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

Autor para correspondencia.
, J.P. Cabrerab, Ó. Martínezc, J. Cabrerad, J. Mattae, V. Dávilaf, J.M. Jiménezg, H. Vilchish, V. Tejerinai, J. Pérezj, R. Yurack,l
a Centro Médico Integral Fitz Roy, Argentina
b Hospital Clínico Regional de Concepción, Chile
c Hospital Universitario Dr. José E. González, México
d Hospital de Traumatología Dr. Victorio de la Fuente Narvaez, IMSS, México
e Hospital Militar Central, Colombia
f Hospital Universitario Dr. Manuel Nuñez Tovar, Venezuela
g Instituto Mexicano del Seguro Social, México
h Unidad Médica de Alta Especialidad, Hospital de Traumatología y Ortopedia Lomas Verdes IMSS, México
i Hospital Traumatología y Ortopedia Magdalena de las Salinas, México
j Clínica de columna Dr. Manuel Dufoo Olvera, México
k Departamento de Ortopedia y Traumatología, Universidad del Desarrollo, Santiago, Chile
l Unidad de Columna Vertebral, Departamento de Traumatología, Clínica Alemana, Santiago, Chile
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribuci&#243;n de las lesiones vertebrales&#58; l&#225;mina 57 &#40;37&#37;&#41;&#59; cuerpo vertebral 134 &#40;32&#37;&#41;&#59; ped&#237;culo 59 &#40;14&#37;&#41;&#59; faceta 48 &#40;11&#37;&#41;&#59; faceta bilateral 7 &#40;2&#37;&#41;&#59; ped&#237;culo bilateral 10 &#40;2&#37;&#41;&#59; disco intervertebral 1 &#40;1&#37;&#41;&#46;BL&#58; faceta bilateral &#40;BL&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0010" class="elsevierStylePara elsevierViewall">En Iberoam&#233;rica se a&#241;aden cada d&#237;a v&#237;ctimas de homicidio a los registros estad&#237;sticos&#46; Los 2<span class="elsevierStyleHsp" style=""></span>continentes americanos contabilizan el 37&#37; de todos los homicidios en el mundo&#44; muchos de los cuales se producen en Iberoam&#233;rica<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a>&#46; Afectan principalmente a civiles j&#243;venes &#40;es decir&#44; ni militares ni polic&#237;as&#41; y las armas de fuego est&#225;n implicadas en el 75&#37; de los homicidios&#46; Las estad&#237;sticas recientes indican una cifra de 16&#44;4 j&#243;venes asesinados por terceros con armas de fuego por cada 100&#46;000 j&#243;venes en Iberoam&#233;rica<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Las lesiones vertebrales por armas de fuego representan del 13 al 17&#37; de todas las lesiones de columna&#44; con gran impacto econ&#243;mico y social<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">3&#44;4</span></a>&#46; Esta es la tercera causa m&#225;s com&#250;n de lesiones de columna en poblaciones civiles&#44; tras las ca&#237;das desde altura y los accidentes automovil&#237;sticos<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Las heridas por disparo son lesiones penetrantes&#44; causadas por balas y por aquellos elementos que se conforman en el momento del disparo<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">6</span></a>&#46; M&#250;ltiples factores&#44; de tipo mec&#225;nico y biol&#243;gico&#44; diferencian las lesiones por disparos de los traumatismos contundentes de alta energ&#237;a<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;8</span></a>&#46; Los factores mec&#225;nicos relacionados con la bal&#237;stica del proyectil determinan la gravedad del da&#241;o&#44; por lo que deben ser evaluados &#40;tipo de armas de fuego&#44; trayectoria&#47;tama&#241;o&#47;velocidad del proyectil y distancia entre el arma de fuego y el objetivo&#41;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">M&#225;s de la mitad de los disparos a la columna afectan a la regi&#243;n tor&#225;cica&#44; seguidos de las heridas en las regiones lumbosacra &#40;30&#37;&#41; y cervical &#40;20&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a>&#46; Su presentaci&#243;n cl&#237;nica fluct&#250;a desde los traumatismos con significaci&#243;n cl&#237;nica m&#237;nima hasta las lesiones de la m&#233;dula espinal completas y la inestabilidad mec&#225;nica&#46; Se ha reportado que se produce compromiso neurol&#243;gico en el 33-92&#44;4&#37; de los pacientes<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a>&#46; Tambi&#233;n pueden producirse otras lesiones org&#225;nicas que&#44; a veces&#44; requieren ser tratadas en primer lugar&#44; dado que son potencialmente mortales<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">6</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">A menudo se indica el tratamiento conservador&#46; Las indicaciones de cirug&#237;a com&#250;nmente aceptadas incluyen inestabilidad de la columna&#44; d&#233;ficits neurol&#243;gicos progresivos&#44; f&#237;stula de l&#237;quido cefalorraqu&#237;deo&#44; restos de balas o de fragmentos &#243;seos en el canal vertebral en la zona de la <span class="elsevierStyleItalic">cauda equina</span>&#44; migraci&#243;n de la bala&#44; heridas sucias que requieren desbridamiento y dolor persistente debido a compresi&#243;n de la ra&#237;z nerviosa&#46; La progresi&#243;n s&#250;bita de d&#233;ficit neurol&#243;gico es una indicaci&#243;n de descompresi&#243;n quir&#250;rgica urgente<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6-11</span></a>&#46; El pron&#243;stico de la lesi&#243;n en la m&#233;dula espinal causada por armas de fuego en civiles guarda una relaci&#243;n estrecha con el alcance del d&#233;ficit neurol&#243;gico inicial<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">En este estudio&#44; nuestro objetivo fue describir las caracter&#237;sticas cl&#237;nicas basales y demogr&#225;ficas de los pacientes con lesiones