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Abstract

Spinal cord injury (SCI) is a major cause of morbidity and disability in the United States. While most SCI is caused by blunt trauma, penetrating spine injuries can be particularly devastating. Our aim is to compare management strategies, surgical intervention, imaging findings, and neurological outcomes in patients sustaining SCI due to direct spinal cord penetration versus indirect spinal cord or blast injury following gunshot wounds (GSWs). This study is a retrospective chart review of patients presenting to Highland Hospital with GSWs to the spine between January 2013 and June 2020. Baseline demographics and outcome parameters were analyzed, and multiple regression analysis was performed to identify predictor variables. A p value of ≤0.05 was considered statistically significant. A total of 111 patients were included in our analysis. Sixty-nine patients sustained blast injuries whereas 42 sustained direct penetrating injuries to the spinal cord. More patients in the blast injury group were classified as American Spinal Injury Association (ASIA) E whereas more patients in the direct penetrating group were classified as ASIA A (p = 0.000). There was no statistically significant difference in treatment modalities utilized between groups. Multiple regression analysis demonstrated that the use of mean arterial pressure (MAP) augmentation was predictive of a change in ASIA class in both groups. Patients with penetrating injuries to the spinal cord had more severe neurological deficits than those with blast injuries. In our study, MAP augmentation was predictive of neurological improvement in both groups; however, larger sample sizes are needed to identify effective management strategies for patients with penetrating and blast SCIs following GSWs to the spine.

Introduction/Background

The National Spinal Cord Injury Statistical Center estimates that 18,000 traumatic spinal cord injuries (SCIs) occur every year in the United States.¹ Most of these injuries are caused by blunt trauma such as falls; however, roughly 16% are the result of penetrating injuries. An overwhelming majority of penetrating SCI is attributed to gunshot wounds (GSWs).¹ According to a recent study, there was a 21% increase in nonfatal firearm injuries in the United States between 2019 and 2020 with an associated 22% cost increase from $7.58 billion to $9.3 billion.² Considering this uptick and the potentially devastating consequences, it is crucial to understand how to best care for patients with GSWs to the spine.

Current treatment guidelines for blunt SCI support both early surgical decompression and mean arterial pressure (MAP) augmentation. However, recent studies of penetrating SCI have not found these interventions to alter patient outcomes. Several studies suggest that surgical intervention after a GSW to the spine is not necessary unless there are progressive neurological deficits, spinal instability, cauda equina syndrome, wound contamination, or cerebrospinal fluid fistula.^3–6 A systematic review and meta-analysis conducted in 2022 found that early surgical intervention was not superior to conservative management in patients with penetrating SCI.⁷

However, what this study and many others do not address is that some patients with SCI following GSWs do not have direct injury to the spinal cord. Rather, the missile itself has directly damaged the surrounding structures—bone, soft tissue, and neural elements—and indirectly damaged the spinal cord through the transfer of kinetic energy.^5,6,8,9 We hypothesize that this subset of patients who have sustained indirect, concussive injuries to the spinal cord may benefit from early surgical decompression and MAP augmentation, or “MAP goals,” independent of spinal instability, need for wound debridement, or repair of CSF leak.

Clinical Materials and Methods

All patients who presented to Highland Hospital, a level one trauma center in Oakland, CA, with GSWs to the spine between January 2013 and June 2020 were identified via a retrospective query in the hospital’s trauma database. Their medical records were reviewed for gender, ethnicity, American Spinal Injury Association (ASIA) Impairment Scale classification (Figure 1), whether they sustained a direct penetrating or blast injury to the spine, level of injury, radiographical findings, other injuries, treatment modalities, length of stay (LOS), discharge disposition, and complications. Direct penetrating injuries were defined as a bullet trajectory through the spinal canal. Blast injuries were defined as structural injuries within the spinal column in which the bullet trajectory did not course through the central canal.

The medical records of those patients with follow-up data available were also reviewed for time to follow-up, mechanism of injury, level of injury, radiographical findings, follow-up ASIA class, treatment modalities implemented, and neurological improvement (Figure 2).

Primary outcomes were treatment modality, complications, discharge disposition, and change in ASIA class. Secondary outcomes were LOS, time to follow-up, and neurological improvement.

This study was approved by the Alameda Health System institutional review board. Individual consent was not obtained given the retrospective nature of the study.

FIG. 1.

