Combat-Related Intradural Gunshot Wound to the Thoracic Spine: Significant Improvement and Neurologic Recovery Following Bullet Removal

Abstract

The vast majority of combat-related penetrating spinal injuries from gunshot wounds result in severe or complete neurological deficit. Treatment is based on neurological status, the presence of cerebrospinal fluid (CSF) fistulas, and local effects of any retained fragment(s). We present a case of a 46-year-old male who sustained a spinal gunshot injury from a 7.62-mm AK-47 round that became lodged within the subarachnoid space at T9-T10. He immediately suffered complete motor and sensory loss. By 24-48 hours post-injury, he had recovered lower extremity motor function fully but continued to have severe sensory loss (posterior cord syndrome). On post-injury day 2, he was evacuated from the combat theater and underwent a T9 laminectomy, extraction of the bullet, and dural laceration repair. At surgery, the traumatic durotomy was widened and the bullet, which was laying on the dorsal surface of the spinal cord, was removed. The dura was closed in a water-tight fashion and fibrin glue was applied. Postoperatively, the patient made a significant but incomplete neurological recovery. His stocking-pattern numbness and sub-umbilical searing dysthesia improved. The spinal canal was clear of the foreign body and he had no persistent CSF leak. Postoperative magnetic resonance imaging of the spine revealed contusion of the spinal cord at the T9 level. Early removal of an intra-canicular bullet in the setting of an incomplete spinal cord injury can lead to significant neurological recovery following even high-velocity and/or high-caliber gunshot wounds. However, this case does not speak to, and prior experience does not demonstrate, significant neurological benefit in the setting of a complete injury.

Gunshot Wounds: Ballistics, Pathology, and Treatment Recommendations, with a Focus on Retained Bullets

“…64 Timely removal of intra-canicular bullets in the case of incomplete SCI can allow for axonal regeneration and has been observed to allow for meaningful neurologic recovery and symptom improvement. 63,188 However, removal of bullet fragments for complete, static SCI are not associated with significant restoration of neurologic function. 180,[189][190][191][192] Overall, if progressive neurological changes, lead intoxication, spinal instability, persistent cerebrospinal fluid leak or infection are identified, the literature supports surgical intervention.…”

Chinese expert consensus on the treatment of modern combat-related spinal injuries

“…Generally, simple debridement is needed for penetrating spine and spinal cord injuries, but thorough intraspinal canal debridement and spinal cord decompression are not recommended, as they are not beneficial for the recovery of neurological functions but instead increase the risk of complications including infection, cerebrospinal fluid leakage and hemorrhage [55, 56]. Surgery is required when penetrating spinal fractures are associated with compression-induced incomplete and deteriorating spinal cord or cauda equina injuries or when there is cerebrospinal fluid leakage or associated thoracic abdominal organ injuries [57–60].…”

An Atypical Location of a Projectile in Sacrum about a Case

“…Ledger wood believes that the question of whether to withdraw the ball must be based on the assessment of the risks involved in leaving it in place in relation to the risks involved in the attempt to withdraw it. Late isolated neurological symptoms can occur up to 15 years after the trauma [7,[13][14][15][16].…”