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Spinal gunshot wounds: A retrospective, multicenter, cohort study
Lesiones vertebrales por proyectil de arma de fuego: estudio de cohorte retrospectivo, multicéntrico
G. Ricciardia,
Corresponding author
guillermoricciardi@gmail.com

Corresponding author.
, O. Martinezb, J. Cabrerac, J. Mattad, V. Davilae, J.M. Jimenezf, H. Vilchisg, V. Tejerinah, J. Perezi, J.P. Cabreraj, R. Yurack,l
a Centro Médico Integral Fitz Roy, Argentina
b Hospital Universitario Dr. José E. González, Mexico
c Hospital de Traumatología “Dr. Victorio de la Fuente Narvaez” IMSS, Mexico
d Hospital Militar Central, Colombia
e Hospital Universitario Dr. Manuel Nuñez Tovar, Venezuela
f Instituto Mexicano del Seguro Social, Mexico
g Unidad Médica de Alta Especialidad Hospital de Traumatología y Ortopedia Lomas Verdes IMSS, Mexico
h Hospital Traumatología y Ortopedia Magdalena de las Salinas, Mexico
i Clínica de columna “Dr. Manuel Dufoo Olvera”, Mexico
j Hospital Clínico Regional de Concepción, Chile
k Department of Orthopedic and Traumatology, University del Desarrollo, Santiago, Chile
l Spine Unit, Department of Traumatology, Clinica Alemana, Santiago, Chile
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        "titulo" => "Lesiones vertebrales por proyectil de arma de fuego&#58; estudio de cohorte retrospectivo&#44; multic&#233;ntrico"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Vertebral injury distribution&#58; lamina 57 &#40;37&#37;&#41;&#59; vertebral body 134 &#40;32&#37;&#41;&#59; pedicle 59 &#40;14&#37;&#41;&#59; facet 48 &#40;11&#37;&#41;&#59; bilateral &#40;BL&#41; facet 7 &#40;2&#37;&#41;&#59; bilateral pedicle 10 &#40;2&#37;&#41;&#59; intervertebral disk 1 &#40;1&#37;&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Every day in Latin America&#44; new homicide victims are added to the statistical record&#46; The two American continents account for 37&#37; of all homicides worldwide and most occur in Latin America&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Predominately affecting young civilians &#40;e&#46;g&#46;&#44; non-military&#44; non-police&#41;&#44; firearms are involved in three quarters of homicides&#46; Recent statistics indicate 16&#46;4 young people killed by others with firearms per 100&#44;000 youth in Latin America&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Spinal gunshot injuries account for 13&#8211;17&#37; of all spinal injuries&#44; with great economic and social impact&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> Such injuries are the third most common cause of spinal injury in civilian populations&#44; after falls from a height and motor vehicle accidents&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Gunshot wounds are penetrating injuries&#44; caused by bullets and those elements that are made up at the moment of the shot&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Multiple factors&#44; mechanical and biological&#44; differentiate gunshot injuries from blunt high-energy trauma&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> Mechanical factors related to the ballistics of the projectile determine the severity of damage and should be evaluated &#40;type of firearms&#44; path&#47;size&#47;speed of projectile and distance between firearm and target&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">More than half of gunshots to the spine affect the thoracic region&#44; followed by lumbosacral &#40;30&#37;&#41; and cervical &#40;20&#37;&#41; wounds&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Clinical presentation ranges from minimal clinically-significant trauma to complete spinal cord injury and mechanical instability&#46; Neurologic compromise has been reported to occur in 33&#8211;92&#46;4&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Other organ injuries may occur&#44; sometimes requiring being treated first because they are life-threatening&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Conservative treatment is frequently indicated&#46; Commonly-accepted indications for surgery include spinal instability&#44; progressive neurological deficits&#44; a cerebrospinal fluid fistula&#44; retained bullet or bone fragments in the spinal canal at the cauda equina level&#44; bullet migration&#44; dirty wounds requiring debridement&#44; and persistent pain due to nerve root compression&#46; Sudden progression of a neurological deficit is one indication for urgent surgical decompression&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;11</span></a> The prognosis of a civilian gunshot-induced spinal cord injury correlates closely with the extent of the initial neurological deficit&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In this study&#44; we sought to characterize the demographic and baseline clinical characteristics of spinal gunshot injury patients spanning multiple centers across Latin America&#44; as well as their assessment and treatment&#46; We also compared patients treated surgically and non-surgically to identify characteristics of the gunshot injury that were predictive of surgical management&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">We conducted a retrospective multicenter cohort study of patients treated for spinal gunshot wounds spanning 12 institutions &#40;3 private centers&#44; 5 public&#47;government hospitals&#44; 3 university hospitals&#44; and 1 military&#47;police hospitals&#41; between January 2015 and January 2022&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">All patients treated for spinal gunshot wounds at these centers were included in analysis&#44; except for those who died