The American Spinal Injury Association (ASIA) Impairment Scale is used to classify the severity of spinal cord injuries. Class A is a complete injury where there is no sensory or motor function at S4-5. Class B is an incomplete sensory injury where sensory function is preserved below the level of injury, including S4-5; however, there is no motor function more than three levels below the motor level of injury. Classes C and D are both incomplete motor injuries. However, in Class C, more than half of the main muscle groups below the level of injury are less than 3/5 strength. In Class D, more than half of the main muscle groups below the level of injury are 3/5 strength or more. Class E is a spinal cord injury with normal motor and sensory testing.

FIG. 2.

Consolidated Standards of Reporting Trials (CONSORT)-like diagram illustrates how patients were identified and grouped for various analyses. GSWs, gunshot wounds; SP, spinous process; TP, transverse process.

Statistical Analysis

Baseline demographics and outcome parameters, including those of each subgroup, were analyzed using chi-squared or Fisher’s exact test for categorical variables and t-test or Wilcoxon rank-sum for continuous parametric and nonparametric data, respectively. Directed acyclic graphs were created to analyze potential causal relationships and minimize bias.¹⁰

Multiple regression analysis was used to assess and adjust for potential confounders given the combination of categorical and continuous variables and identify potential predictor variables. Dummy coding was used to incorporate categorical variables into the regression models. A p value of ≤0.05 was considered statistically significant. Statistical analysis was performed using a combination of Microsoft Excel and R version 4.3.1 (2023).

Results

We identified 111 patients who sustained GSWs to the spine between January 2013 and June 2020. The mean age was 29.4 years and 17.1% were female. Thirty patients were classified as ASIA A, 5 as ASIA B, 10 as ASIA C, 17 as ASIA D, and 49 as ASIA E. Injuries involving only the thoracic spine were most common (n = 49, 44.1%), followed by the those limited to the lumbar spine (n = 38, 34.2%).

The direct penetrating group was comprised of 42 patients. The mean age was 30.2 years, 5 (11.9%) were female, and 27 patients (64.2%) were classified as ASIA A. Half of the patients sustained injuries to the lumbar spine, and the posterior spinal column was most frequently involved (n = 31, 73.8%). The bullet traversed the spinal canal in 34 patients, and the bullet was seen radiographically in the canal of 21 patients. Nine patients were treated with MAP augmentation, nine with antibiotics, seven with surgery, five with bracing, and one with steroids. One patient had a complication related to the migration of the bullet. Mean LOS was 12.5 days, and most were discharged to an acute rehabilitation unit (Tables 1 and 2).

Table 1.

Comparisons Between Blast and Direct Penetrating Groups

	Blast (n = 69)	Direct penetrating (n = 42)	p value
Mean age (years)	28.8	30.16	0.284
Gender (n, %)
Male	55 (79.7)	37 (88.1)	0.255
Female	14 (20.2)	5 (11.9)
Ethnicity (n, %)
Black	43 (62.3)	26 (61.9)	0.530
Asian	3 (4.3)	4 (9.5)
Hispanic	7 (10.1)	1 (2.4)
White	5 (7.2)	3 (7.1)
Other	10 (14.4)	8 (19.0)
Unknown	1 (1.4)	0
ASIA class (n, %)
A	3 (4.3)	27 (64.2)	0.000
B	3 (4.3)	2 (4.8)
C	4 (5.7)	6 (14.2)
D	12 (17.4)	5 (11.9)
E	47 (68.1)	2 (4.8)
Other injury (n, %)
Oropharyngeal	9 (13.0)	1 (2.4)	0.047
Intra-abdominal	23 (33.3)	18 (42.8)
Mean LOS (days)	13.8	12.5	0.386
Discharge disposition (n, %)
Home	46 (66.7)	5 (11.9)	0.000
ARU	8 (11.6)	32 (76.2)
SNF	4 (5.7)	1 (2.4)
Other hospital	3 (4.3)	4 (9.5)
Custody	4 (5.7)	0
Morgue	4 (5.7)	0
Complications	0	1 (2.4)	0.378

ASIA, American Spinal Injury Association; LOS, length of stay.

Table 2.

