Intradural migration of a bullet following spinal gunshot injury

Treatment of gunshot wounds of the spine using full-endoscopic surgery: analysis of a small clinical series

Objective. To assess the effectiveness of the treatment of gunshot wounds of the spine using percutaneous full-endoscopic technique.

Material and Methods. Three patients with gunshot shrapnel wounds of the spine were treated using percutaneous full endoscopy.

Results. The patients underwent a removal of foreign bodies (metal fragments) at the cervical, thoracic and lumbosacral levels of the spine using percutaneous full endoscopic surgery. The operations were carried out without complications, with minimal additional trauma to soft tissues and the spinal motion segment. In all three cases, there was a positive dynamics in the form of regression of the pain syndrome. There were no infectious complications.

Conclusion. The successful use of percutaneous full endoscopy in the surgical treatment of blind shrapnel wounds of the spine is shown. The results indicate the expediency of further research and development of this area to address the issue of introducing the technique into the routine practice of treating gunshot wounds both in peacetime in neurosurgical hospitals and centers of spinal neurosurgery, and in wartime at the stages of specialized care.

Bullet retrieval from the cauda equina after penetrating spinal injury: A case report and review of the literature

Background:

When gunshot injuries occur to the spine, bullet fragments may be retained within the spinal canal. Indications for bullet removal include incomplete spinal cord injury, progressive loss of neurologic function including injury to the cauda equina, and dural leaks with impending risk of meningitis.

Case Description:

Here, we present a 34-year-old male with a missile penetrating spinal injury to the cauda equina. In addition to the computed tomography scan demonstrating retention of a bullet in the left L1/2 disc space, the scan suggested likely dural injury. The patient underwent a decompression/instrumented fusion with retrieval of the retained bullet fragment. A laminectomy was performed from T12 to L3, and at L1 and L2, a large traumatic durotomy was identified and repaired. The patient, unfortunately, continued to have bilateral lower extremity plegia with neurogenic bladder/bowel dysfunction at 1-year follow-up.

Conclusion:

We discuss the operative management and provide an intraoperative video showing the bullet extraction and dural closure.

Percutaneous Transforaminal Endoscopic Removal of Spinal Shrapnel

BACKGROUND

Gunshot injuries are one of the most common causes of the penetrating injuries of the spine. The victims of these injuries usually have neurologic deficits. Percutaneous endoscopic lumbar surgery is one of the most popular surgical spine interventions. We report a case with incomplete radiculopathy due to shrapnel located in L5 foramen that was removed by percutaneous endoscopic technique.

CASE DESCRIPTION

A 23-year-old man sustaining a gunshot injury penetrating to the abdomen presented to our hospital. His first examination revealed a single gunshot wound with entry hole in the left low lumbar region without exit hole and right lower abdominal quadrant tenderness. Plain radiographs and computed tomography showed a bullet in the abdomen and left L5 transverse process fracture and shrapnel in L5 foraminal zone. The bullet was removed by abdominal surgeons without any surgical plan for the shrapnel in the foramen. He was referred to our clinic 3 weeks after discharge. Without any further neurologic deterioration, he had uninterrupted severe pain that was mostly unbearable during the night. Despite gradually increasing dosages of different drugs, his pain relief was insufficient. Percutaneous transforaminal endoscopic removal of the shrapnel was planned.

CONCLUSIONS

Despite the absence of a universally approved algorithm in the treatment of spinal gunshot injuries, endoscopic technique can be kept in mind for a minimal access and invasiveness in case of indication for removal. With experience in endoscopic procedures and familiarity with surgical anatomy, the treatment of this unique case was completed successfully.

Unusual case of a migrating spinal bullet: An opportunity for reflection

The following case report documents the presentation of a 28 year old male who presented to the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) trauma unit following a single gunshot wound to the spine. He presented walking, with no neurological dysfunction. On further investigation he was found to have a retained bullet at the L3 level of the spinal canal, which migrated within the canal from its initial point of entry. He was subsequently taken for a laminectomy and bullet removal under fluoroscopic guidance. Post operatively he was noted to have reduced proprioception bilaterally.