prior to evaluation&#44; those with soft tissue injuries alone and those lacking adequate medical history records&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Demographic and clinical data were recorded&#44; including the time of injury &#40;time of day and day of week&#41;&#44; time from injury to admission to the hospital of record&#44; initial assessment findings&#44; nature of the vertebral gunshot injury&#44; and treatment&#46; Data of interest included patient sex&#44; age&#44; education and socioeconomic level&#44; and country&#59; type of hospital &#40;e&#46;g&#46;&#44; public&#44; private&#44; university&#44; military&#41;&#59; type of work&#44; categorized by level of gunshot injury risk &#40;e&#46;g&#46;&#44; military or police officer versus civilian worker&#41;&#59; previous morbidity&#59; previous gunshot injury&#59; and toxicology screening results at the time of hospital admission&#46; Also recorded was whether patients were admitted directly or referred from another medical center and the general mechanism of injury &#40;assault&#44; intentionally self-induced&#44; accidental&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Clinical data extracted from the initial assessment were spinal injury level&#44; injury severity score &#40;ISS&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> Glasgow Coma Scale &#40;GCS&#41; score&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> presence&#47;absence of hemodynamic instability&#44; presence&#47;absence and nature of neurological compromise&#44; American Spinal Injury Association Impairment Scale &#40;AIS&#41; score &#40;if applicable&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and the results of spinal imaging&#46; A broad description of the spinal injury included the site of bullet entry and&#47;or exit&#59; type of wound &#40;clean or dirty&#41;&#59; presence&#47;absence and nature of abdominal organ perforation&#59; projectile velocity &#40;low or high&#41;&#59; bullet location&#59; number of bullets&#59; nature of the vertebral injury&#59; whether the injury occurred at a single or multiple spinal levels&#59; presence&#47;absence and degree of canal compromise&#59; presence&#47;absence of bullet and&#47;or bone fragments in the canal&#59; presence&#47;absence of dural sac injury&#59; and trajectory of the penetrating bullet according to the NOPAL classification system&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Spinal gunshot wounds with concomitant visceral perforation and injuries with significant soft tissue destruction as well as local tissue contamination were considered as dirty wounds&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Treatment data extracted for analysis included the general class of treatment &#40;non-surgical&#47;conservative or surgical&#41;&#59; length of delay between the injury and surgery&#44; in hours&#59; whether antibiotic prophylaxis or steroids were used&#59; peri-operative complications and 90 days mortality&#46; Additionally&#44; in surgically-treated cases&#44; data were collected on the surgical approach and specific surgical procedure&#40;s&#41; performed&#44; categorized as fixation&#44; decompression&#47;laminectomy&#44; bullet removal&#44; and&#47;or dural repair&#44; and whether a mini-invasive or conventional open surgery approach was used&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Statistical analysis&#58; Categorical variables were summarized as counts and percentages&#44; and compared between groups by either Pearson chi-square analysis or Fisher&#39;s Exact test&#44; as appropriate&#46; Continuous variables were summarized as either a mean or median value&#44; depending on the nature of distribution &#40;normal vs&#46; non-normal&#41;&#44; along with standard deviation &#40;SD&#41; and minimum-maximum values&#59; and compared between groups using either the unpaired Student&#39;s t test or non-parametric analysis &#40;Mann&#8211;Whitney U test&#41;&#44; depending on the normality of distribution&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Inferential testing consisted of comparing spinal injury patients treated surgically versus non-surgically &#40;conservatively&#41;&#44; specifically comparing variables traditionally linked to surgery decision-making patterns&#46; All inferential testing was two-tailed with values of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 considered statistically significant&#46; The statistical software package SPSS 25 was used for all analysis&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patient characteristics</span><p id="par0070" class="elsevierStylePara elsevierViewall">Data were extracted on 423 patients with gunshot injuries to the spine treated at trauma centers in Mexico&#44; Argentina&#44; Brazil&#44; Colombia&#44; and Venezuela&#44; with patients predominantly from Mexico &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>348&#44; 82&#46;3&#37;&#41;&#46; Most of the patients had been healthy prior to their trauma &#40;256 with no prior comorbidity&#59; 63&#37;&#41;&#44; and a sizeable majority were young males &#40;367&#59; 87&#37;&#41; of lower&#47;middle socioeconomic status &#40;365&#59; 86&#37;&#41;&#46; Just over half &#40;217&#59; 51&#37;&#41; had at least completed secondary school&#46; The mean age at admission was 31&#46;5 &#40;SD<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#41; years old&#46; Less than 1&#37; of cases had suffered a previous firearm projectile wound&#46; Toxicology screening was primarily negative &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>121&#59; 31&#37;&#41; or not reported &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>175&#59; 42&#46;9&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Most patients were treated at a public or government hospital &#40;273&#59; 64&#46;5&#37;&#41;&#44; followed by university &#40;113&#44; 26&#46;7&#37;&#41; and military &#40;25&#59; 5&#46;9&#37;&#41; institutions&#46; Only 12 patients in our sample &#40;2&#46;8&#37;&#41; were treated for their spinal gunshot wound at a private institution &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Injury time</span><p id="par0075" class="elsevierStylePara elsevierViewall">The vast majority of the injuries were the result of an assault by another person &#40;403&#59; 95&#46;3&#37;&#41;&#44; with just one self-inflicted wound and 19 accidental shootings&#46; The lion&#39;s share of injuries &#40;45&#46;6&#37;&#41; occurred during the eight night-time hours from 20&#58;00 to 3&#58;59&#44; including 135 &#40;31&#46;9&#37;&#41; between 20&#58;00 and 23&#58;59<span class="elsevierStyleHsp" style=""></span>h&#44; 58 &#40;13&#46;7&#37;&#41; between midnight and 3&#58;59&#46; Mornings were a low period for gunshot injuries&#44; accounting for just 12&#46;0&#37; between 4&#58;00 and 11&#58;59&#44; with afternoon and early evening &#40;noon to 7&#58;59&#41; accounting for roughly 25&#37;&#59; however&#44; daytime of injury was not reported for almost one in five patients&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">54&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>227&#41; of assaults occurred during weekdays &#40;defined as Mon&#46; to Thurs&#46;&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>227&#59; 54&#37;&#41; versus 46&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>196&#41; over weekends &#40;Fri&#46; to Sun&#46;&#41; plus holidays&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">There was a wide range in the duration of time&#44; in hours&#44; between trauma and admission to the center at which the patients were definitively treated &#40;19&#46;5&#59; SD<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>72&#46;7&#59; range&#58; 0&#8211;720&#41;&#44; with 183 cases &#40;43&#37;&#41; referred from other centers&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Initial assessment</span><p id="par0090" class="elsevierStylePara elsevierViewall">Vertebral injuries mainly affected the thoracic and lumbar spine&#46; Neurological involvement &#40;spinal cord injury or radicular injury&#47;cauda equina syndrome&#41; was documented in 320 &#40;76&#37;&#41; patients&#44; and spinal cord injuries in 269 &#40;63&#37;&#41;&#46; In terms of neurological compromise&#44; AIS grade A injuries &#40;full motor and sensory loss below the injury&#41; accounted for almost half of the injuries &#40;49&#37;&#41; followed by AIS grade E &#40;normal neurological function&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>83&#59; 20&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Almost all the vertebral injuries underwent imaging with CT &#40;400&#59; 94&#46;6&#37;&#41;&#44; with roughly half examined with plain radiographs &#40;203&#59; 48&#37;&#41;&#46; Only a few patients had an MRI &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#59; 7&#37;&#41; or some other imaging study &#40;23&#59; 5&#37;&#59; including dynamic X-rays&#44; angiotomography&#41;&#46; Associated injuries were reported in 83&#37; of the patients &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>349&#41;&#44; and the mean Injury Severity Score &#40;ISS&#41; among the <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>171 patients who had this documented was 23 &#40;&#177;22 SD&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Vertebral gunshot injury</span><p id="par0100" class="elsevierStylePara elsevierViewall">Almost every injury was caused by a conventional &#40;410&#59; 97&#37;&#41;&#44; low-velocity &#40;361&#59; 85&#37;&#41; firearm&#46; Most bullets entered the body via either the thorax &#40;177&#59; 41&#46;8&#37;&#41; or abdomen &#40;136&#59; 32&#37;&#41;&#44; and 77&#46;3&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>326&#41; of the wounds were considered clean &#40;326&#59; 77&#37;&#41;&#46; Abdominal organ perforation was documented in 140 &#40;33&#37;&#41; patients&#46; No bullet exit wound was described in 289 cases &#40;68&#46;5&#37;&#41;&#46; The spinal canal was frequently affected &#40;59&#46;7&#37;&#41;&#46; In addition&#44; in 82&#37; of cases the bullet&#39;s trajectory compromised the vertebral canal either directly &#40;penetrating or transfixing injury&#41; or indirectly &#40;penetrating tangentially&#41;&#46; More than one third of spinal fractures &#40;157&#59; 37&#37;&#41; involved the lamina&#44; followed by the vertebral body in 32&#37;&#46; Bilateral facet &#40;7&#59; 2&#37;&#41; and pedicle injuries &#40;10&#59; 3&#37;&#41; both were rarely reported in our sample &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> and <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Treatment</span><p id="par0105" class="elsevierStylePara elsevierViewall">The usual treatment of firearm vertebral injuries was conservative and accompanied by antibiotic prophylaxis&#46; Use of steroids was reported in just 20 &#40;5&#37;&#41; cases&#46; Only 90 &#40;21&#37;&#41; patients were treated surgically&#44; principally accessed using the posterior open midline approach to the spine &#40;79&#59; 87&#37;&#41;&#46; Surgical management included bullet removal &#40;24&#59; 27&#37;&#41;&#44; fixation &#40;17&#59; 19&#37;&#41;&#44; decompression &#40;27&#59; 30&#37;&#41;&#44; and dural repair &#40;8&#59; 9&#37;&#41;&#46; Use of minimally-invasive surgery was rare &#40;2&#46;2&#37;&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The overall complication rate of gunshot injury to the spine was 36&#37; &#40;156&#41; and most were linked to associated injuries &#40;80&#59; 18&#46;9&#37;&#41;&#46; Persistent pain was the most prevalent complication&#44; followed by sepsis&#47;septic shock&#44; pneumonia and neurogenic bladder&#46; There were just four post-operative complications &#40;4&#37; of the surgical cases&#41;&#46; The 90 days mortality rate was 6&#46;4&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>27&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Comparing surgical versus conservative treatment</span><p id="par0115" class="elsevierStylePara elsevierViewall">Surgical treatment was associated with neurological compromise &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41; canal compromise &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; dirty wounds &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; bullet or bone fragment remains in the canal &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and injury pattern &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">After a multivariate analysis through a binary logistic regression model&#44; the aforementioned variables remained statistically significant except neurological compromise&#46; Dirty wounds &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;07&#59; OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;178&#59; 95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;236&#8211;3&#46;836&#41;&#59; canal compromise &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#59; OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;6&#59; 95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;338&#8211;5&#46;5286&#41;&#59; bullet or bone fragments remains in the canal &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#59; OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;715&#59; 95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;504&#8211;4&#46;902&#41;&#59; and injury pattern &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; were related to surgical treatment&#46; According to injury pattern subtypes&#44; the differences were statistically significant between lamina versus facets &#40;&#60;0&#46;001 OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;755&#59; 95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;183&#8211;10&#46;358&#41;&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">Our cohort of spinal gunshot injury patients from across Latin America was heavily represented by young males in low-risk-of-gunshot-injury jobs &#40;e&#46;g&#46;&#44; non-military or police&#41; who suffered low-energy gunshots to the spine&#44; similar to the demographics reported in previous publications from Latin America and other world regions&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;9&#44;11&#44;17&#8211;21</span></a> Almost all patients were lower&#47;middle class victims of firearm violence&#44; in line with the results of a United Nations study&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> To better describe this scenario&#44; we found similar numbers of gunshot injuries to the spine on weekdays and weekends&#47;holidays&#44; but a preponderance of injuries late at night and in the wee hours of the morning &#40;before 4&#58;00&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">As described previously in other retrospective studies&#44; the lion&#39;s share of injuries were to the thoracic spine &#40;45&#37;&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;9&#44;18</span></a> but we also found more upper cervical injuries than previously reported &#40;3&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;9</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Gunshot injury patients have a wide range of clinical presentations on admission&#44; from isolated&#44; stable vertebral fractures to severe cases of multiple trauma for which treatment is both complex and challenging&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In our sample&#44; 75&#37; of the patients presented to us with a neurological deficit&#44; 11&#37; with a Glasgow Coma Scale score under 8&#44; and 38&#37; hemodynamically unstable&#46; Associated injuries were the rule &#40;82&#37;&#41;&#44; with the mean Injury Severity Score equal to 23 &#40;&#177;22&#41;&#44; when recorded&#59; unfortunately&#44; the ISS was reported in just a minority of patients &#40;171&#44; 40&#46;4&#37;&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In a recent systematic review of the literature&#44; the rate of complete spinal cord injury reported was found to range from 13&#37; to 78&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> In our sample&#44; 320 &#40;76&#37;&#41; patients exhibited some level of neurological compromise and almost half were classified as having AIS grade A injuries&#44; indicating the complete loss of both motor and sensory function below the injury&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Computed tomography and radiographs have classically been proposed as the gold standard for assessing bone injury patterns and the mechanical stability of spinal gunshot injuries&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4&#44;10&#44;22</span></a> Tomography provides an accurate assessment of bullet location&#44; delineates any bone damage&#44; and identifies bullet and bony fragments within the spinal canal&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Few indications support the use of MRI in spinal gunshot patients due to concerns about the effect of the magnetic field on the