Stability of the Subaxial Spine after Penetrating Trauma: Do Classification Systems Apply?

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Abstract

8. Global Spine J. 2026 Mar;16(2):1300-1316. doi: 10.1177/21925682251379371. Epub 2025 Sep 11. Mechanical Instability After Civilian Thoracolumbar Gunshot Injuries: A Systematic Review to Support Classification Development. Ricciardi GA(1)(2)(3), Cirillo I(4)(5)(6), Cabrera JP(7)(8), Alvarenga Pereira OV(9), Vialle EN(9), Carazzo C(10), Dittmar M(11), Guiroy A(12), Yurac R(13)(14), Schroeder GD(15)(16). Author information: (1)Orthopaedic and Traumatology, Sanatorio Güemes, Buenos Aires, Argentina. (2)Orthopaedic and Traumatology, Centro Médico Integral Fitz Roy, Buenos Aires, Argentina. (3)Orthopedic and Traumatology, Hospital General de Agudos Dr. Teodoro Álvarez, Buenos Aires, Argentina. (4)Orthopedic and Traumatology, Hospital del Trabajador, Santiago, Chile. (5)Orthopedic and Traumatology. Clínica Las Condes, Santiago, Chile. (6)Facultad de Medicina,Universidad Andrés Bello, Hospital del Trabajador, Santiago, Chile. (7)Department of Neurosurgery, Hospital Clínico Regional de Concepción, Concepción, Chile. (8)Faculty of Medicine, University of Concepción, Concepción, Chile. (9)Spinal Surgery Group, Department of Orthopedics, Cajuru Hospital, Catholic University of Parana, Curitiba, Brazil. (10)Neurosurgery, University of Passo Fundo, São Vicente de Paulo Hospital, Passo Fundo, Brazil. (11)Orhtopedic and Traumatology, Centro Médico Puerta de Hierro, Zapopan, México. (12)Neurosurgery, Elite Spine Health and Wellness Center (Florida), State of Florida, USA. (13)Department of Orthopedic and Traumatology, University del Desarrollo, Santiago, Chile. (14)Spine Unit, Department of Traumatology, Clínica Alemana, Santiago, Chile. (15)Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA, USA. (16)Orthopedic and Traumatology, The Rothman Institute, State of Philadelphia, USA. Study DesignSystematic Review.ObjectivesIdentify risk factors for mechanical instability in thoracolumbar gunshot wounds to develop a new classification system.MethodsA systematic review following PRISMA 2020 guidelines was conducted across multiple databases from January 1, 1990, to September 12, 2024 (PROSPERO: CRD42023458804).ResultsOf 2400 records, 33 studies (3195 patients) met inclusion criteria, mostly retrospective and single-center, with varying definitions of instability. Direct comparison was limited due to clinical heterogeneity. Only 12 studies defined mechanical instability, mainly using the Denis three-column theory. Instability was reported in less than 10% of cases, except for one higher-rate outlier. The main markers included vertebral body comminution and potential ligamentous injury. Management was mainly conservative, with a low fixation rate (1.5-9.7%). Imaging relied on CT and static X-rays, with some studies advocating for dynamic radiographs.ConclusionThere is a lack of standardized definitions for mechanical instability in civilian thoracolumbar gunshot injuries. Four recurrent unstable patterns were detected, with vertebral body comminution as the most consistent marker. The need for a standardized classification system and further prospective studies is evident. DOI: 10.1177/21925682251379371 PMCID: PMC12425954