Posterior lumbar interbody fusion graft penetrated the lumbar thecal sac in a patient with rheumatoid arthritis: A case report

INTRODUCTION

Intradural foreign bodies have been reported to be associated with disc material, tumors, and bullets following spinal gunshot injuries. In this report, we describe a case of non-union with minor trauma that caused interbody bone graft material to migrate into the intrathecal area in a patient with RA.

PRESENTATION OF CASE

We present the case of a 65-year-old woman visited an outpatient clinic of our hospital after experiencing progressive lower extremity weakness, and voiding and defecation difficulty after fell down several times in the past. She had a history of two spinal decompression with fixation surgeries due to spinal stenosis with a herniated intervertebral disc. She was prescribed steroids and methotrexate for the RA. The results of MRI and CT demonstrated an intradural bone graft material migration with cauda equina syndrome after revision lumbar stenosis surgery. Calcified material protruded to the intracanal area and compressed the cauda equina fiber. After the removal of fragments operation, she recovered from cauda equina symptoms. A follow-up examination two years postoperatively revealed clinical resolution of cauda equina symptoms and a return to partial walking with a cane.

DISCUSSION

The patient had a minor or major trauma, such as a fall, after the revision surgery. After that trauma, the patient presented with some dural injury, kyphotic position, or non-union state causing the dural penetration of the interbody fusion material.

CONCLUSION

The first report describing displaced PLIF graft material that penetrated the dural sac and caused cauda equina symptoms in a patient with RA. Establishing strategies to minimize these complications is indicated when treating degenerative lumbar spine conditions in patients with RA.

Removal of Migrating Lumbar Spine Bullet: Case Report and Surgical Video

BACKGROUND

Gunshot wounds to the spine are devastating injuries. Rarely, the bullet has been reported to migrate. Migration is associated with progressive neurologic deficits that often improve with bullet removal. The authors report a case of removal of a migrating lumbar spine bullet. This is supplemented by an operative video and a review of the literature.

CASE DESCRIPTION

A 31-year-old man presented to the emergency department with multiple gunshot wounds and lower-extremity paresthesia. A ballistic injury occurred with an entry wound in the right posterior soft tissues, traversing the right paraspinal muscle and fracturing the left lumbar 5 pedicle and left lumbar 4 transverse process. The bullet was positioned within the spinal canal at the lumbar 3/4 interspace. His spinal injury was managed nonoperatively due to his traumatic injuries and findings of minimal neurologic deficit without cerebrospinal fluid leak. The patient returned to the neurosurgery clinic a year later and was found to have worsening low back pain, decreased sensation throughout the left leg, and radiating pain throughout the right leg. Imaging demonstrated the bullet had migrated caudally to the midlumbar 5 vertebral body. Given the patient's progressive symptoms and migration of the bullet fragment, informed consent was obtained for a laminectomy and removal of the intradural bullet fragment.

CONCLUSIONS

Neurosurgical treatment for gunshot wounds remains controversial. Cauda equina or lumbosacral level wounds are often incomplete and may improve with surgical decompression and bullet removal. Migrating bullet fragments throughout the spine and brain lead to worsened neurologic function, which can be reversed by removal. Movement of the bullet during surgery should be expected, and intraoperative fluoroscopy and patient positioning can help to properly localize the bullet and aid in its removal.

Operative Versus Nonoperative Management of Civilian Gunshot Wounds to the Spinal Cord: Novel Use of the Functional Independence Measure for Validated Outcomes

BACKGROUND

Surgery for patients with gunshot wound spinal cord injury (GSCI) remains controversial. Few recent studies provide standardized follow-up and detailed functional outcomes. To our knowledge, the research we present in this study is unique in that we are the first to incorporate Functional Independence Measure (FIM) scores as an outcomes measure for neurologic recovery in patients with GSCI.

METHODS

Patients with GSCI were divided into surgical and nonsurgical groups. Neurologic function was measured according to the American Spinal Injury Association impairment scale and defined as either complete or incomplete injury. Outcomes were then analyzed separately for complete and incomplete GSCI groups during hospitalization and rehabilitation.