components of ferromagnetic bullets that could exacerbate the original injury&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Almost every patient in our cohort had their spinal injury assessed via CT &#40;94&#37;&#41;&#44; with roughly half having radiographs &#40;48&#37;&#41;&#46; MRI was performed in just 30 patients&#46; Injuries mainly affected the vertebral canal &#40;60&#37;&#41;&#44; lamina &#40;37&#37;&#41;&#44; and vertebral body &#40;32&#37;&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Treatment of patients with penetrating trauma should be guided by Advanced Trauma Life Support &#40;ATLS&#41; principles&#44; which argue for life-threatening injuries to be identified and treated immediately&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Tetanus vaccination status should be checked and broad-spectrum antibiotics should be started immediately and continued for 48&#8211;72<span class="elsevierStyleHsp" style=""></span>h in all cases&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The full duration of antibiotic treatment remains controversial&#44; however&#46; Retrospective reviews have highlighted how perforated abdominal organs and&#44; especially&#44; wounds that perforate the colon confer a much higher risk of infection and should be treated with longer-term antibiotic coverage to prevent deep spinal infections&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Prophylactic antibiotic treatment was used in 94&#37; of our sample cohort&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">We noted a low rate &#40;&#60;5&#37;&#41; of high-dose steroid use at our 12 Latin American centers&#44; consistent with the body of published evidence suggesting that they typically are contraindicated in patients with penetrating trauma&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;24</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Surgical treatment of spinal gunshot injuries remains controversial&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;10&#44;22&#44;25&#8211;27</span></a> The surgical indications most frequently discussed in the literature are neurological decompression&#44; removing bullets in the vertebral canal&#44; repairing cerebrospinal fluid leak&#44; and treating spinal instability&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;5&#8211;7&#44;10&#44;25&#44;26</span></a> In our retrospective analysis&#44; surgical cases were more frequently associated with certain injury patterns that included vertebral canal compromise&#44; dirty wounds&#44; bullet or bone fragment remains in the canal&#44; and injuries to the lamina&#44; all of which is consistent with the literature&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Spinal gunshot wounds are commonly thought to be stable&#44; but there is a lack of consensus on the definition and classification of unstable fracture types&#46; Gunshot injuries that fracture both pedicles or facet joints have been proposed to be unstable and require fixation&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;26</span></a> In our sample&#44; fewer than 3&#37; of the patients had this type of injury&#44; so we cannot expand upon current literature regarding this issue&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Our study has several limitations&#44; which include the retrospective nature of data collection&#44; a sizeable percentage of missing data for some variables&#44; and the highly disproportionate number of patients from a single country&#46; Fortunately&#44; the vast majority of missing data were among demographic variables and the time of day when the injury occurred&#44; all of which have been reported elsewhere&#59; while almost all the variables related to the nature of the injury and treatment provided were fully or near complete&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusions</span><p id="par0175" class="elsevierStylePara elsevierViewall">This study describes a Latin American multicenter cohort study of gunshot injuries to the spine&#46; The vast majority of gunshot victims were males in low-risk professions and of lower&#47;middle social status who suffered low-energy firearm assaults&#46; Neurological compromise was the rule&#44; with vertebral canal compromise and fractures of the lamina common&#44; but bilateral facet involvement rare&#46; Treatment was largely non-surgical&#44; with surgical cases distinguished by higher rates of vertebral canal compromise&#44; bullet or bone fragments in the vertebral canal&#44; and fractures involving the lamina&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Level of evidence</span><p id="par0185" class="elsevierStylePara elsevierViewall">Level of evidence IV&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interests</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare no conflicting interests&#46;</p></span></span>"
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              "titulo" => "Initial assessment"
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              "titulo" => "Vertebral gunshot injury"