vertebrales por armas de fuego en varios centros a lo largo de Iberoam&#233;rica&#44; as&#237; como su evaluaci&#243;n y tratamiento&#46; Tambi&#233;n realizamos una comparaci&#243;n de los pacientes tratados quir&#250;rgica y no quir&#250;rgicamente para identificar las caracter&#237;sticas de las lesiones por disparo que fueron predictivas de manejo quir&#250;rgico&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><p id="par0040" class="elsevierStylePara elsevierViewall">Realizamos un estudio de cohorte retrospectivo y multic&#233;ntrico de pacientes tratados de heridas vertebrales por disparo en 12 instituciones &#40;3 centros privados&#44; 5 hospitales p&#250;blicos&#47;gubernamentales&#44; 3 hospitales universitarios y un hospital militar&#47;de la polic&#237;a&#41; entre enero de 2015 y enero de 2022&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Se incluy&#243; en el an&#225;lisis a los pacientes tratados de heridas vertebrales por disparo en dichos centros&#44; exceptuando a aquellos que murieron antes de la evaluaci&#243;n&#44; a aquellos con lesiones del tejido blando &#250;nicamente y a aquellos que carec&#237;an de historias cl&#237;nicas&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Se registraron los datos demogr&#225;ficos y cl&#237;nicos&#44; incluyendo el momento de la lesi&#243;n &#40;hora del d&#237;a y d&#237;a de la semana&#41;&#44; el tiempo transcurrido entre la lesi&#243;n y el ingreso hospitalario&#44; los hallazgos de la evaluaci&#243;n inicial&#44; la naturaleza de la lesi&#243;n vertebral del disparo y el tratamiento&#46; Los datos de inter&#233;s incluyeron sexo&#44; edad&#44; formaci&#243;n y estatus socioecon&#243;mico del paciente&#44; as&#237; como su pa&#237;s&#59; tipo de hospital &#40;p&#250;blico&#44; privado&#44; universitario&#44; militar&#41;&#59; tipo de trabajo&#44; categorizado por nivel de riesgo de lesi&#243;n del disparo &#40;por ejemplo&#44; militar u oficial de polic&#237;a frente a trabajador civil&#41;&#59; morbilidad previa&#59; lesi&#243;n por disparo previa y resultado del cribado toxicol&#243;gico en el momento del ingreso hospitalario&#46; Tambi&#233;n se registr&#243; si los pacientes fueron ingresados directamente o fueron trasladados de otro centro m&#233;dico&#44; as&#237; como el mecanismo general de la lesi&#243;n &#40;asalto&#44; autoinducida intencionadamente&#44; accidental&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Los datos cl&#237;nicos extra&#237;dos de la evaluaci&#243;n inicial fueron el nivel de la lesi&#243;n vertebral&#44; las puntuaciones Injury Severity Score &#40;ISS&#41;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">10&#44;12</span></a> y Glasgow Coma Scale<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a>&#44; la presencia&#47;ausencia de inestabilidad hemodin&#225;mica&#44; la presencia&#47;ausencia y naturaleza de compromiso neurol&#243;gico&#44; la puntuaci&#243;n de discapacidad de la American Spinal Injury Association &#40;AIS&#41;&#44; si proced&#237;a<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">14</span></a>&#44; y los resultados del esc&#225;ner vertebral&#46; La descripci&#243;n amplia de la lesi&#243;n vertebral incluy&#243; el sitio de entrada&#47;salida de la bala&#44; el tipo de herida &#40;limpia o sucia&#41;&#44; la presencia&#47;ausencia y la naturaleza de la perforaci&#243;n de &#243;rganos abdominales&#44; la velocidad del proyectil &#40;baja o alta&#41;&#44; la localizaci&#243;n de la bala&#44; el n&#250;mero de balas&#44; la naturaleza de la lesi&#243;n vertebral&#44; si la lesi&#243;n se produjo en una v&#233;rtebra individual o en m&#250;ltiples&#44; la presencia&#47;ausencia y el grado de compromiso del canal&#44; la presencia&#47;ausencia de fragmentos de bala o hueso en el canal&#44; presencia&#47;ausencia de lesi&#243;n del saco dural y la trayectoria de la bala penetrante&#44; conforme al sistema de clasificaci&#243;n NOPAL<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a>&#46; Las heridas vertebrales por disparo con perforaci&#243;n visceral concomitante y las lesiones con destrucci&#243;n significativa de tejido blando&#44; as&#237; como la contaminaci&#243;n tisular local&#44; fueron consideradas heridas sucias<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Los datos del tratamiento extra&#237;dos para el an&#225;lisis incluyeron la clase de tratamiento general &#40;no quir&#250;rgico&#47;conservador o quir&#250;rgico&#41;&#44; la duraci&#243;n de la demora entre la lesi&#243;n y la cirug&#237;a&#44; en horas&#44; el uso de profilaxis antibi&#243;tica o esteroides&#44; las complicaciones perioperatorias y la mortalidad a 90 d&#237;as&#46; Adem&#225;s&#44; en los casos tratados con cirug&#237;a&#44; se recopilaron datos sobre la t&#233;cnica quir&#250;rgica y los procedimientos quir&#250;rgicos espec&#237;ficos&#44; categorizados como fijaci&#243;n&#44; descompresi&#243;n&#47;laminectom&#237;a&#44; extracci&#243;n de bala o reparaci&#243;n dural&#44; as&#237; como el uso de t&#233;cnica quir&#250;rgica miniinvasiva o abierta convencional&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Respecto al an&#225;lisis estad&#237;stico&#44; las variables categ&#243;ricas se expresaron como cifras y porcentajes&#44; compar&#225;ndose entre grupos mediante las pruebas &#967;<span class="elsevierStyleSup">2</span> de Pearson o exacta de Fisher&#44; seg&#250;n el caso&#46; Las variables continuas se expresaron como media o mediana&#44; dependiendo de la naturaleza de la distribuci&#243;n &#40;normal frente a no