Spinal gunshot wounds: A systematic review of the literature

The appropriate management of spinal gunshot wounds (GSWs) remains controversial. This systematic review presents an overview of the available scientific evidence in the literature regarding efficacy and complication rates of surgical management and antibiotic prophylaxis for spinal GSWs.

A systematic review of PubMed/Medline was conducted, with a screening of articles for low-velocity civilian spinal GSWs. Collected information included patient demographics, injury description, management decision, outcomes of surgical versus conservative management, and the incidence of intra and extraspinal infections with prophylactic antibiotic use. Improvement was defined as the recovery of 1 or more ASIA levels. Statistical analysis involved chi-squared analysis and meta-analysis where feasible.

Thirty-four retrospective cohort studies were included. About 11% of patients were treated surgically whereas 89% were treated conservatively. Of the surgically managed patients, 88% received decompression, and only 11% received stabilization. Surgically managed patients had similar rates of neurological improvement in comparison to conservative treatment (95% CI -0.99, 13.45; p = .06), but 7% higher complication rate which was statistically significant (95% CI 0.66, 13.10; p = .02). Intraspinal infection rates were similar between the prophylaxis versus no prophylaxis groups (95% CI 1.12, 3.23; p = .35). However, the prophylaxis cohort had a higher rate of extraspinal infections (95% CI 34.82, 50.14; p < .01).

An understanding of the factors which impact decision-making in spinal GSWs is of paramount importance. We found no statistically significant difference in neurological recovery between surgically and conservatively treated patients, although surgical patients had a statistically higher rate of complications. The possible deleterious effects of antibiotic prophylaxis on extraspinal infections warrants further research regarding confounding factors and which antibiotics regimens may be implicated.