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            0 => "Heridas por proyectil de arma de fuego"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To describe the demographic and clinical characteristics and treatment of patients with spinal gunshot wounds across Latin America&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Retrospective&#44; multicenter cohort study of patients treated for gunshot wounds to the spine spanning 12 institutions across Latin America between January 2015 and January 2022&#46; Demographic and clinical data were recorded&#44; including the time of injury&#44; initial assessment&#44; characteristics of the vertebral gunshot injury&#44; and treatment&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Data on 423 patients with spinal gunshot injuries were extracted from institutions in Mexico &#40;82&#37;&#41;&#44; Argentina&#44; Brazil&#44; Colombia&#44; and Venezuela&#46; Patients were predominantly male civilians in low-risk-of-violence professions&#44; and of lower&#47;middle social status&#44; and a sizeable majority of gunshots were from low-energy firearms&#46; Vertebral injuries mainly affected the thoracic and lumbar spine&#46; Neurological injury was documented in <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>320 &#40;76&#37;&#41; patients&#44; with spinal cord injuries in 269 &#40;63&#37;&#41;&#46; Treatment was largely conservative&#44; with just 90 &#40;21&#37;&#41; patients treated surgically&#44; principally using posterior open midline approach to the spine &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>79&#59; 87&#37;&#41;&#46; Injury features distinguishing surgical from non-surgical cases were neurological compromise &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41;&#44; canal compromise &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; dirty wounds &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; bullet or bone fragment remains in the spinal canal &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and injury pattern &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; After a multivariate analysis through a binary logistic regression model&#44; the aforementioned variables remained statistically significant except neurological compromise&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In this multicenter study of spinal gunshot victims&#44; most were treated non-surgically&#44; despite neurological injury in 76&#37; and spinal injury in 63&#37; of patients&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Describir las caracter&#237;sticas cl&#237;nico-demogr&#225;ficas y el tratamiento de pacientes con heridas vertebrales por proyectil de arma de fuego en una cohorte retrospectiva de centros de Am&#233;rica Latina&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio de cohorte&#44; multic&#233;ntrico&#44; retrospectivo de pacientes tratados por lesiones vertebrales por proyectil de arma de fuego en 12 instituciones entre enero de 2015 y enero de 2022&#46; Se registraron datos demogr&#225;ficos y cl&#237;nicos&#44; incluidos tiempo de la lesi&#243;n&#44; evaluaci&#243;n inicial&#44; variables bal&#237;sticas y tratamiento&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Un total de 423 pacientes con lesiones vertebrales por arma de fuego de instituciones en M&#233;xico &#40;82&#37;&#41;&#44; Argentina&#44; Brasil&#44; Colombia y Venezuela&#46; Predominantemente varones&#44; civiles&#44; con profesiones con bajo riesgo de violencia y estatus social medio&#47;bajo&#46; Mayoritariamente&#44; por disparos de armas de fuego de baja energ&#237;a&#46; Lesiones frecuentemente tor&#225;cicas y lumbares&#46; Lesi&#243;n neurol&#243;gica en n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>320 &#40;76&#37;&#41; pacientes&#44; con lesi&#243;n medular en 269 &#40;63&#37;&#41;&#46; Tratamiento frecuentemente conservador&#44; con solo 90 &#40;21&#37;&#41; casos quir&#250;rgicos&#46; Las caracter&#237;sticas que distinguieron casos quir&#250;rgicos de los no quir&#250;rgicos fueron compromiso neurol&#243;gico &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;004&#41;&#44; compromiso del canal &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; heridas sucias &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; restos de fragmentos de bala o de hueso en el canal espinal &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y el patr&#243;n de la lesi&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Las variables mencionadas se mantuvieron estad&#237;sticamente significativas luego del an&#225;lisis multivariado&#44; excepto el compromiso neurol&#243;gico&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En este estudio multic&#233;ntrico de v&#237;ctimas de lesiones vertebrales por proyectil de arma de fuego la mayor&#237;a recibi&#243; tratamiento no quir&#250;rgico&#44; a pesar de la lesi&#243;n neurol&#243;gica en el 76&#37; y de la lesi&#243;n en la columna en el 63&#37; de los pacientes&#46;</p></span>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#177;11 &#40;9&#8211;71&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#40;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&#40;2&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Colombia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;5&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">348&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;82&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Venezuela &#40;Bolivarian Republic of&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;5&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>High risk &#40;Military&#44; police&#44; security personnel&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">265&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;62&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;12&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Negative&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">127&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;31&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alcohol&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;14&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Drugs&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;8&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">175&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;42&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  """
