Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXXIII: Wounds and Injuries of the Spinal Column and Cord
United States Department of Defense
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High-velocity missile wounds of the spine, especially those with dural disruption, require immediate debridement. Low-velocity missile injuries of the spinal cord require less extensive debridement. The operative approach to the management of open wounds of the spine includes exploration of the path of the missile, assessment of the nature and extent of the anatomical disruption, and management of other concurrent surgical problems. Missiles that pass through the esophagus or colon, before striking the vertebral column, can cause osteomyelitis of the spine or disc-space infection. Consequently, when the colon or esophagus and the vertebral column are sequentially injured by a missile, both structures must be managed surgically. Intravenous antibiotic administration (a combination of first-generation cephalosporin and an aminoglycoside is recommended) and tetanus prophylaxsis should be started immediately. Where cerebral spinal fluid (CSF) leakage from the wound is identified following debridement, the wound can be closed loosely and a compression dressing applied. Continued subcutaneous spinal fluid collection or persistent leakage is an indication for wound exploration and dural repair.
In the presence of extensive open wounds of the spine, every attempt should be made to repair muscle and skin, and to perform a watertight closure of the dura within the first 6-12 hours post-injury. If logistics make it impossible to manage an open spine wound during the first 48 hours, it is preferable to debride and loosely pack the open wound. If there is no CSF leakage, the wound may be left open for 35 days followed by delayed closure, or allowed to heal by second intention. In those injuries with complete anatomical disruption of the spinal cord, the dural sack can be ligated to prevent CSF leak. Although not optimal, tissue deficits may require dural repairs or "patch" grafts to be left uncovered. Instrumentation for spinal stabilization and fusion (i.e., rods, etc) is contraindicated in the presence of an open wound.
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