Thoracolumbar infections in penetrating injuries to the spine.

A detailed review of the TJUH experience and the published literature on gunshot and stab wounds to the spine has been presented. The following statements are supported. (1) Military (high-velocity) gunshot wounds are distinct entities, and the management of these injuries cannot be carried over to civilian (low-velocity) handgun wounds. (2) Gunshot wounds with a resultant neurologic deficit are much more common than stab wounds and carry a worse prognosis. (3) Spinal infections are rare following a penetrating wound of the spine and a high index of suspicion is needed to detect them. (4) Extraspinal infections (septic complications) are much more common than spinal infections following a gunshot or stab wound to the spine. (5) Steroids are of no use in gunshot wounds to the spine. In fact, there was an increased incidence of spinal and extraspinal infections without a difference in neurologic outcome compared with those who did not receive steroids. (6) Spinal surgery is rarely indicated in the management of penetrating wounds of the spine. The recommendations for treatment at TJUH of victims of gunshot or stab wounds with a resultant neurologic deficit are as follows. (1) Spine surgery is indicated for progressive neurologic deficits and persistent cerebrospinal fluid leaks (particularly if meningitis is present), although these situations rarely occur. (2) Consider spine surgery for incomplete neurologic deficits with radiographic evidence of neural compression. Particularly in the cauda equina region, these surgeries may be technically demanding because of frequent dural violations and nerve root injuries/extrusions. These cases must be evaluated in an individual case-by-case manner. The neurologic outcomes of patients with incomplete neurologic deficits at TJUH who underwent acute spine surgery (usually for neural compression secondary to a bullet) were worse than the outcomes for the patients who did not have spine surgery. A selection bias against the patients undergoing spine surgery was likely present as these patients had evidence of ongoing neural compression. (3) A high index of suspicion is necessary to detect spinal and extraspinal infections. (4) Do not use glucorticoid steroids for gunshot wound victims. (5) Conservative (nonoperative) treatment with intravenous broad spectrum antibiotics and tetanus prophylaxis is the sole therapy indicated in the majority of patients who sustain a penetrating wound to the thoracic or lumbar spines.