Firearm bullet settling into the lumbar spinal canal without causing neurological deficit: A report of two cases

BACKGROUND

Uncertainty still exists regarding the treatment of the patients presenting with gunshot wounds to the spine. Neurological insults, cerebrospinal fluid fistula, infection, lead or copper toxicity, migration of bullets, and spinal instability are included among the common challenging issues.

CASE DESCRIPTION

An 18-year-old woman was admitted with low back pain following a gunshot injury five days ago. She was neurologically intact. Radiological examinations showed that a bullet was settled in L4-5 disc space. The bullet was removed with a unilateral L4-5 partial hemilaminectomy and discectomy from the left side. The second case was of a 29-year-old man admitted with radiating leg pain on the right side following a gunshot injury from his left side of lower back four months ago. He had only positive straight leg raising test. Radiological studies showed two bullets, one was in the psoas muscle on the left side and the other was in spinal canal that had caused a burst fracture of the L5 vertebra. Following L5 laminectomy and bilateral L5-S1 facetectomy, the bullet was removed from the spinal canal and L5-S1 transpedicular posterior stabilization was performed. The postoperative period of both patients was unremarkable.

CONCLUSION

Bullet settling into the lumbar spinal canal without causing neurological deficit may require surgical intervention. Removal of bullets provided not only pain relief in both the cases but also prevented future complications such as migration of the bullets, plumbism, and neuropathic pain and instability.

Asymptomatic pellet migration to the heart: report of a case and update on proper management

We report a case of a 42-year-old male patient who was transferred to our emergency department suffering from a gunshot wound in his left lateral thigh. The patient was haemodynamically stable, and the physical examination of the abdomen and thorax was unremarkable. There was no obvious exit point and there were no other injuries. The radiologic control of the left thigh showed an intact femur and multiple pellets within the adjacent soft tissues. Routine X-ray evaluation of the thorax revealed a small-sized round object of metal density—possibly a migrated pellet—in the proximity of the right heart atrium. Computed tomography imaging confirmed this finding and showed no other cardiac or mediastinal injury. Ultrasonography of the heart was unremarkable as well. The patient was managed conservatively for the discovered pellet, and remained asymptomatic throughout the entire hospital stay, and 6 months after the discharge. Pellet migration or embolism should be suspected in any gunshot victim without a corresponding exit wound or when the signs and symptoms do not correlate with the suspected course of the missile. Conservative management remains the first choice in asymptomatic patients, although close monitoring at first and regular observation after discharge are indicated.

Spontaneous migration of bullet from arm to forearm and its ultrasound guided removal

Spontaneous migration of a retained bullet is rare. We are presenting here a case of a 24-year-old male with spontaneous migration of bullet from arm to forearm. At the time of initial injury, bullet was left inside the arm as it was deep and patient had no complaints. Three months after injury, he started complaining of pain over forearm and tingling sensations in the forearm and hand over median nerve distribution. Radiographs showed bullet in the proximal forearm. The bullet was than precisely localized and removed under ultrasound guidance. This case report emphasizes the fact that spontaneous migration of bullet in extremities may occur and have the potential to cause neurovascular damage. Removal under ultrasound guidance is a viable option in such locations.

Lead poisoning by intradiscal firearm bullet: a case report

STUDY DESIGN

The report of a rare case of lead poisoning by an intradiscal firearm bullet is presented.

OBJECTIVE

To describe and discuss the clinical and radiologic features (by computed tomography and magnetic resonance imaging) of a gunshot wound in the L2-L3 space which caused lead poisoning 5 years afterwards.

SUMMARY OF BACKGROUND DATA

Lead poisoning from firearm bullets is rare, but the possibility should be investigated in the case of bullets lodged in the joints.

METHODS

A 30-year-old man presented to the emergency room with an intense lumbar pain complaint, colic, intestinal constipation, insomnia, and progressive headache for 20 days. He had a history of a gunshot wound 5 years previously, and the bullet was left in situ, in the intravertebral disc between L2 and L3, as confirmed by radiographs, computed tomography, and magnetic resonance imaging. The hypothesis of lead poisoning was confirmed by the laboratory results. Chelation treatment with calcium versenate (disodium ethylenediaminetetraacetate, or CaNa (2) EDTA) was indicated. The patient was admitted and treated once again, before surgical removal of the bullet.

RESULTS

After removal of the bullet, the patient had an episode of recurrence, and a new chelation cycle was performed, with complete resolution.

CONCLUSION

Lead poisoning can result in severe clinical disorders that require rapid treatment. In this case, both clinical and surgical treatments led to complete resolution of the symptoms.