Radiological Comparisons Between Blast and Direct Penetrating Groups

	Blast (n = 69)	Direct penetrating (n = 42)	p value
Spinal level (n, %)
Cervical	17 (24.6)	1 (2.4)	0.002
Thoracic	28 (40.6)	20 (47.6)
Lumbar	19 (27.5)	21 (50.0)
Sacral	1 (1.4)	0
Multiple	2 (2.9)	0
Brachial plexus	2 (2.9)	0
Column injury (n, %)
Anterior	15 (21.7)	0	0.000
Posterior	18 (26.0)	31 (73.8)
Both	2 (2.9)	10 (23.8)
TP/SP	34 (49.3)	0
Other	0	1 (2.4)
Radiographical findings (n, %)
Air in canal	8 (11.6)	14 (33.3)	0.000
Trajectory through canal	0	34 (80.9)
Bullet in canal	1 (1.4)	21 (50.0)
Isolated nerve root injury	6 (8.7)	3 (7.1)

SP, spinous process; TP, transverse process.

Twenty-six patients in the direct penetrating group had follow-up data available for review. The mean time to follow-up was 7.3 weeks. Overall, six patients had laminectomies and five patients were treated with MAP goals. Five patients had motor improvement and three had sensory improvement. Of these patients, one had thoracic laminectomies and one was treated with MAP augmentation.

Of the total 111 patients, 69 sustained blast injuries to the spinal cord. The average age was 28.8 years, and 14 patients (20.2%) were female; 68.1% of these patients were classified as ASIA E. Thoracic spine injuries were most common (n = 28, 40.6%). Nineteen patients had isolated transverse process (TP) or spinous process (SP) fractures. Air was seen in the spinal canal of eight patients. One patient had bullet fragments visualized radiographically within the spinal canal; however, the bullet’s trajectory was not through the canal and the patient only sustained thoracolumbar TP, SP, and laminar fractures. Eight patients were treated with antibiotics, six with bracing, four with MAP goals, three with surgery, and none with steroids. The mean LOS was 13.8 days. There were no complications related to the spinal injuries themselves, although four patients died due to other injuries. Most were discharged home (Tables 1 and 2).

Thirty-eight of the original 69 patients in the blast injury group had available follow-up data. The mean time to follow-up was 5 weeks. Of those who followed up, two had undergone surgery and one was treated with MAP augmentation. Four patients had motor improvement and three had sensory improvement. One of these patients underwent T4-6 laminectomies, debridement, and bullet removal. None of the patients who had neurological improvement were treated with MAP augmentation.

The differences in ASIA classes, spinal levels involved, columns injured, radiographical findings, other injuries, and discharge dispositions between the blast and direct penetrating groups were statistically significant. There was no statistically significant difference in treatment modalities utilized between the two groups (Table 3). Of the patients with follow-up data available, the direct penetrating group had longer mean time to follow-up (p = 0.027), more patients treated with surgery (p = 0.034), and more patients treated with MAP goals (p = 0.025).

Table 3.

Management Comparisons Between Groups (p = 0.643) and Multiple Regression Model Summary

	Blast (n, %)	Direct penetrating (n, %)	R ²	Adjusted R²	p value
Surgery	3 (4.3)	7 (16.7)	0.189	0.041	0.225
Brace	6 (8.7)	5 (11.9)	0.233	0.093	0.064
Steroids	0	1 (2.4)	0.271	0.128	0.025
MAP goals	4 (5.8)	9 (21.4)	0.247	0.110	0.040
Antibiotics	8 (11.6)	9 (21.4)	0.108	−0.055	0.832

MAP, mean arterial pressure.

Multiple regression models

The overall regression models for steroids and MAP augmentation were statistically significant. We found that a direct penetrating injury and missile trajectory through the spinal canal significantly predicted surgical intervention. We also found that direct penetrating injury, ASIA D, missile trajectory through the spinal canal, and isolated nerve root injury significantly predicted the use of steroids.

The overall regression for complications was statistically significant, and direct penetrating injury, missile trajectory through the spinal canal, use of a brace, and longer LOS significantly predicted the presence of complications. Additionally, the overall regression for improvement in the ASIA class was statistically significant. We found that ASIA classes B and E and the presence of peripheral nerve injury significantly predicted neurological improvement.

Multiple regression models—direct penetrating group

In the direct penetrating group, the overall regression models for ASIA classes A and D, discharges to ARU and home, change in ASIA class, and LOS were statistically significant.

ASIA A was significantly predicted by age, presence of thoracic injury, and missile trajectory through the spinal canal. A sacral injury, isolated nerve root injury, and missile trajectory through the spinal canal significantly predicted ASIA D. ASIA E was significantly predicted by a sacral injury.