RESULTS

Baseline admissions characteristics were similar between surgical and nonsurgical groups except for a greater median injury severity score in the nonsurgical group (34 vs. 27; P = 0.02). For complete GSCI, total length of stay (LOS) was significantly longer in the surgical group (52 vs. 42 days; P = 0.04), and no difference was observed in overall FIM scores (58 vs. 54; P = 0.7). For incomplete GSCI, rehabilitation LOS was longer (35 vs. 21; P = 0.02) and a trend towards longer total LOS was observed in the surgical group (40 vs. 32; P = 0.07). No difference was observed in overall FIM scores (61 vs. 62; P = 0.9).

CONCLUSIONS

Surgery for patients with GSCI is associated with increased LOS and is not associated with improved FIM scores for patients with either complete or incomplete spinal cord injuries.

Migratory low velocity intradural lumbosacral spinal bullet causing cauda equina syndrome: report of a case and review of literature

BACKGROUND

Migration of the bullet within the spinal subarachnoid space has long been recognized as unusual complication of spinal gunshot injury.

OBJECTIVE

We report a case of migratory low velocity intradural lumbosacral spinal bullet causing cauda equina syndrome. The relevant literature is reviewed and all cases of migratory spinal bullet are summarised, and management strategies are discussed.

STUDY DESIGN

Literature review.

METHODS

A 32-year-old male suffered abdominal gunshot injury for which emergency laparotomy and repair of colonic perforation were performed. The bullet was seen lodged within the sacral spinal canal behind the S1 vertebral body. The probable entry point was at L2-L3 level. Caudal migration of the bullet within the spinal subarachnoid space leads to the appearance of cauda equina syndrome.

RESULTS

Bullet was retrieved following upper sacral and lower lumbar laminectomy. Prone positioning of the patient had lead to cranial migration of the bullet at L4 level which was confirmed on fluoroscopy. Laminectomy had to be extended upwards with the patient in reverse Trendelenburg position for bullet removal.

CONCLUSIONS

Caudal migration of the bullet within the lumbosacral subarachnoid space results in cauda equina syndrome. Surgical retrieval of the bullet ensures the early recovery of neurological symptoms. Prone patient positioning can influence bullet location. Intraoperative fluoroscopy prior to skin incision is essential in addition to preoperative imaging to locate the bullet and thus avoid incorrect lower level laminectomy. Trapping the bullet after durotomy using suction and dissector in reverse Trendelenburg position is a useful aid in bullet removal.

When the bullet moves! Surgical caveats from a migrant intraspinal bullet

Rarely, spinal gunshot injuries result in migrating intraspinal bullets. Use of MRI is controversial and other radiographic imaging might mimic an extradural bullet, even though it is intradural and migratory. Here, we present a case of spinal missile injury resulting in an intraoperatively mobile intradural bullet. The challenges faced during diagnosis and surgical removal are described. We also show that intraoperative ultrasonography may be useful in clarifying whether the bullet is intradural. A 32-year-old male presented with weakness and paraesthesia in his right leg following an accidental gunshot injury to his spine. Facet joint destruction and an intraspinal bullet were detected. Immediate surgical removal and transpedicular instrumentation was performed. The surgical procedure was complicated by lack of an identifying dural perforation at the bullet entry point and a gliding bullet inside the spinal canal during surgery. Gliding of the bullet was caused by the pushing effect of the bone rongeur and further gliding was avoided by performing the next laminectomy with an electric drill. Where other modalities indicated for a possible extradural location, intraoperative USG clearly showed the intradural position of the bullet and provided clear images without major artifacts. Surgical treatment of a mobile intradural bullet is challenging and open to surprises. Location of the bullet may shift as result of surgical procedure itself. Laminectomy should be performed with a power drill. Where fluoroscopy was inadequate and MRI not available, intraoperative USG proved useful in ascertaining the intradural versus extradural position of the bullet and allowed for a tailored dural opening.