normal&#41;&#44; junto con desviaci&#243;n est&#225;ndar &#40;DE&#41; y valores m&#237;nimo-m&#225;ximo&#44; que se compararon entre grupos utilizando la prueba t de Student no pareada o el an&#225;lisis no param&#233;trico &#40;prueba U de Mann-Whitney&#41;&#44; dependiendo de la normalidad de la distribuci&#243;n&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">La prueba inferencial consisti&#243; en comparar los pacientes con lesi&#243;n vertebral tratados de forma quir&#250;rgica y no quir&#250;rgica &#40;de manera conservadora&#41;&#44; comparando las variables tradicionalmente vinculadas a los patrones de la toma de decisi&#243;n quir&#250;rgica&#46; Todas las pruebas inferenciales fueron bidireccionales&#59; se consideraron significativos desde el punto de vista estad&#237;stico los valores <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46; Se utiliz&#243; el paquete de programa estad&#237;stico SPSS 25 para los an&#225;lisis&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Caracter&#237;sticas del paciente</span><p id="par0075" class="elsevierStylePara elsevierViewall">Se extrajeron datos de 423 pacientes con lesiones por arma de fuego tratados en los centros traumatol&#243;gicos de M&#233;xico&#44; Argentina&#44; Brasil&#44; Colombia y Venezuela&#44; con predominancia de pacientes de M&#233;xico &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>348&#59; 82&#44;3&#37;&#41;&#46; Muchos de los pacientes estaban sanos antes del traumatismo &#40;256 sin comorbilidad previa&#59; 63&#37;&#41; y una mayor&#237;a considerable eran varones j&#243;venes &#40;367&#59; 87&#37;&#41; con estatus socioecon&#243;mico bajo&#47;medio &#40;365&#59; 86&#37;&#41;&#46; La mitad aproximada &#40;217&#59; 51&#37;&#41; hab&#237;a completado la escuela secundaria&#46; La edad media en el momento del ingreso fue de 31&#44;5 a&#241;os &#40;DE<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#41;&#46; Menos del 1&#37; de los casos hab&#237;a tenido una herida previa por arma de fuego&#46; El cribado toxicol&#243;gico fue primariamente negativo &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>121&#59; 31&#37;&#41; o no reportado &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>175&#59; 42&#44;9&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Muchos pacientes fueron tratados en un hospital p&#250;blico o gubernamental &#40;273&#59; 64&#44;5&#37;&#41;&#44; seguido de universitario &#40;113&#44; 26&#44;7&#37;&#41; y de instituciones militares &#40;25&#59; 5&#44;9&#37;&#41;&#46; Solo 12 pacientes de nuestra muestra &#40;2&#44;8&#37;&#41; fueron tratados en una instituci&#243;n privada debido a su herida vertebral por disparo &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Momento de la lesi&#243;n</span><p id="par0080" class="elsevierStylePara elsevierViewall">La amplia mayor&#237;a de las lesiones fueron resultado de asaltos por terceras personas &#40;403&#59; 95&#44;3&#37;&#41;&#44; con solo una herida autoinfligida y 19 disparos accidentales&#46; El mayor porcentaje de las lesiones &#40;45&#44;6&#37;&#41; se produjo durante las 8<span class="elsevierStyleHsp" style=""></span>h nocturnas&#44; de 20&#58;00 a 3&#58;59&#44; incluyendo 135 &#40;31&#44;9&#37;&#41; entre las 20&#58;00 y las 23&#58;59<span class="elsevierStyleHsp" style=""></span>h y 58 &#40;13&#44;7&#37;&#41; entre la medianoche y las 3&#58;59<span class="elsevierStyleHsp" style=""></span>h&#46; Las ma&#241;anas fueron un periodo bajo de lesiones por arma de fuego&#44; con solo el 12&#37; &#40;entre las 4&#58;00 y las 11&#58;59<span class="elsevierStyleHsp" style=""></span>h&#41;&#59; por la tarde y el atardecer &#40;de las 12&#58;00 a las 7&#58;59<span class="elsevierStyleHsp" style=""></span>h&#41; se contabilizaron el 25&#37;&#44; aproximadamente&#46; Sin embargo&#44; el horario de la lesi&#243;n no fue reportado en al menos uno de cada 5<span class="elsevierStyleHsp" style=""></span>pacientes&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">El 54&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>227&#41; de los asaltos se produjo entre semana &#40;de lunes a jueves&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>227&#59; 54&#37;&#41; frente al 46&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>196&#41; durante el fin de semana &#40;de viernes a domingo&#41; y los d&#237;as de fiesta&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">La franja temporal fue muy variable&#44; en t&#233;rminos de horas transcurridas entre el traumatismo y el ingreso en el centro en el que los pacientes fueron tratados definitivamente &#40;19&#44;5&#59; DE<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>72&#44;7&#59; rango&#58; 0-720&#41;&#59; se derivaron 183 casos &#40;43&#37;&#41; a otros centros&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Evaluaci&#243;n inicial</span><p id="par0095" class="elsevierStylePara elsevierViewall">Las lesiones vertebrales afectaron principalmente a las columnas tor&#225;cica y lumbar&#46; No se document&#243; compromiso neurol&#243;gico &#40;lesi&#243;n medular o lesi&#243;n radicular &#47;s&#237;ndrome de <span class="elsevierStyleItalic">cauda equina</span>&#41; en 320 pacientes &#40;76&#37;&#41;&#44; ni lesi&#243;n medular en 269 pacientes &#40;63&#37;&#41;&#46; En t&#233;rminos de compromiso neurol&#243;gico&#44; las lesiones AIS de grado A &#40;p&#233;rdidas motora y sensorial completas por debajo la lesi&#243;n&#41; supusieron casi la mitad de las lesiones &#40;49&#37;&#41; seguidas de las lesiones AIS de grado E &#40;funci&#243;n neurol&#243;gica