Bullet retrieval from the cauda equina after penetrating spinal injury: A case report and review of the literature
- St. George’s University, School of Medicine, Great River, New York, United States,
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, New York, United States.
Disep I. Ojukwu
Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, New York, United States.
DOI:10.25259/SNI_238_2021Copyright: © 2021 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 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: Disep I. Ojukwu1, Timothy Beutler2, Carlos R. Goulart2, Michael Galgano2. Bullet retrieval from the cauda equina after penetrating spinal injury: A case report and review of the literature. 14-Apr-2021;12:163
How to cite this URL: Disep I. Ojukwu1, Timothy Beutler2, Carlos R. Goulart2, Michael Galgano2. Bullet retrieval from the cauda equina after penetrating spinal injury: A case report and review of the literature. 14-Apr-2021;12:163. Available from: https://surgicalneurologyint.com/?post_type=surgicalint_articles&p=10723
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.
Keywords: Bullet retrieval, Cauda equina, Missile penetrating spinal injury, Neurosurgery, Spine
There continues to be an increase in missile penetrating spinal injuries (MPSIs) resulting from the discharge of firearms.[
Here, we report a case involving a 34-year-old male who sustained multiple gunshot wounds, including an MPSI to the cauda equina. The clinical, radiological, and surgical management of this patient are presented, along with the intraoperative video and literature review.
A 34-year-old male presented following multiple gunshot wounds to his abdomen, left flank, right shoulder, and L1-L2 spine resulting in a T12 complete paraplegia (ASIA A).
Computed tomography (CT) of the abdomen/pelvis and general surgical intervention
Abdominal/pelvic CT studies showed intra-abdominal injuries/hemorrhages, which immediately required an exploratory laparotomy for bowel resection and evacuation of a retroperitoneal hematoma.
CT of the lumbar spine
The CT scan of the lumbar spine revealed a bullet lodged in the left L1/2 disc space/spinal canal resulting in severe cauda equina compression, destruction of the left L2 pedicle, and destruction of the left L1/2 facet joint [
When the T12 to L3 laminectomy was performed, the bullet was found lodged in the L1/2 disc space and the left L2 pedicle was destroyed. Utilizing a rough diamond burr, the retained bullet fragment was removed and the cauda equina was decompressed [
Decompression should be considered for any patient with an incomplete neurological injury with associated spinal canal compromise (ideally within 24–48 hours of injury). The main surgical indications for bullet retrieval include progressive clinical deterioration secondary to incomplete injury of cord;[
Notably, patients with lesions between T12 and L4 experience significantly greater motor recovery after removal of the bullet versus patients with no bullet removal.[
Removal of a retained bullet from a penetrating injury to the cauda equina at the L1–L2 level should be considered if there is an incomplete spinal cord injury with progressive neurologic deterioration, migration of the bullet within the spinal canal contributing to an increased deficit, a dural leak, or a significant risk of infection/meningitis.
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