Migrating bullet in the thecal sac at the level of the conus medullaris without neurological deficit

Bullets can lodge in the organs, blood vessels or thecal sac. To our knowledge, a migrating bullet at the level of the conus medullaris without neurological deficit has never been reported. We present our patient along with a discussion of bullet migration in the spinal canal and its mechanisms, diagnosis and treatment. A 29-year-old man was admitted to the emergency department due to a gunshot wound in the right upper quadrant of his abdomen. He had no neurological deficit. Spinal CT scan and plain radiography showed the bullet had passed through the L2 vertebral body and had migrated downwards until it had lost its energy and come to rest in the spinal canal at the L3 vertebra level. There was a grade 5 injury to the pancreas head concomitant with mesenteric injury of the transverse colon, harboring a 0.5 cm hole. He had an emergent laparotomy to have a Roux-en-Y reconstruction and repair of the transverse colon. After his general status stabilized, he was taken back to the operating room to extract the bullet from the spinal canal. L3 and partial L2 laminectomy were performed. The dura was opened and the bullet was observed intrathecally. No cerebrospinal fluid fistula was observed. The surgeries and post-operative period were uneventful.

Gunshot wound causing complete spinal cord injury without mechanical violation of spinal axis: Case report with review of literature

Penetrating spine injury (PSI) forms the third most common cause of spine injury, only next to road traffic accidents and fall. Gunshot wound (GSW) forms the major bulk of PSI. Due to easy availability of firearms and antisocial behavior, GSW which were predominant in military population is now increasingly seen in civilized society. Here, we present a detail case review of unique case of civilian GSW indirectly causing complete spinal cord injury due to shock wave generated by the bullet, along with its systematic management.

Gunshot injuries of the spine

BACKGROUND CONTEXT

Spinal gunshot injuries (spinal GSIs) are a major cause of morbidity and mortality in both military and civilian populations. These injuries are likely to be encountered by spine care professionals in many treatment settings. A paucity of resources is available to summarize current knowledge of spinal GSI evaluation and management.

PURPOSE

The aim was to summarize the ballistics, epidemiology, evaluation, treatment, and outcomes of spinal GSI among civilian and military populations.

STUDY DESIGN

This was a review of the current literature reporting spinal GSI management.

METHODS

MEDLINE (PubMed) was queried for recent studies and case reports of spinal GSI evaluation and management.

RESULTS

Spinal GSI now comprise the third most common cause of spinal injury. Firearms that produce spinal GSI can be divided into categories of high- and low-energy depending on the initial velocity of the projectile. Neural and mechanical spinal damage varies with these types and results from several factors including direct impact, concussion waves, tissue cavitation, and thermal energy. Management of spinal GSI also depends on several factors including neurologic function and change over time, spinal stability, missile tract through the body, and concomitant injury. Surgical treatment is typically indicated for progressive neurologic changes, spinal instability, persistent cerebrospinal fluid leak, and infection. Surgical treatment for GSI affecting T12 and caudal often has a better outcome than for those cranial to T12. Surgical exploration and removal of missile fragments in the spinal canal are typically indicated for incomplete or worsening neurologic injury.

CONCLUSIONS

Treatment of spinal GSI requires a multidisciplinary approach with the goal of maintaining or restoring spinal stability and neurologic function and minimizing complications. Concomitant injuries and complications after spinal GSI can present immediate and ongoing challenges to the medical, surgical and rehabilitative care of the patient.

Gunshot wound in lumbar spine with intradural location of a bullet

The presence of a migratory bullet in the spinal canal after a gunshot injury is a rare finding, specially without causing permanent neurologic damage. We present the case of a patient who suffered a gunshot wound with an entry point in the posterior arc of L2-L3 and a migratory bullet detected at the level of L5-S1 in the CT scan. The patient complained about intense headache, dizziness, and variable sensitive impairment in lower legs apparently depending on the patient's position in bed. We decided to remove the bullet in order to prevent the delayed neurological damage and lead toxicity. We discuss technical details of this surgery.

Magnetic resonance imaging in lumbar gunshot wounds: an absolute contraindication?

Object

Performance of MR imaging in patients with gunshot wounds at or near the lumbar spinal canal is controversial. The authors reviewed the literature on the use of MR imaging in gunshot wounds to the spine. They discuss the results from in vitro and clinical studies, analyze the physical properties of common projectiles, and evaluate the safety and indications for MR imaging when metallic fragments are located near the spinal canal.