normal&#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">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">En casi todas las lesiones vertebrales se obtuvo imagen de TC &#40;400&#59; 94&#44;6&#37;&#41; y casi la mitad fueron examinadas con radiograf&#237;as simples &#40;203&#59; 48&#37;&#41;&#46; A pocos pacientes se les realiz&#243; RM &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#59; 7&#37;&#41; o alg&#250;n otro estudio de imagen &#40;23&#59; 5&#37;&#44; incluyendo rayos X din&#225;micos&#44; angiotomograf&#237;a&#41;&#46; Se reportaron lesiones asociadas en el 83&#37; de los pacientes &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>349&#41;&#44; en los que el valor de la puntuaci&#243;n ISS media&#44; entre los <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>171 pacientes en los que se document&#243;&#44; fue igual a 23 &#40;&#177;22 DE&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Lesiones vertebrales por disparos</span><p id="par0105" class="elsevierStylePara elsevierViewall">Casi todas las lesiones fueron causadas por un arma de fuego convencional &#40;410&#59; 97&#37;&#41;&#44; de baja velocidad &#40;361&#59; 85&#37;&#41;&#46; Muchas de las balas se introdujeron a trav&#233;s del t&#243;rax &#40;177&#59; 41&#44;8&#37;&#41; o el abdomen &#40;136&#59; 32&#37;&#41; y el 77&#44;3&#37; de las heridas &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>326&#41; fueron consideradas limpias &#40;326&#59; 77&#37;&#41;&#46; Se document&#243; perforaci&#243;n de &#243;rganos abdominales en 140 pacientes &#40;33&#37;&#41;&#46; No se describi&#243; la salida de la bala en 289 casos &#40;68&#44;5&#37;&#41;&#46; El canal espinal se vio afectado con frecuencia &#40;59&#44;7&#37;&#41;&#46; Adem&#225;s&#44; en el 82&#37; de los casos la trayectoria de la bala comprometi&#243; el canal vertebral&#44; bien de manera directa &#40;lesi&#243;n penetrante o paralizante&#41; o indirectamente &#40;por trayectoria tangencial&#41;&#46; M&#225;s de un tercio de las fracturas espinales &#40;157&#59; 37&#37;&#41; comprometi&#243; la l&#225;mina y despu&#233;s el cuerpo vertebral en el 32&#37; de los casos&#46; Las lesiones facetarias bilaterales &#40;7&#59; 2&#37;&#41; y pediculares &#40;10&#59; 3&#37;&#41; fueron raramente reportadas en nuestra muestra &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a> y <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Tratamiento</span><p id="par0110" class="elsevierStylePara elsevierViewall">El tratamiento habitual de las lesiones vertebrales por arma de fuego fue conservador&#44; acompa&#241;ado de profilaxis antibi&#243;tica&#46; El uso de esteroides se report&#243; solo en 20 casos &#40;5&#37;&#41;&#46; Solo 90 pacientes &#40;21&#37;&#41; fueron tratados quir&#250;rgicamente&#44; en los que el abordaje principal fue la l&#237;nea media abierta posterior de la columna &#40;79&#59; 87&#37;&#41;&#46; El manejo quir&#250;rgico incluy&#243; extracci&#243;n de la bala &#40;24&#59; 27&#37;&#41;&#44; fijaci&#243;n &#40;17&#59; 19&#37;&#41;&#44; descompresi&#243;n &#40;27&#59; 30&#37;&#41; y reparaci&#243;n dural &#40;8&#59; 9&#37;&#41;&#46; Fue infrecuente el uso de cirug&#237;a m&#237;nimamente invasiva &#40;2&#44;2&#37;&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">La tasa global de complicaciones de las lesiones vertebrales por disparo fue del 36&#37; &#40;156&#41;&#44; la mayor&#237;a vinculadas a las lesiones asociadas &#40;80&#59; 18&#44;9&#37;&#41;&#46; El dolor persistente fue la complicaci&#243;n m&#225;s prevalente&#44; seguido de sepsis o <span class="elsevierStyleItalic">shock</span> s&#233;ptico&#44; neumon&#237;a y vejiga neurog&#233;nica&#46; Solo hubo 4<span class="elsevierStyleHsp" style=""></span>complicaciones postoperatorias &#40;4&#37; de los casos quir&#250;rgicos&#41;&#46; La tasa de mortalidad a 90 d&#237;as fue del 6&#44;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">Comparaci&#243;n del tratamiento quir&#250;rgico y del conservador</span><p id="par0120" class="elsevierStylePara elsevierViewall">El tratamiento quir&#250;rgico estuvo asociado a compromiso neurol&#243;gico &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;004&#41;&#44; compromiso del canal &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; heridas sucias &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; restos de bala o de fragmentos de hueso en el canal &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y patr&#243;n de la lesi&#243;n &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Tras un an&#225;lisis multivariante mediante un modelo de regresi&#243;n log&#237;stica binario&#44; las variables antes mencionadas conservaron su significaci&#243;n estad&#237;stica&#44; exceptuando el compromiso neurol&#243;gico&#46; Las heridas sucias &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;07&#59; OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#44;178&#59; IC&#160;95&#37;&#58; 1&#44;236-3&#44;836&#41;&#44; el compromiso del canal &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;005&#59; OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#44;6&#59; IC&#160;95&#37;&#58; 1&#44;338-5&#44;5286&#41;&#44; los restos de bala o de fragmentos de hueso en el canal &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#59; OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#44;715&#59; IC&#160;95&#37;&#58; 1&#44;504-4&#44;902&#41; y el patr&#243;n de la lesi&#243;n &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; guardaron relaci&#243;n con el tratamiento quir&#250;rgico&#46; De