Technical ReviewsMinimally invasive retrieval of a bullet from the L5–S1 neural foramina after transperitoneal gunshot wound
Introduction
Civilian gunshot wounds account for approximately 13% to 17% of all spine and spinal cord injuries [1], [2]. Neurologic deficits resulting from gunshot injury range from radiculopathy to complete spinal cord injury, depending on the level of injury [2]. The role of surgery in patients with no deficit or complete spinal cord injury is limited; however, clear indications exist for patients with incomplete spinal cord injury or progressive neurologic deficits [2], [3], [4], [5], [6], [7], [8]. Spinal instability, lead intoxication, copper-induced neural toxicity, and progressive neurologic deficit have been the main indications reported in the literature [9], [10], [11], [12]. The reports in the literature of bullet retrieval have been done by laminectomy or vertebrectomy [2], [9], [12], [13]. To date, reports of bullet retrieval by minimally invasive techniques have been limited [14].
The authors report their experience in the management of a patient who suffered a transperitoneal gunshot wound with a copper-jacketed bullet. Over the course of 6 weeks, the patient became progressively symptomatic with an L5 radiculopathy and exhibited dorsiflexion weakness. The authors present the clinical and radiographic findings, discuss the operative technique for bullet retrieval. The relevant literature regarding the operative management of gunshot wounds to the spine is reviewed.
Section snippets
History
A 25-year-old man, who was the victim of a transperitoneal gunshot wound, presented to our institution 6 weeks after his injury reporting right lower extremity pain and weakness. At the time of his injury, the patient had undergone an exploratory laparotomy for repair of his multiple enterotomies. Given the patient's critical condition at the time of the injury, he had no recollection of right lower extremity symptoms at the time of presentation.
The patient had been discharged 2 weeks after his
Discussion
The location of the bullet in the patient reported herein, anterior and lateral to the nerve root, lodged in between the transverse process of L5 and the alar wing of S1, presented several surgical options. Anterior, retroperitoneal, and posterior approaches to the area could be performed to reach the bullet. An anterior or retroperitoneal approach in this case has the advantage of retrieving the bullet from the direction in which it traveled. Thus, the surgeon may identify the bullet first,
Conclusion
A symptomatic retained bullet in the lumbosacral spine may be safely removed through a minimally invasive approach. The use of intraoperative myelography and electrophysiological monitoring are valuable adjuncts to further elucidate the surgical anatomy for a minimally invasive approach onto the neural foramen, lateral to midline. In this case, these techniques collectively compensated for the limited field of vision and minimized risk of injury to the nerve root.
Acknowledgments
The authors are grateful for the editorial assistance rendered by Andrea J. Porter and Rhonda Everett.
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The effect of surgically implanted metallic bullet fragments on the intervertebral disc using a canine model☆
2019, Spine JournalCitation Excerpt :Our findings on plain films of a pseudocyst adjacent to the intervertebral disc containing the lead fragment are consistent with other reports described elsewhere [4,20,23,26]. Copper has repeatedly been shown to exert a toxic and immunogenic effect on brain tissue resulting in necrosis [8,10,27–31]. Examining the histologic and gross specimens retrieved in this study suggests that copper exerts similar toxic effects on the intervertebral disc.
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FDA device/drug status: approved for this indication (META-RA tubular retractor).
The authors do not have a financial relationship that creates, or may be perceived as creating, a conflict related to this article.