Methods

A review of the English-language literature was performed. Data from 25 articles were analyzed, including 5 in vitro studies of the interaction between 95 projectiles and the MR system's magnetic fields, and the clinical outcomes in 22 patients with metallic fragments at or near the spinal canal who underwent MR imaging.

Results

Properties of 95 civilian and military projectiles were analyzed at a magnet strength of 1, 1.5, 3, and 7 T. The most common projectiles were bullets with a core of lead, either with a copper jacket or unjacketed (73 [76.8%] of 95). Steel-containing (core or jacket) projectiles comprised 14.7%. No field interaction was evident in 78 (96.3%) of the 81 nonsteel projectiles. All steel projectiles showed at least positive deflection forces, longitudinal migration, or rotation. Heating of the projectiles was clinically insignificant. Image artifact was significant in all 9 steel bullets tested, but was not significant in 39 (88.6%) of the 44 nonsteel bullets tested. Overall, 22 patients with complete (82%) and incomplete (14%) spinal cord injury secondary to a projectile lodged inside the spinal canal underwent MR imaging. Discomfort and further physical or neurological deficits were not reported by any patient. Two patients with spinal cord injuries underwent MR imaging studies before surgical decompression and had subsequent, significant neurological improvement.

Conclusions

Metallic implants near or at the spinal canal are a relative contraindication for MR imaging. However, safe MR imaging might be feasible when a projectile's properties and a patient's individualized clinical presentation are considered.

Concept of gunshot wound spine

Gunshot wound (GSW) to the spine which was earlier common in the military population is now being increasingly noted in civilians due to easy availability of firearms of low velocity either licensed or illegal combined with an increased rate of violence in the society. Contributing to 13% to 17% of all spinal injuries, the management of complex injury to the spine produced by a GSW remains controversial. Surgery for spinal cord injuries resulting from low velocity GSWs is reserved for patients with progressive neurologic deterioration, persistent cerebrospinal fluid fistulae, and sometimes for incomplete spinal cord injuries. Surgery may also be indicated to relieve active neural compression from a bullet, bone, intervertebral disk, or a hematoma within the spinal canal. Spinal instability rarely results from a civilian GSW. Cauda equina injuries from low velocity GSWs have a better overall outcome after surgery. In general, the decision to perform surgery should be made on consideration of multiple patient factors that can vary over a period of time. Although there have been plenty of individual case reports regarding GSW to the spine, a thorough review of unique mechanical and biological factors that affect the final outcome has been lacking. We review the key concepts of pathogenesis and management of GSW to the spine and propose an algorithm to guide decision making in such cases.

Penetrating spinal injuries and their management

Penetrating spinal trauma due to missile/gunshot injuries has been well reported in the literature and has remained the domain of military warfare more often. Civic society's recent upsurge in gunshot injuries has created a dilemma for the treating neurosurgeon in many ways as their management has always involved certain debatable and controversial issues. Both conservative and surgical management of penetrating spinal injuries (PSI) have been practiced widely. The chief neurosurgical concern in these types of firearm injuries is the degree of damage sustained during the bullet traversing through the neural tissue and the after-effects of the same in long term. We had an interesting case of a penetrating bullet injury to cervical spine at C2 vertebral level. He was operated and the bullets were removed from posterior midline approach. Usually, the management of such cases differs from region to region depending on the preference of the surgeon but still certain common principles are followed world over. Thus, we realized the need to review the literature regarding spinal injuries with special emphasis on PSI and to study the recent guidelines for their treatment in light of our case.

Treatment strategy in a child with a retained bullet in the cerebellomedullary cistern

A 6-year-old girl was admitted to our emergency room because of a gunshot wound in the posterior craniocervical junction. On admission, she was alert, but left hemiplegia and right hemiparesis were noted. Cranial CT scanning showed a retained bullet in the cerebellomedullary cistern without bone destruction. Moreover, fourth ventricle hemorrhage was observed. There were no signs of acute hydrocephalus. The patient underwent suboccipital craniectomy and C-1 laminectomy for bullet removal. Postoperatively, the patient experienced significant neurological improvement. To the best of the authors' knowledge, this is the first documented case of a patient with a retained bullet in the cerebellomedullary cistern. The management strategies in such a unique case are discussed.