Abstract
INTRODUCTION
This report describes a rare case of the gunshot injury of the spine and spinal cord.
PRESENTATION OF CASE
A rare case of the bullet lodged intra-durally in the upper cervical region without damaging the vertebrae or the spinal cord. The bullet was removed as microneurosurgical and duraplasty was performed.
DISCUSSION
Surgical management of the gunshot wounds of the spine and spinal cord is not widely advocated and controversial.
CONCLUSION
Advances in microneurosurgical instrumentation and microscopic techniques may open up a new era of surgical treatment of spinal cord gunshot wounds.
Keywords: Upper cervical spine, Gunshot injury, Bullet
1. Introduction
The most common cause of spinal cord injury is road traffic accidents, followed by gunshot injuries.1,2 Gunshot injuries to the upper cervical region that involve the spinal cord often result in fatality.3,4 In gunshot injuries, spinal cord is damaged due to transection, contusion and vascular injury and consequent ischemia when the projectile disrupts the bones and soft tissues. The extent of the tissue damage correlates with the distance between the gun, trajectory, shape, size and the velocity of the bullet.3–5
The objective of the present study is to report a patient with a bullet lodged intra-durally and a rare neurological deficit though the framework of the vertebrae and ligaments were preserved after a gunshot injury to the upper cervical region.
2. Presentation of case
A 24 year old male patient injured during a military operation was admitted to the Emergency Service. At the time of admission, the patient was in stable condition with plegia of left upper extremity and 3/5 strength in left lower extremity. Small (0.5 cm) skin gunshot defect with leakage of CSF noted in posterior mid-cervical area. Cervical CT revealed a metallic object not penetrating the spinal cord at the level of C1–C2 vertebrae with intact bone structures (Fig. 1a and b and Fig. 2). During surgery, bones and ligaments were intact and partial laminectomy of C1–2 revealed laceration of the dura and bullet in the subdural space without visible damage to the cord. The bullet was removed and duraplasty was performed. In postoperative period, the strength of left arm recovered to 2/5 and left leg to 4/5.
Fig. 1.
(a) Lateral X-ray showing the bullet inferior to the laminae of C1–2. (b) Axial CT depicting the bullet within the spinal canal.
Fig. 2.
Reconstructed CT image head and neck clearly shows the bullet within the spinal canal without any bone destruction.
3. Discussion
With gunshot injuries, the injury is most commonly confined to the thoracic, followed by thoracic-lumbar and cervical regions. Cervical region injuries can be associated with sudden death, Braun–Sequard Syndrome and cruciate paralysis.1,4,6 Brohi and colleagues reported an 8-year-old patient who presented with Braun–Sequard Syndrome due to a bullet embedded beneath C1–C2.4 Our patient had hemiparesis, more prominently of the left upper limb, without a sensory deficit due to isolated corticospinal tract injury secondary to compression or thermal effect of the bullet.
Only two cases of a bullet lodged within the spinal canal without any damage to the osseous structures of the spinal column have been reported, but in both cases the injury was in the thoracic region.7,8 The joint between the atlas and axis is the most movable, and therefore the least stable section of the vertebral column.9 Loveluck and Schuster have found radiologically that the atlantoaxial spinolaminar was consistently less than 2 cm in adult men and women in a neutral position.10 Tubbs and colleagues found that the range of atlanto-axial interlaminar distance in flexion was 20–26 mm (mean: 22.8 mm) in males aged between 15 and 18 years.11 In the light of these findings, we concluded that the neck of the patient was flexed at the time of the gunshot injury and, depending on the distance and velocity and trajectory, the 9-mm-caliber bullet traveled between the posterior aspects of the C1–C2 vertebrae and lodged without injuring the bones or the spinal cord in the subdural region.
Surgical intervention is not always warranted in spinal gunshot wounds. However, surgery has proven beneficial if there is CSF fistula, infection, compression due to foreign body, instability or rapid neurological deterioration.12,13 Leaving the bullet in situ can rarely cause delayed infection, delayed neurological deterioration, and lead toxicity.14 Instability was not observed in our patient since the bone structure was intact but CSF fistula and hemiparesis due to compression entailed microneurosurgical removal of the bullet and duraplasty. Near-total neurological improvement was achieved in 3 months with the help of physical therapy in the post-operative period.
4. Conclusion
Surgical management of the gunshot wounds of the spine and spinal cord is not widely advocated and controversial. Advances in microneurosurgical instrumentation and microscopic techniques may open up a new era of surgical treatment of spinal cord gunshot wounds. We consider that treatment modality should be chosen individually in an effort to restore neurological function maximally.
Conflict of interest
None.
Funding
None.
Ethical approval
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
Author contributions
Seçer M. played a role in writing the manuscript, Yayla E. and Çınar K. did the study design, Ulutaş did both data collection and edition.
Footnotes
This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-No Derivative Works License, which permits non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.
Note: This case was presented as an electronic poster at the 2nd scientific conference of the Middle East Spine Meeting.
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