Traumatic Lumbar Bullet Injury
The patient is a 45-year-old male who, three weeks earlier, sustained spinal trauma from a bullet. The bullet entered the patient's body from the left paraspinal area and crossed the midline exactly through the spinal canal and entered the abdomen splitting the L3 vertebral body. Fortunately, the great vessels were spared.
At that time, the patient was surgically treated to repair multiple gastrointestinal perforations caused by the bullet's trajectory. During surgery, the bullet was removed from the right side of the anterior abdominal wall.
S. Srivastava, MD
Max Institute of Neurosciences
New Delhi, India
Using the Medical Research Council (MRI) scale, motor power in the hips was a grade 2 and grade 0 below. Function was absent below L2; there was no movement of any muscle group below the hip joint. Knee and ankle reflexes were absent as well.
Axial CT scans demonstrate the bullet's pathway through the L3 vertebral body and spinal canal. (Figs. 1, 2) The posterior elements were shattered and chips of bone and ligament tissue were entangled with the nerve roots. A small pallet (shrapnel, bullet shards) of the bullet tore through the dura.
Burst fracture of the L3 vertebral body with fracture of the posterior elements; dural tear with nerve root compression.
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A L3 decompression and fusion was performed. The pallets and bone fragments were removed and the shattered dura was repaired after decompression of nerve roots entangled in bone chips. The dura was repaired using artificial dural graft sutured to the dural margins and a glue applied over the suture line. The anterior tear of the dura was not repaired.
During surgery, it was found the bone chips from the lamina and right L3 pedicle had pierced the dural sac. Decompression of the dural sac and nerve roots was performed followed by L2-L4 fusion.
Intervertebral body devices were not used as the end plates were normal with no disc prolapsed. The aim of the fusion was to splint the involved segment. Titanium pedicle screws and rods were used. Moreover, the height of the involved segment was maintained, so no graft was used. (Figs. 3, 4)
The patient improved after decompression and repair of the dural sac. The patient continues to improve with no intermittent catheterization for bladder emptying. His hip and knee power are improved; grade 3 in his hips, grade 1 in his ankles ankle with bilateral foot drop. He has recovered sensation up to L4 bilaterally and is walking with some support. He continues active in physiotherapy.
This case demonstrates the importance of anticipating the amount of damage a bullet can cause. The spinal surgery was delayed in view of recovery from spinal shock and the abdominal surgery. The risk of infection was low, as the bullet entered posteriorly and did not enter the gastrointestinal tract before the spinal column.
This patient made a nice recovery, especially being decompressed three weeks out from injury. Surgery in this case is well-supported over nonoperative management.
Gunshot wounds to the cauda equina may be considered operative even despite complete deficits (1-4). Closure of the cerebrospinal fluid leak may be an indication for surgery, especially to reduce postural headaches and pseudomeningocoele formation. Some would even argue that removal of the bullet fragments alone is indicated based on the local and systemic toxicity of copper jackets and lead respectively. Furthermore there are several published cases of intrathecal migration of bullets.
While instability is rare in gunshot wounds to the spine, fixation is certainly justified given this patient's three-column injury. A short segment fixation is adequate in my opinion. However, the decompression included a bilateral pars resection and medial facetectomy (Fig. 3). There is also some angulation of the L3 vertebral body. Some may argue that the absence of bony fusion in this case could lead to long-term instability and instrumentation failure.
In addition, I would have placed a lumbar drain to reinforce the dural closure, although the anterior perforation, which could not be addressed, would likely negate any such benefit.
I concur that interbody fusion is not needed. Likewise, an anterior approach three weeks out from an open abdominal exploration with bowel injury is difficult to justify in this patient.
1. Robertson DP, Simpson RK. Penetrating Injuries Restricted to the Cauda Equina: A Retrospective Review. Neurosurgery 31: 265-270, 1992.
2. Yoshida GM, Gardland D, Waters RL. Gunshot Wounds to the Spine. Orthopedic Clinics of North America 26: 109-116, 1995.
3. Bono CM, Heary RF. Gunshots Wounds to the Spine. The Spine Journal 4: 230-240, 2004.
4. Moon E, Kondrashov D, et al. Gunshot Wounds to the Spine: Literature Review and Report on a Migratory Intrathecal Bullet. American Journal of Orthopedics 37: E47-51, 2008.