Fig. 14.1
(a) CT of brain. 2.5 × 1.5 cm foreign body with right middle and inferior frontal gyri with overlying comminuted frontal bone fracture. (b) CT brain. Metallic foreign body in the subcutaneous tissue of the right frontal area measuring 1.2 cm with underlying depressed frontal bone fracture. (c) Foreign bodies after removal in the operating room. (d) Intraoperative picture with the foreign body prior to removal (yellow arrow)
Case 2
A healthy 27-year-old male sustained a bullet injury to his head in Iraq, one and a half months prior to presentation to our institution. His head injury caused a left parietal depressed fracture. Patient underwent a same day craniectomy in his native country, with wound debridement, while the dura was left open. He was kept on mechanical ventilation for 3 days. After extubation, he had right sided weakness and expressive aphasia. Upon presentation to our hospital, patient had no motor power over his right upper extremity, with associated weakness over his right face and right lower extremity. He had a GCS of 15. CT scan was done and revealed postsurgical changes due to left parietal craniotomy (Fig. 14.2a) with a fracture extending from the left parietal to the left occipital bone and squamous portion of the left temporal bone (Fig. 14.2b).
Fig. 14.2
(a) CT of brain showing post left parietal craniotomy . Encephalomalacia involving the left parietal lobe. (b) CT brain revealing fracture of left parietal bone (floating bone fragment ) extending into left occipital bone and squamous portion of the left temporal bone. Metallic shrapnels noted over anterior part of left parietal lobe
There was metallic shrapnel anterior to the left parietal bone with associated encephalomalacia involving the left parietal lobe and small bone fragments in the left corona radiate.
He was taken to operating room where he underwent left parietal craniotomy, closure of dura with synthetic dural graft. The bone fragments were fixed again using Tevdek sutures and a cranioplasty was carried on using methyl methacrylate in order to close the residual bony defect. Intraoperative cultures were negative and patient was discharged to a rehabilitation center 2 days later in stable condition.
War Injury to Spine
War-associated spine injuries have been reported in ancient historical documents since the fourth century BC. It was first documented by Greeks while pharos described ways dealing with spine fractures. Nonetheless, before creating gunpowder, most of the endured spine injuries were either lethal or not curable [19]. However, with the introduction of ballistic and advancement of medicine , more people survived spine injuries with higher reported occurrence rate [20].
Since declaring the global war on terrorism , war tactics have changed from the standard combat to new improvised approaches by using improvised explosive devices (IED ) , roadside bombs, and rocket-propelled grenades. This unconventional war led to harsher complex multisystem traumatic presentations. Moreover, it presents higher incidence of war spinal cord injuries (WSCI) [21]. They are among the most incapacitating conditions affecting the wounded both among soldiers and civilians . Increasing numbers of spinal injuries were reported over the recent wars (Iraq/Afghanistan invasion) compared to the World War II and Vietnam War. Most common types of injuries were transverse process fractures , burst and compression fractures , and WSCI [22]. Other types of spinal damage included pedicle, facet, or burst fractures and ligamentous injuries. In addition, most traumatized subjects endured other associated injuries to head, chest, abdomen, and extremities delaying the recovery and aggravating the outcome .
Despite that gunshot wounds constitute a minor percentage of spinal injuries compared to damage inflicted by blast or explosive devices, they cause more severe damage to the spinal cord. High-velocity bullets which produce vertebral destruction are most likely to cause direct spinal cord injury due to dissipating energy and osseous fragmentation [23]. Additionally, secondary or indirect damage by means of bullet-induced cavitation in proximity of the spinal structures can take place, along with destruction of vascular supply. This causes a brisk intense movement of the cord within the spinal canal, mimicking sometimes the outcome of spinal transection [23]. Other factors determining the amount of damage is the size of the bullet, its composition, design (jacket vs. non-jacket), and form [24].
