Should we Remove Bullets from the Spinal Cord?

Abstract

Materials and MethodsA 45 year-old gentleman presented with gunshot wound, with a loss of sensation below his chest and loss of power in his lower limbs. On examination there was a single 1cmx0.5cm bullet entry wound on the anterolateral aspect of the left shoulder, with a T3 motor and sensory level. PR revealed reduced tone and no squeeze. A full body CT showed a bullet within the spinal canal adjacent to the T3 vertebral body. The spinal injuries team diagnosed a T3 complete ASIA A paraplegia. He underwent a posterior decompression of T3 and intra-dural bullet removal with dura repair on the same day. Surgery revealed a dural tear and an intra-dural bullet with obvious cord damage. This was removed with rubberised forceps and handed to police for ballistics. He was given flucloxacillin and transferred to the spinal injuries unit for rehabilitation. He made no neurological recovery but did not develop any further complications. ResultsA thorough literature search revealed the role of surgery in gaining lost neurological function remains ambiguous. Indications for bullet removal include acute neurological deterioration and CSF fistulas. Epidural haematoma/abscesses, radiological compression or a destabilized spine are also considerations. Removals of bullets below T12 have had an effect on motor recovery. However similar neurological recoveries have been reported in both surgical and conservative management of incomplete deficits. Compete deficits are unlikely to improve neurologically regardless of surgical intervention, however cervical injuries with early detection of compressive pathology should be considered. Complication rates are reported to be higher if operated. Prophylactic antibiotics should be started immediately on admission. Surgery does not reduce the incidence of infection. Pain may be intensified when caused by a gunshot injury, but there is no evidence of improvement with bullet removal. One indication for surgery in this case was to prevent post traumatic syringomyelia (PTS). The incidence is 0.3–3.2%, however radiological/autopsy studies suggest up to 22%. There has been one prior reported case where a patient developed symptoms 14 months following initial gunshot injury. However due to lack of data it is uncertain if initial surgical management reduces development of future syrinxes. ConclusionsThis appears to be the first reported case of an intra-dural bullet in the UK. Treatment should be focused on ensuring spine stability, enhancing potential for neurological recovery and preventing complications. The role of surgery versus non-surgical treatment is still debate.