acuerdo con los subtipos del patr&#243;n de la lesi&#243;n&#44; existieron diferencias estad&#237;sticamente significativas en t&#233;rminos de l&#225;minas y facetas &#40;&#60;0&#44;001 OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#44;755&#59; IC&#160;95&#37;&#58; 2&#44;183-10&#44;358&#41;&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discusi&#243;n</span><p id="par0130" class="elsevierStylePara elsevierViewall">Nuestra cohorte de pacientes con lesiones vertebrales por disparo en Iberoam&#233;rica estuvo ampliamente representada por varones j&#243;venes con trabajos de bajo riesgo de lesi&#243;n por disparo &#40;es decir&#44; que no eran militares ni polic&#237;as&#41; que recibieron disparos de baja energ&#237;a en la columna&#44; de manera similar a los datos demogr&#225;ficos reportados en publicaciones previas de Iberoam&#233;rica y otras regiones del mundo<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#44;9&#44;11&#44;16-20</span></a>&#46; Casi todos los pacientes&#44; v&#237;ctimas de disparo de arma de fuego&#44; fueron de clase baja&#47;media&#44; lo cual concuerda con los resultados de un estudio de Naciones Unidas<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a>&#46; Para describir mejor este escenario&#44; encontramos cifras similares de lesiones por disparo entre semana y fines de semana y festivoss&#44; y preponderancia de las lesiones a altas horas de la noche y primeras horas del d&#237;a &#40;antes de las 4&#58;00<span class="elsevierStyleHsp" style=""></span>h&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Como se ha descrito en otros estudios retrospectivos&#44; la mayor proporci&#243;n de las lesiones se produjo en la columna tor&#225;cica &#40;45&#37;&#41;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#44;9&#44;17</span></a>&#44; aunque tambi&#233;n encontramos un mayor n&#250;mero de lesiones cervicales superiores que en estudios previos &#40;3&#37;&#41;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#44;9</span></a>&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Los pacientes con lesiones por disparo tienen una amplia gama de presentaciones cl&#237;nicas en el momento del ingreso&#58; desde fracturas vertebrales estables aisladas hasta casos graves de m&#250;ltiples traumatismos&#44; en los que el tratamiento es complejo y dif&#237;cil a la vez<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">6</span></a>&#46; En nuestra muestra&#44; el 75&#37; de los pacientes que se nos presentaron ten&#237;a d&#233;ficit neurol&#243;gico&#44; el 11&#37; ten&#237;a puntuaci&#243;n de Glasgow Coma Scale inferior a 8 y el 38&#37; era hemodin&#225;micamente inestable&#46; Las lesiones asociadas eran la norma &#40;82&#37;&#41;&#44; con una puntuaci&#243;n ISS media igual a 23 &#40;&#177;22&#41;&#44; cuando esta se reportaba&#46; Lamentablemente&#44; la puntuaci&#243;n ISS se report&#243; solo en una minor&#237;a de los pacientes &#40;171&#59; 40&#44;4&#37;&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">En una revisi&#243;n sistem&#225;tica de la literatura reciente&#44; se encontr&#243; que la tasa de lesi&#243;n medular completa reportada fluctu&#243; del 13 al 78&#37;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">21</span></a>&#46; En nuestra muestra&#44; 320 pacientes &#40;76&#37;&#41; reflejaron alg&#250;n nivel de compromiso neurol&#243;gico y casi la mitad fueron clasificados con lesiones AIS de grado A&#44; lo cual indica la p&#233;rdida completa de las funciones motora y sensorial por debajo de la lesi&#243;n&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">De manera cl&#225;sica&#44; la TC y las radiograf&#237;as han sido propuestas como las t&#233;cnicas de referencia para evaluar los patrones de lesi&#243;n &#243;sea y la estabilidad mec&#225;nica de las lesiones vertebrales por disparo<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">3&#44;4&#44;10&#44;21</span></a>&#46; La tomograf&#237;a aporta una evaluaci&#243;n precisa de la localizaci&#243;n de la bala&#44; delinea cualquier da&#241;o &#243;seo e identifica la bala y los fragmentos &#243;seos dentro del canal espinal<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a>&#46; Pocas indicaciones respaldan el uso de la RM en los pacientes con lesi&#243;n vertebral por disparo debido a la inquietud por el efecto del campo magn&#233;tico en los componentes de las balas ferromagn&#233;ticas&#44; que podr&#237;an exacerbar la lesi&#243;n original<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a>&#46; En casi todos los pacientes de nuestra cohorte se evalu&#243; su lesi&#243;n vertebral mediante TC &#40;94&#37;&#41; y se hicieron radiograf&#237;as a casi la mitad de ellos &#40;48&#37;&#41;&#46; Se realiz&#243; RM solo a 30 pacientes&#46; Las lesiones afectaron al canal vertebral &#40;60&#37;&#41;&#44; la l&#225;mina &#40;37&#37;&#41; y el cuerpo vertebral &#40;32&#37;&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">El tratamiento de los pacientes con traumatismo penetrante deber&#225; guiarse por los principios <span class="elsevierStyleItalic">Advanced trauma life support</span> &#40;ATLS&#41;&#44; que argumentan que las lesiones potencialmente mortales deben identificarse y tratarse de inmediato<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a>&#46; Deber&#225; revisarse la situaci&#243;n de la vacuna contra el t&#233;tanos&#44; inici&#225;ndose de inmediato tratamiento antibi&#243;tico de amplio espectro&#44; que se mantendr&#225; durante 48-72<span class="elsevierStyleHsp" style=""></span>h en todos