ronald W. Lindsey, M.D., Professor
MLJ. Penetrating gunshot wounds of the cervical spinal Baylor College of Medicine, 6560 Fannin, Suite 1900,
cord in civilians: Review of 38 cases. J. Neurosurg. Houston, Texas 77030, Tel: 713-790-4818, Fax: 713-793-
1975;42:575-579.
7669
23. Morgan TH, Wharton GW, Austin GW. The results of
laminectomy in patients with incomplete spinal cord
injuries. Paraplegia 1971;9:14-23.
24. Venger B, Simpson R, Narayan R. Neurosurgical inter-
vention in penetrating spinal trauma associated with vis-
ceral injuries. J. Neurosurg. 1989;70:514-518.
25. Waters RL, Adkins RH. The effects of removal of bullet
fragments retained in the spinal canal: A collaborative
study by the National Spinal Cord Injury Model Systems.
Spine 1991;16:934-939.
26. Simpson R, Venger B, Narayan R. Treatment of acute pen-
etrating injuries of the spine: A retrospective analysis.
J. Trauma 1989;29:42-46.
27. Stauffer ES, Wood RW, Kelly EG. Gunshot wounds of the
spine: The effects of laminectomy. J. Bone Joint Surg.
1979;61A:389-392.
28. Benzel EC, Hadden TA, Coleman JE. Civilian gunshot
wounds to the spinal cord and cauda equina. Neuro-
surgery 1987;20:281-285.
29. Cybulski GR, Sone JL, Kant R. Outcome of laminectomy
for civilian gunshot injuries of the terminal spinal cord and
cauda equina: Review of 88 cases. Neurosurgery
1989;24(3):392-397.
30. Arasil E, Tascioglu AO. Spontaneous migration of an
intracranial bullet to the cervical spinal canal causing Lher-
mitte’s sign: A case report. J. Neurosurg. 1982;56:158.