Age and the presence of a cervical injury significantly predicted surgical intervention. The cervical injury also significantly predicted the use of a brace, while the presence of an intra-abdominal injury significantly predicted the use of MAP goals, and classification as ASIA D significantly predicted the use of steroids.

We found that the presence of complications was significantly predicted by classification as ASIA B and negatively predicted by the missile trajectory through the spinal canal.

Regarding discharge dispositions, discharge to ARU was significantly predicted by ASIA class D or E; cervical, sacral, or isolated nerve root injury; and the use of steroids. Discharge home was also significantly predicted by ASIA D or E, isolated nerve root injury, and use of steroids. The presence of cervical or lumbar injury and complications significantly predicted discharge to another hospital. Age was significantly predictive of discharge to SNF.

We also found that change in ASIA class was significantly predicted by age, intra-abdominal injury, ASIA C, lumbar or isolated nerve root injury, surgical intervention, brace, MAP goals or antibiotics, discharge home, and presence of complications.

Lastly, the presence of oropharyngeal injury and classification as ASIA D significantly predicted the LOS in the direct penetrating group.

Multiple regression models—blast injury group

In the blast injury group, the following overall regression models were statistically significant: ASIA classes A, D, and E, use of MAP goals, discharges to home, ARU and SNF, change in ASIA class, and LOS.

We found that ASIA A was significantly predicted by age and the presence of air in the spinal canal on imaging, ASIA B was significantly predicted by the presence of peripheral nerve injury, ASIA C was significantly predicted by the presence of an isolated nerve root injury, ASIA D was significantly predicted by sacral injury, peripheral nerve injury, and isolated nerve root injury, and ASIA E was significantly predicted by the presence of air in the spinal canal and isolated nerve root injury.

Surgical intervention was significantly predicted by the patient being classified as ASIA B, while the use of MAP goals was significantly predicted by the presence of air in the spinal canal on imaging.

Improvement in ASIA class was significantly predicted by classification as ASIA B or C, the presence of cervical, lumbar, peripheral nerve, or isolated nerve root injury, use of MAP goals, and discharge to SNF.

Classification as ASIA A, surgical intervention or MAP goals, and the presence of complications statistically predicted the LOS.

Multiple regression models—blast group excluding patients with isolated TP or SP fractures

When patients with isolated TP and/or SP fractures were excluded from regression analyses, the overall regression models for change in ASIA class, radiographical presence of air in the spinal canal, isolated nerve root injury, ASIA D, ASIA E, and dispositions to ARU and custody were statistically significant.

Classification as ASIA A was predicted by age and radiographical air in the spinal canal. ASIA B was predicted by peripheral nerve injury. ASIA C was predicted by gender, presence of intra-abdominal injury, and isolated nerve root injury. ASIA D was predicted by sacral, peripheral, and isolated nerve root injuries.

The radiographical presence of air in the spinal canal was significantly predicted by ASIA A classification and sacral injury and negatively predicted by age and peripheral nerve injury. A bullet fragment within the spinal canal was significantly predicted by oropharyngeal injury and injury to the thoracic and lumbar spine. Isolated nerve root injury was significantly predicted by ASIA D and peripheral nerve injury.

Improvement in ASIA class was significantly predicted by initial classification as either ASIA A, B, or C, peripheral nerve injury, isolated nerve root injury on imaging, treatment with MAP goals, and discharges to home or ARU.

Discussion

Of the roughly 18,000 new traumatic SCIs each year, most patients are male, and about 15% of these injuries occur due to acts of violence, primarily GSWs.¹ Spitzer et al. reported that in California between 2005 and 2015, there were 81,085 visits to the emergency department for nonfatal firearm injuries.¹¹ Again, most of these patients were male, and the mean age was 27.5 years. Similarly, our patients were primarily male with an average age of 29.4 years. Most of our patients were Black—in part, this reflects the fact that the community our hospital serves is over 20% Black or African American.¹² However, these demographics are also consistent with known epidemiological trends in firearm injuries and other previously published studies.^3,5–7

When compared with those with blast injuries to the spine following GSWs, we found patients with direct penetrating injuries to have more severe SCIs as defined by ASIA classification. The patients with direct penetrating injuries also had more radiographical evidence of spinal canal involvement either from the presence of air or a bullet in the canal or the missile trajectory through the canal. Additionally, more of these patients were discharged to ARU whereas more patients with blast injuries were discharged home. This difference in disposition is likely due to differences in injury severity and neurological deficit between the two groups.