los casos<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a>&#46; Sin embargo&#44; la duraci&#243;n completa del tratamiento antibi&#243;tico sigue siendo controvertida&#46; Las revisiones retrospectivas han destacado el modo en que deben tratarse los &#243;rganos abdominales perforados y&#44; en especial&#44; las heridas que perforan el colon&#44; que confieren un riesgo mucho m&#225;s alto de infecciones y que deber&#225;n tratarse con cobertura antibi&#243;tica a largo plazo para prevenir las infecciones profundas de la columna<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a>&#46; Se utiliz&#243; tratamiento antibi&#243;tico profil&#225;ctico en el 94&#37; de la cohorte de nuestra muestra&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Observamos una baja tasa &#40;&#60;5&#37;&#41; de uso de altas dosis de esteroides en nuestros 12 centros de Iberoam&#233;rica&#44; lo cual es consistente con el cuerpo de la evidencia publicada&#44; que indica que suelen estar contraindicados en los pacientes con traumatismo penetrante<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">21&#44;23</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">El tratamiento quir&#250;rgico de las lesiones vertebrales por disparo sigue siendo controvertido<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">3&#44;10&#44;21&#44;24-26</span></a>&#46; Las indicaciones quir&#250;rgicas m&#225;s debatidas en la literatura son la descompresi&#243;n neurol&#243;gica&#44; la extracci&#243;n de balas del canal vertebral&#44; la reparaci&#243;n de fugas de l&#237;quido cefalorraqu&#237;deo y el tratamiento de la inestabilidad de la columna<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">3&#44;5-7&#44;10&#44;24&#44;25</span></a>&#46; En nuestro an&#225;lisis retrospectivo&#44; los casos quir&#250;rgicos estuvieron asociados con m&#225;s frecuencia a ciertos patrones de la lesi&#243;n&#44; que incluyeron compromiso del canal vertebral&#44; heridas sucias&#44; restos de bala o de fragmentos &#243;seos en el canal y lesiones de la l&#225;mina&#44; todo ello consistente con la literatura&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Normalmente se piensa que las heridas vertebrales por disparo son estables&#44; pero existe falta de consenso acerca de la definici&#243;n y clasificaci&#243;n de los tipos de fracturas inestables&#46; Se ha propuesto que las lesiones por disparo que fracturan ambos ped&#237;culos o las articulaciones facetarias sean consideradas inestables y que requieren fijaci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#44;25</span></a>&#46; En nuestra muestra&#44; menos del 3&#37; de los pacientes tuvo este tipo de lesi&#243;n&#44; por lo que no podemos ampliar la literatura actual relacionada con esta cuesti&#243;n&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Nuestro estudio tiene diversas limitaciones&#44; que incluyen la naturaleza retrospectiva de la recopilaci&#243;n de los datos&#44; el porcentaje considerable de datos ausentes para algunas variables y el n&#250;mero desproporcionado de pacientes procedentes de un &#250;nico pa&#237;s&#46; Afortunadamente&#44; la amplia mayor&#237;a de los datos ausentes guardaron relaci&#243;n con las variables demogr&#225;ficas y el momento del d&#237;a en el que se produjo la lesi&#243;n&#44; habi&#233;ndose reportado en alg&#250;n otro lugar&#44; mientras que casi todas las variables que guardaron relaci&#243;n con la naturaleza de la lesi&#243;n y el tratamiento realizado fueron completas o casi completas&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusiones</span><p id="par0180" class="elsevierStylePara elsevierViewall">Esta investigaci&#243;n describe un estudio multic&#233;ntrico de una cohorte iberoamericana con lesiones vertebrales por disparo&#46; La amplia mayor&#237;a de las v&#237;ctimas por disparo eran varones de profesiones de bajo riesgo y de estatus social bajo&#47;medio asaltados con arma de fuego de baja energ&#237;a&#46; El compromiso neurol&#243;gico fue la norma&#44; fueron comunes el compromiso del canal vertebral y las fracturas de la l&#225;mina y fue poco com&#250;n el compromiso facetario bilateral&#46; El tratamiento&#44; en general&#44; fue no quir&#250;rgico&#59; los casos quir&#250;rgicos se distingu&#237;an por las altas tasas de compromiso del canal vertebral&#44; fragmentos de bala o de hueso en el canal vertebral y fracturas que afectan a la l&#225;mina&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Nivel de evidencia</span><p id="par0185" class="elsevierStylePara elsevierViewall">Nivel de evidencia IV&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicto de intereses</span><p id="par0190" class="elsevierStylePara elsevierViewall">Los autores declaran la ausencia de conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introducci&#243;n y objetivo</span><p id="spar0005" 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 Iberoam&#233;rica&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materiales y m&#233;todos</span><p id="spar0010" 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="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se analiz&#243; a 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; Predominaban los varones&#44; civiles&#44; con profesiones con bajo riesgo de violencia y estatus social medio&#47;bajo&#46; La mayor&#237;a&#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 320 &#40;76&#37;&#41; pacientes&#44; con lesi&#243;n medular en 269 &#40;63&#37;&#41;&#46; El tratamiento sol&#237;a ser conservador&#44; con