- Okan University, The Vocational School of Health Services, Tuzla, Istanbul, Turkey
- Neurosurgery Clinic, Kurtkoy Ersoy Hospital, Istanbul, Turkey
- Orthopedic Clinic, Kurtkoy Ersoy Hospital, Istanbul, Turkey
Orthopedic Clinic, Kurtkoy Ersoy Hospital, Istanbul, Turkey
DOI:10.4103/2152-7806.181978Copyright: © 2016 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Hakan T, Ajlan Çerçi, Serkan Gürcan, Serkan Akçay. Firearm bullet settling into the lumbar spinal canal without causing neurological deficit: A report of two cases. Surg Neurol Int 06-May-2016;7:
How to cite this URL: Hakan T, Ajlan Çerçi, Serkan Gürcan, Serkan Akçay. Firearm bullet settling into the lumbar spinal canal without causing neurological deficit: A report of two cases. Surg Neurol Int 06-May-2016;7:. Available from: http://surgicalneurologyint.com/surgicalint_articles/firearm-bullet-settling-into-the-lumbar-spinal-canal-without-causing-neurological-deficit-a-report-of-two-cases/
Background:Uncertainty still exists regarding the treatment of the patients presenting with gunshot wounds to the spine. Neurological insults, cerebrospinal fluid fistula, infection, lead or copper toxicity, migration of bullets, and spinal instability are included among the common challenging issues.
Case Description:An 18-year-old woman was admitted with low back pain following a gunshot injury five days ago. She was neurologically intact. Radiological examinations showed that a bullet was settled in L4-5 disc space. The bullet was removed with a unilateral L4-5 partial hemilaminectomy and discectomy from the left side. The second case was of a 29-year-old man admitted with radiating leg pain on the right side following a gunshot injury from his left side of lower back four months ago. He had only positive straight leg raising test. Radiological studies showed two bullets, one was in the psoas muscle on the left side and the other was in spinal canal that had caused a burst fracture of the L5 vertebra. Following L5 laminectomy and bilateral L5-S1 facetectomy, the bullet was removed from the spinal canal and L5-S1 transpedicular posterior stabilization was performed. The postoperative period of both patients was unremarkable.
Conclusion:Bullet settling into the lumbar spinal canal without causing neurological deficit may require surgical intervention. Removal of bullets provided not only pain relief in both the cases but also prevented future complications such as migration of the bullets, plumbism, and neuropathic pain and instability.
Keywords: Bullet, gunshot, penetrating spinal injury, retained bullet, spine, spine trauma
Ambrose Pare described a penetrating spinal cord injury caused by a gunshot for the first time in 1557.[
In this study, two cases of a gunshot wound in which the bullets lodged in the lumbar spine without any neurological injury are reported.
Case report 1
An 18-year-old woman was admitted with low back pain following a gunshot injury to the back in the Libyan combat five days ago. During physical examination, an entry wound in her posterior left flank was detected. She had pain around the bullet entry zone and in the low back. Her examination was completely normal. Radiological studies revealed a bullet in the left side of the L4-5 disc space [
Case report 2
A 29-year-old man was admitted with radiating leg pain on his right side following a gunshot injury from his back in the Libyan combat four months ago. His neurological examination was completely normal except a positive straight leg raising test on the right side. Radiological studies showed two bullets, one was in the psoas muscle on the left side and the other was in the spinal canal that had caused a burst fracture of the L5 vertebra [
The bullet (arrow head) in spinal canal with L5 corpus fracture (arrow) in axial CT scan (a), the bullets lodged in spinal canal and the congenital lamina defect just medial to the bullet at S1 level and the bullet lodged in psoas muscle on left side in plain anteroposterior radiography (b), L4-S1 posterior stabilization seen in postoperative lateral plain anteroposterior radiography (c)
We present two referred cases of combat-related gunshot injury of the spine in the Libyan conflict. In civilian practice, incidence of gunshot wounds to spine accounts 13–17% of all gunshot injuries.[
Penetrating gunshot injuries to the spine with high caliber bullets have mostly permanent neurological defects. The degree of neural and mechanical damage depends upon the physical properties and the direct impact of the bullet, the pressure shock waves, and the temporary cavitation.[
Thoracic region is the most commonly affected area[
Plain films can be used for determining the existence and/or level of the bullet and/or damage of the spine.[
There is still controversy for optimal treatment for bullets lodged in the spinal canal. The treatment modalities for such patients need to be managed individually. The treatment strategies—bullet removal from lumbar disc space and bullet removal from spinal canal and stabilization—were decided after detailed evaluation of each patient in view of clinical and radiological findings.
Klimo et al.[
Such studies help in the accumulation of scientific data. Studies reported regarding wartime spinal gunshot injuries are limited, and it seems there is no ethical and scientific way of conducting prospective, double blind clinical studies in the near future. Indeed, it should not to be; humanity must find a way of living without this kind of conflict.
Bullet settling into the lumbar spinal canal without causing neurological deficit may require surgical intervention. In the presented study, removal of bullets provided not only pain relief in both the cases but also prevented future possible complications such as migration of the bullets, plumbism, and neuropathic pain and instability problems. The problem reported here is caused by one of the most important issues of our world, the war economy. There is a direct relationship between war economy and people with gunshot spine injuries. If we would spend our energy for construction of a better world to live in peace, this paper would not exist.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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