We found no statistically significant difference in treatment modalities employed and follow-up characteristics between the two groups. We attribute this to small sample sizes. Few patients in each group were treated with surgical intervention, steroids, bracing, antibiotics, or MAP goals, and only 64 of our 111 patients (58%) had follow-up data available. Of those with follow-up data available who were found to have an improvement in ASIA class, one was treated with MAP augmentation, two underwent surgery, and most were discharged to ARU. There was no pattern in terms of the initial ASIA class. Larger sample sizes are necessary to delineate commonalities among those patients who exhibit neurological improvement.

Our regression results across all groups generally demonstrated that more severe neurological injury predicted surgical intervention, steroid administration, and/or MAP goals. After our initial analysis, we identified a new subgroup of blast injury patients without isolated TP or SP fractures. These fractures are generally treated nonoperatively. In the analysis of this new subgroup, we found the use of MAP goals was predicted by the radiographical presence of air in the spinal canal; however, no other treatment modality had statistically significant predictors. Once again, we suspect this is due to small sample sizes as previously discussed.

We used a change in ASIA class as a standardized measure of neurological improvement. In summary, our regression results show that patients with GSW to the spine with any neurological impairment or injury at any spinal level can improve. Within the blast injury group and the subgroup without isolated TP or SP fractures, the use of MAP goals predicted a change in the ASIA class. MAP augmentation, along with the other treatment modalities included in our study, also predicted a change in the ASIA class in the direct penetrating group.

MAP augmentation to 75–80 mmHg but not higher than 90–95 mmHg for 3–7 days is suggested by recent guidelines for hemodynamic management in acute SCI.¹³ At our institution, all patients with a blunt SCI are treated with MAP augmentation >85 mmHg for 5 days. It is thought that hypotension can cause secondary injury to the spinal cord by impairing oxygen and nutrient delivery and limiting the removal of inflammatory cytokines from the site of injury.¹⁴ While MAP augmentation has been shown to improve neurological outcomes in patients with blunt SCI^14,15—although one meta-analysis points out that there is limited high-quality evidence to guide this practice¹⁶—few studies evaluate its role in the management of patients with penetrating SCI. One study found that patients with complete penetrating SCI who were treated with MAP augmentation were less likely to exhibit neurological improvement compared with patients with complete blunt SCI.¹⁷ Another study also did not find significant neurological improvement in patients with penetrating SCI who were treated with MAP augmentation compared with those with penetrating SCI who were not treated with MAP augmentation.¹⁸ However, these studies did not separately evaluate those patients with indirect SCI from the penetrating injury—we have defined these patients in our study as the blast injury group. Further investigation is needed to determine if this subset of patients could benefit from treatment with MAP augmentation like those with blunt SCI.

Although we hypothesized patients in the blast injury group could benefit from surgical decompression, surgery did not correlate with a change in ASIA class in those with blast injuries when isolated TP and SP fractures were excluded. The three patients in the blast injury group who underwent surgery all had posterior column injuries. Two were classified as ASIA E while the third was ASIA B. Two sustained thoracic injuries and were treated with MAP goals in addition to surgery. The ASIA B patient, who had a T5 injury, exhibited neurological improvement at discharge, and the exam was stable at follow-up. The other patients were neurologically stable at discharge. A larger sample size is needed to determine if surgical intervention does lead to improved neurological outcomes in patients sustaining a blast injury to the spine.

The purpose of neurosurgical intervention in trauma settings is to stabilize the spine and prevent neurological deterioration.^18,19 Recent guidelines recommend early surgical decompression within 24 h of injury regardless of spinal level for adults with acute SCI.²⁰ Surgical indications in our patients were spinal instability, concern for expanding epidural hematoma, and CSF leak. It is generally accepted that GSWs to the spine do not produce unstable fractures, and much of the available data suggest that surgery does not improve outcomes in patients with penetrating SCI from GSWs.^18,21–23 Notably, in these studies, patients with blast injuries to the spinal cord were not analyzed separately from those with direct penetrating injuries. It is possible that patients with blast injuries may have similar issues with spinal stability and neurological dysfunction akin to patients with blunt SCI. While our analysis did not demonstrate this, further studies with larger sample sizes may help assess whether specific fracture patterns could warrant surgical intervention. This may prove to be particularly difficult as there is significant heterogeneity associated with missile injuries including visceral injuries, and management algorithms such as TLICS may not be applicable.^8,18,24,25