solo 90 &#40;21&#37;&#41; casos quir&#250;rgicos&#46; Las caracter&#237;sticas que distinguieron los casos quir&#250;rgicos de los no quir&#250;rgicos fueron el compromiso neurol&#243;gico &#40;<span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#44;004&#41;&#44; compromiso del canal &#40;<span class="elsevierStyleItalic">p</span>&#160;&#60;&#160;0&#44;001&#41;&#44; heridas sucias &#40;<span class="elsevierStyleItalic">p</span>&#160;&#60;&#160;0&#44;001&#41;&#44; restos de fragmentos de bala o hueso en el canal espinal &#40;<span class="elsevierStyleItalic">p</span>&#160;&#60;&#160;0&#44;001&#41; y el patr&#243;n de la lesi&#243;n &#40;<span class="elsevierStyleItalic">p</span>&#160;&#60;&#160;0&#44;001&#41;&#46; Las variables mencionadas se mantuvieron estad&#237;sticamente significativas&#44; luego del an&#225;lisis multivariado&#44; excepto el compromiso neurol&#243;gico&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">En este estudio multic&#233;ntrico de v&#237;ctimas de lesiones vertebrales por proyectil de arma de fuego&#44; 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 la lesi&#243;n en la columna en el 63&#37; de los pacientes&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introducci&#243;n y objetivo"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Materiales y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusiones"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction and objective</span><p id="spar0025" 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="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material and methods</span><p id="spar0030" 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="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" 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 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;79&#59; 87&#37;&#41;&#46; Injury features distinguishing surgical from non-surgical cases were neurological compromise &#40;<span class="elsevierStyleItalic">P</span>&#160;&#61;&#160;0&#46;004&#41;&#44; canal compromise &#40;<span class="elsevierStyleItalic">P</span>&#160;&#60;&#160;0&#46;001&#41;&#44; dirty wounds &#40;<span class="elsevierStyleItalic">P</span>&#160;&#60;&#160;0&#46;001&#41;&#44; bullet or bone fragment remains in the spinal canal &#40;<span class="elsevierStyleItalic">P</span>&#160;&#60;&#160;0&#46;001&#41; and injury pattern &#40;<span class="elsevierStyleItalic">P</span>&#160;&#60;&#160;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="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" 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>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introduction and objective"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusions"
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        "etiqueta" => "Figura 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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        "descripcion" => array:1 [
          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribuci&#243;n de las lesiones vertebrales&#58; l&#225;mina 57 &#40;37&#37;&#41;&#59; cuerpo vertebral 134 &#40;32&#37;&#41;&#59; ped&#237;culo 59 &#40;14&#37;&#41;&#59; faceta 48 &#40;11&#37;&#41;&#59; faceta bilateral 7 &#40;2&#37;&#41;&#59; ped&#237;culo bilateral 10 &#40;2&#37;&#41;&#59; disco intervertebral 1 &#40;1&#37;&#41;&#46;BL&#58; faceta bilateral &#40;BL&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">DE&#58; desviaci&#243;n est&#225;ndar&#46;</p>"
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                  \t\t\t\t">&#40;86&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">401&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;95&#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\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
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" 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
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;63&#44;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</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;4&#44;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  " 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="left" 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;49&#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="left" 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;5&#44;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="left" 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;12&#44;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="left" 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;7&#44;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="left" 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;20&#44;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>NC&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="left" 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;5&#44;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">Entrada de la bala</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>Cabeza&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="left" 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;5&#44;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>Cuello&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="left" 