Civilian ballistic spinal cord injuries versus blunt trauma: comparative analysis of clinical characteristics, management, and outcomes.

Background context: There are no current guidelines for the management of civilian gunshot wound injuries (GSW) to the spine and patient management often relies on algorithms derived from blunt trauma (BT). However, spinal cord injury due to GSW or blunt trauma mechanism may have significantly different clinical presentation, management, and outcomes. To ensure improved and evidence-based treatment, we need to understand the outcome determining characteristics of civilian GSW to the spine and identify the differences to the well-studied BT.

Purpose: The aim of this study was to compare clinical characteristics, management, functional outcomes, and mortality associated with GSW to the spine versus BT.

Design: Retrospective single-center analysis.

Patient sample: One thousand nine hundred thirty-nine unique patients admitted to a level 1 trauma center with spinal cord injuries due to GSW or BT between the years 2003-2022.

Outcome measures: Primary outcome measure was the progression in American Spinal Injury Association (ASIA) motor score.

Methods: Clinical characteristics were compared followed by age-matched analysis (<45years) of neurological injury, the need for surgery, neurological outcomes and mortality. Stratification by neurological injury allowed for more homogenous subgroups for outcome analysis.

Results: Of the 1939 patients with spinal cord injury, 566 were included in GSW group, and 1373 patients in BT group. Most patients in the GSW group were males (94.9% GSW vs. 83.5% BT; p<0.001) and younger (28.2 (range 13-62) years vs. 37.9, (range 12-91) years, p<0.001). The age-matched dataset comprised 1536 patients, with 540 in GSW group, and 996 in BT group. There were significantly more complete neurological injuries at admission in GSW group compared with BT (63.5% GSW vs. 34.4% BT, p<0.001). The ASIA motor Score at admission was significantly lower in GSW group (p<0.001), and changed without significant difference between the groups from admission to discharge (p<0.001, p=0.222). Subgroup analysis based on spinal cord injury showed that a higher proportion of patients with incomplete injuries improved neurologically, opposed to complete injuries, with significantly more patients improving in GSW group compared to BT (incomplete 58.9% GSW vs. 44.3% BT, p<0.001). Likewise, a higher proportion of paraplegic patients improved, opposed to quadriplegic patients, and in the paraplegic subgroup GSW patients improved rather than BT (paraplegic 65.1% GSW vs. 35.3%BT, p<0.001). In GSW group significantly less patients were managed operatively compared to BT group (12.2% GSW vs 76.8% BT, p<0.001). Most surgeries were bullet removals (81,4%) and involved the lumbar spine: 38.6% lumbar surgeries (of all GSW surgeries) and 31.4% surgery rate of all lumbar GSW patients. There was no significant difference in ASIA motor and sensory score improvement between patients who underwent surgery for bullet removal compared to nonoperatively managed patients in GSW group (p=0.199). The incidence rate of surgery showed a downwards trend over the study period. GSW group showed significantly less complications than BT group (22.8% GSW vs 27.0% BT, p<0.001). There was no significant difference in mortality rates (p ≥ 0.289).

Conclusion: To our knowledge, this is the largest single-center dataset of civilian ballistic spinal cord injuries compared to BT. GSW affect mostly young males and result in significantly more severe, complete neurologic injuries compared with BT at similar mortality rates. Nevertheless, the present data suggest a greater potential for neurological improvement for paraplegic patients and incomplete injuries in GSW group. Patients with spinal cord injuries due to GSW undergo surgery less frequently compared to BT. Operated GSW cases primarily involved the lumbar spine. This study revealed differences between spinal cord injuries due to GSW and BT. In clinical application, this means that guidelines based on BT may not directly be transferable to civilian ballistic spinal cord injuries.