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Results &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>423&#41;</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Injury level</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Upper cervical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;3&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lower cervical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;17&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Thoracic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">192&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;45&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lumbar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">133&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;31&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sacral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Associated injuries</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">349&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Neurological compromise</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>None identified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;19&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Radicular injury&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;12&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Spinal cord injury&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">269&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;63&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Not evaluable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;4&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">AIS</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">202&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;49&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;5&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;12&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;7&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;20&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>NT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;5&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Bullet entry</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Head&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;5&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Neck&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;18&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Bullet exit</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Head&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#40;0&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Neck&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#40;4&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Thorax&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Abdomen&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pelvis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>None&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">289&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Wound</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Clean&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">326&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#40;77&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#40;22&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Vertebral canal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;14&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Vertebral body&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Posterior arch&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#40;6&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Intervertebral disk&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;1&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Soft tissue&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;22&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Internal organ&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;4&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Limbs&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Multiple locations&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;10&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">129&nbsp;\t\t\t\t\t\t\n
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        "texto" => "<p id="par0195" class="elsevierStylePara elsevierViewall">The authors acknowledge support from the AOSpine Latin America&#46; This study was organized by the AO Spine Latin America Trauma Study Group and Spinal Gunshot Injuries Group&#58; Michael Dittmar&#44; David Servin&#44; Cristobal Herrera&#44; Cristobal Herrera Palacios&#44; Janicke Rodriguez&#44; Luis Mu&#241;iz&#44; Manuel Perez&#44; Juan Mandujano&#44; Rodrigo Garcia&#44; Oscar Montes&#44; Jesahiro Hidalgo&#44; Bairon Lovera&#44; Madeline Bilbao&#44; Marcelo Wirz&#44; Raul Alcaraz&#44; Daniel Ricciardi&#44; Vin&#237;cius Marques Carneiro&#44; Denylson Sanches Fernandes&#46; AO Spine is a clinical division of the AO Foundation&#44; which is an independent&#44; medically guided not for-profit organization&#46; The authors would like to thank Idaura Lobo and Carla Ricci &#40;AO Spine&#41; for her administrative assistance&#46;</p>"
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Article information
ISSN: 18884415
Original language: English
DOI:10.1016/j.recot.2023.07.001
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