88th Medical Group, Wright-Patterson Air Force Base, Ohio 45433, USA.
Neurosurg Focus. 2010 May;28(5):E4. doi: 10.3171/2010.2.FOCUS1036.
Penetrating spinal injury (PSI), although an infrequent injury in the civilian population, is not an infrequent injury in military conflicts. Throughout military history, the role of surgery in the treatment of PSI has been controversial. The US is currently involved in 2 military campaigns, the hallmark of both being the widespread use of various explosive devices. The authors reviewed the evidence for or against the use of decompressive laminectomy to treat PSI to provide a triservice (US Army, Navy, and Air Force) consensus and treatment recommendations for military neurosurgeons and spine surgeons.
A US National Library of Medicine PubMed database search that identified all literature dealing with acute management of PSI from military conflicts and civilian urban trauma centers in the post-Vietnam War period was undertaken.
Nineteen retrospective case series (11 military and 8 civilian) met the study criteria. Eleven military articles covered a 20-year time span that included 782 patients who suffered either gunshot or blast-related projectile wounds. Four papers included sufficient data that analyzed the effectiveness of surgery compared with nonoperative management, 6 papers concluded that surgery was of no benefit, 2 papers indicated that surgery did have a role, and 3 papers made no comment. Eight civilian articles covered a 9-year time span that included 653 patients with spinal gunshot wounds. Two articles lacked any comparative data because of treatment bias. Two papers concluded that decompressive laminectomy had a beneficial role, 1 paper favored the removal of intracanal bullets between T-12 and L-4, and 5 papers indicated that surgery was of no benefit.
Based on the authors' military and civilian PubMed literature search, most of the evidence suggests that decompressive laminectomy does not improve neurological function in patients with PSI. However, there are serious methodological shortcomings in both literature groups. For this and other reasons, neurosurgeons from the US Air Force, Army, and Navy collectively believe that decompression should still be considered for any patient with an incomplete neurological injury and continued spinal canal compromise, ideally within 24-48 hours of injury; the patient should be stabilized concurrently if it is believed that the spinal injury is unstable. The authors recognize the highly controversial nature of this topic and hope that this literature review and the proposed treatment recommendations will be a valuable resource for deployed neurosurgeons. Ultimately, the deployed neurosurgeon must make the final treatment decision based on his or her opinion of the literature, individual abilities, and facility resources available.
穿透性脊柱损伤（PSI）虽然在平民人群中并不常见，但在军事冲突中却并非罕见。纵观军事史，手术在治疗 PSI 中的作用一直存在争议。美国目前正在参与 2 场军事行动，其特点是广泛使用各种爆炸装置。作者回顾了减压性椎板切除术治疗 PSI 的证据，以提供三军（美国陆军、海军和空军）共识，并为军事神经外科医生和脊柱外科医生提供治疗建议。
对美国国家医学图书馆 PubMed 数据库进行了检索，检索了自越南战争后军事冲突和城市创伤中心治疗急性 PSI 的所有文献。
19 项回顾性病例系列研究（11 项来自军队，8 项来自民用）符合研究标准。11 篇军队文章涵盖了 20 年的时间跨度，包括 782 名因枪击或爆炸相关弹丸受伤的患者。4 篇论文提供了足够的数据来分析手术与非手术治疗的效果，其中 6 篇论文认为手术没有益处，2 篇论文表明手术有一定作用，3 篇论文没有发表评论。8 篇民用文章涵盖了 9 年的时间跨度，包括 653 例脊髓枪伤患者。有 2 篇文章因治疗偏见而缺乏任何比较数据。有 2 篇论文认为减压性椎板切除术具有有益作用，1 篇论文支持在 T-12 和 L-4 之间切除椎管内子弹，5 篇论文表明手术没有益处。
根据作者对军队和民用 PubMed 文献的检索，大多数证据表明，减压性椎板切除术并不能改善 PSI 患者的神经功能。然而，这两个文献组都存在严重的方法学缺陷。出于这个原因，以及其他原因，来自美国空军、陆军和海军的神经外科医生一致认为，对于任何不完全性神经损伤且脊髓管持续受压的患者，仍应考虑减压术，最好在损伤后 24-48 小时内进行；如果认为脊柱损伤不稳定，应同时进行稳定。作者认识到这个话题极具争议性，希望这篇文献综述和提出的治疗建议能为部署中的神经外科医生提供有价值的资源。最终，部署中的神经外科医生必须根据他或她对文献的个人意见、个人能力和可用设施资源来做出最终的治疗决策。