The use of steroids in the treatment of acute SCI is controversial. Since the 1960s, animal models of SCI examining the utility of steroids have produced conflicting results. In addition, newer data in humans and challenges to the National Acute Spinal Cord Injury Studies trials suggest steroids may not aid in neurological recovery and may be associated with increased adverse effects.^26–28 In our study, only one patient received steroids out of concern for cauda equina syndrome in the setting of the missile’s trajectory and subsequent embedment. This patient presented as ASIA D, and their neurological exam remained stable after treatment with surgery and steroids. While research to clearly delineate the role of steroids in the treatment of SCI is ongoing, it is necessary to consider potential adverse effects such as hyperglycemia, immunosuppression, and gastric ulcer formation as well as patient-specific factors that could amplify these effects in clinical decision-making.

Limitations

Our study has several limitations. First, it is retrospective in nature. While our hospital’s trauma database is robust, there is inevitably missing information that could not be analyzed in this study. For example, information about ballistics was not included in our analysis, although the missile’s size, shape, composition, and velocity can lead to different injury patterns.⁹

Second, a small number of patients were included in each treatment modality group, especially surgery, steroids, and MAP augmentation, and only slightly more than half of our patients had follow-up data available. These limited sample sizes could certainly have led to a type II statistical error and thus affected our conclusions. Patients may not follow up for various reasons, including lack of access to care. Our institution is a safety net hospital with many social and financial assistance programs available, but our patients can still face many barriers to care.

Of those patients who did follow up, the mean times to follow-up were 5 and 7 weeks in the blast and direct penetrating groups, respectively. While early assessments of neurological function can guide rehabilitation treatments, they may not capture the full recovery potential of patients with SCI. According to Gittler et al., it may take a minimum of 3 weeks for the first distal muscle to start recovering from paralysis. In addition, functional recovery from an SCI likely continues for at least 3 months after the injury.²⁹ Studies with increased patient recruitment and retention will likely provide more insight into the prognosis of patients with SCIs from GSWs.

Finally, despite all patients sustaining GSWs to the spine, there was significant heterogeneity in the injury patterns. Many factors influence this such as ballistics, spinal level of injury, any visceral, bony, and/or neural involvement, and body habitus. We attempted to group our patients by SCI mechanism, level of injury, radiographical findings, etc. However, it is challenging to make generalizable conclusions given the complex nature of GSWs.

Conclusion

In this retrospective analysis of patients with GSWs to the spine, we differentiated those with direct penetrating injuries to the spinal cord from those with indirect blast injuries. We found that patients with direct penetration of the spinal cord had more severe neurological deficits although management strategies were not significantly different between the two groups. We also found that the use of MAP augmentation may improve neurological outcomes in patients with direct and blast injuries from spinal GSWs, whereas surgical intervention did not correlate with neurological improvement. Given the prevalence and morbidity of firearm injuries and traumatic SCI, further research is critical to the formation of management guidelines for penetrating GSWs to the spine and specifically for patients with blast injuries to the spinal cord.

Footnotes

Authors’ Contributions

Z.R.: Data curation, investigation, formal analysis, visualization, writing—original draft preparation, writing—reviewing and editing. L.C.: Conceptualization, data curation, investigation. M.R.: Conceptualization, data curation, investigation, visualization, writing—original draft preparation, writing—reviewing and editing, supervision.

Transparency,Rigor,and Reproducibility Statement

This study and analysis plan were not formally registered. Data were acquired between January 2013 and June 2020. During this period, 111 patients met the inclusion criteria. All 111 patients had primary measurements collected, analyzed, and assessed. Four patients died and 47 were lost to follow-up. Data collection and analysis were performed by investigators who were aware of relevant participant characteristics. All software used to perform acquisition and analysis are widely available from sources listed in the text. The primary diagnoses are established standards in the field. The statistical tests utilized were based on their inherent assumptions. Implications of possible violations of these assumptions include alterations in statistical significance leading to incorrect conclusions. To our knowledge, no replication or external validation studies have been performed or are planned/ongoing. De-identified data from this study are not available in a public archive but will be made available (as allowable according to institutional review board standards) by emailing the corresponding author as of the publication date. There is no specialized analytic code associated with this study. The authors agree to provide the full content of the article on request by contacting the corresponding author.

Author Disclosure Statement

The authors have no competing interests to disclose.

Funding Information

There was no funding provided for this research.

Abbreviations Used

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Comparison of Direct Penetrating Versus Blast Injuries Following Gunshot Wounds to the Spine