Surgical management for WSCI is debatable. Its classification is based on the American Spinal Injury Association (ASIA) for assessing the neurological status of the patients [25]. Although Magnetic resonance imaging (MRI ) is considered as the diagnostic modality for examining the extent of spinal damage in terms of spinal soft tissue injuries, inter-spinous ligament, intervertebral disk, and para-spinal muscle injuries [26], it has limited primary use due to the presence of shrapnels and metallic foreign bodies . Nonetheless, dural tears aren’t revealed by MRI but are usually discovered during surgical intervention [27]. CSF leak , a consequence of dural tear , is associated with spontaneous intracranial hypotension (SIH) , subdural hematoma (SDH) , and meningitis [28, 29]. Moreover, a special care should be carried out when a chest tube with suction is to be inserted in a patient with chest injury concomitant with a dural sac tear, for fear of cerebral herniation [30].
Battle-induced spinal column and spinal canal injuries are different from noncombat traumatic incidents. They should be treated as totally distinct entities with a different long-term outcome between the two categories [31].
Similar to civilian traumas, initial therapy is directed towards stabilization of the patient, by applying the standard protocol of advanced trauma life support. Whenever a spinal injury is in question, patient immobilization is a must to limit further neurologic damage and decline. During combat , the primary concern is to evacuate the casualties rather than preserve spinal stability. However, once transported, suspected spinal injuries presenting with signs of focal neurological deficit, change in mental status, limb fractures, or presence of major distracting injuries should trigger prompt stabilization of the spine [32]. This is managed by a hard backboard, a rigid cervical collar, lateral buttress tools, and straps over the head, chest, and legs. Sand or IV bags are not advised since they can slide despite taping them over the board [33]. High arm in endangered spine (HAINES) is preferred over the log roll maneuver, to prevent lateral displacement of the lumbar spine in case of un-identified injury [34]. In cases of penetrating wounds and major traumatic injuries, spine stabilization is related to worst mortality rate, hence it is aborted from fear of missing dangerous injuries [35].
Doubt still prevails concerning the efficiency of surgical intervention in WSCI and its long-standing outcome . Nonetheless, acute surgical decompression is a must in case of deteriorating neurological behavior, spinal instability or presence of bone fragments , bullet or shrapnel within the spinal canal [36]. Avoiding intervention might lead to drawbacks such as foreign body migration which can similarly induce neurological deficit both in acute and chronic phases [37]. In addition, closure of dura is required when a cerebral spinal fluid (CSF) leak /fistula is suspected.
Location of WSCI is greatly associated with the long-term outcome in terms of regain of the neurological functions. In fact, the conus medullaris and cauda equina are less prone to injury when compared to the rest of the spinal cord. In contrast to thoracic spine, thoracolumbar and lumbar anatomy have better recovery rate. This could be interpreted by the larger ratio of lower to upper motor neurons in the distal spinal cord and the probability of root escape and root recovery phenomenon [38].
Clinical Cases
Case 3
A 33-year-old male, Iraqi soldier endured a blast injury while on combat duty 1 year prior to presentation. He was securing an occupied building from enemy forces when an implanted bomb inside the construction detonated. He survived a falling roof on his back and severe burns over his lower extremities. In March of 2014 the patient underwent bilateral laminectomies T12-L1 and L2 followed by transpedicular screws and rods insertion from T11 to L4, sparing L2 and left L1 pedicles, and had skin grafts for his burn wounds. He reports no improvement in his symptoms after his initial surgery and presented to our institution 1 year later seeking surgical treatment. He had bilateral numbness over both lower extremities reaching the big toes, urinary and fecal incontinence, and inability to ambulate without assistance. On physical exam there was loss of cold/hot discrimination over his lower extremities and severe right foot extension weakness. CT was ordered first to rule out any shrapnel or metallic objects embedded in the spinal canal followed by an MRI (Fig. 14.3) which revealed a severely comminuted burst fracture involving the L2 vertebral body with significant spinal canal compression and fracture lines extending to the pedicles and transverse processes. In addition, a partly healed comminuted fracture involving the left aspect of the L1 vertebral body extending to the left pedicle was noticed. There was a secondary narrowing of the left L1–L2 neural foramen with compression of the left L1 nerve. At L5–S1, meningeal calcification and nerve roots clumping and thickening, extending over a craniocaudal length of approximately 5 cm, were seen. In addition, noted were displaced fractures of the left transverse processes of L3 and L4.
Fig. 14.3
MRI of spine. Loss of height of the vertebral body, most severe at its mid-portion reaching 55% and significant retropulsion of the fracture fragments into the spinal canal with severe compression of the conus medullaris at same level
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