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;18&#44;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>T&#243;rax&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">177&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;41&#44;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>Abdomen&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">136&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;32&#44;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>Pelvis&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;2&#44;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>M&#250;ltiple&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="left" 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;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" 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">Salida de la bala</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>Cabeza&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;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>Cuello&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="left" 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;4&#44;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>T&#243;rax&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;15&#44;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>Abdomen&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;9&#44;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>Pelvis&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;1&#44;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>Ninguna&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">289&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;68&#44;5&#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">Herida</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>Limpia&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">326&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;77&#44;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>Sucia&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="left" 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;22&#44;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">Localizaci&#243;n de la bala</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>Canal vertebral&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="left" 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
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;14&#44;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>Cuerpo vertebral&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;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>Arco posterior&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;6&#44;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>Disco intervertebral&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;1&#44;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>Tejido blando&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="left" 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;22&#44;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>&#211;rgano interno&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="left" 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;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>Extremidades&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="left" 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;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>Localizaciones m&#250;ltiples&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="left" 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;10&#44;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>Otro&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">129&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;30&#44;6&#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">Lesi&#243;n vertebral</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>L&#225;mina&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">157&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;37&#44;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>Cuerpo vertebral&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">134&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;32&#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>Disco intervertebral&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;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>Ped&#237;culo unilateral&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="left" 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;14&#44;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>Ped&#237;culo bilateral&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;2&#44;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>Masa lateral unilateral&#47;faceta articular&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;11&#44;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>Masa lateral unilateral&#47;faceta articular&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="left" 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;1&#44;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">Trayectoria de la bala</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>Tangencial no penetrante&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="left" 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;17&#44;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>Tangencial penetrante&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&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="left" valign="\n
                  \t\t\t\t\ttop\n
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Información del artículo
ISSN: 18884415
Idioma original: Español
DOI:10.1016/j.recot.2024.01.022
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