Gunshot injury to the head and spine

The principles of management of civilian gunshot wounds (GSWs) to the head and spine have evolved directly from the experience gained in war by military neurosurgeons. The type of craniocerebral wounds being produced in urban gang warfare and suicide attempts using handguns or rifles at close range vary considerably from the lower velocity fragment injuries which are common in modern warfare. Civilian craniocerebral GSWs are often devastating. The in-hospital mortality for civilians with penetrating craniocerebral injury is 52-95% depending on the proportion of suicide victims in the series. The most important predictive factor is the post-resuscitation Glasgow Coma Score (GCS). Many civilian victims (47%) present with GCS 3-5 and only approximately 8.1% survive. Of these survivors, 1.4% will have nil, mild or moderate disability without surgery and 4.8% with surgery. Higher post-resuscitation GCS is associated with a significantly improved survival: GCS 6-8, 35.6% and GCS 9-15, 90.5%. A selective treatment policy is recommended for the patients with GCS 3-5. There are many clinical and radiological correlates with poor outcome that help the neurosurgeon decide on operative versus supportive treatment. Early aggressive resuscitation, surgery and vigorous control of intracranial pressure offers the best chance of achieving a satisfactory outcome. Spinal GSWs are uncommon and the neurosurgeon should be aware of the principles of management and prognosis. The indication for acute spinal cord decompression is deteriorating neurological status. Steroids are not indicated for these injuries. Neurosurgeons should take an active role in formulating and supporting public policy which aims to reduce possession and usage of firearms and therefore the prevalence of gunshot injuries.