Cervical spinal cord bullet fragment removal using a minimally invasive surgical approach: a case report

Abstract

Introduction: We present a case of penetrating gunshot injury to the high-cervical spinal cord and describe a minimally invasive approach used for removal of the bullet fragment. We present this report to demonstrate technical feasibility of a minimally invasive approach to projectile removal.

Case presentation: An 18-year-old African-American man presented to our hospital with a penetrating gunshot injury to the high-cervical spine. The bullet lodged in the spinal cord at the C1 level and rendered our patient quadriplegic and dependent on a ventilator. For personal and forensic reasons, our patient and his family requested removal of the bullet fragment almost one year following the injury. Given the significant comorbidity associated with quadriplegia and ventilator dependency, a minimally invasive approach was used to limit the peri-operative complication risk and expedite recovery. Using a minimally invasive expandable retractor system and the aid of a microscope, the posterior arch of C1 was removed, the dura was opened, and the bullet fragment was successfully removed from the spinal cord.

Conclusions: Here we describe a minimally invasive procedure demonstrating the technical feasibility of removing an intramedullary foreign object from the high-cervical spine. We do not suggest that the availability of minimally invasive procedures should lower the threshold or expand the indications for the removal of bullet fragments in the spinal canal. Rather, our objective is to expand the indications for minimally invasive procedures in an effort to reduce the morbidity and mortality associated with spinal procedures. In addition, this report may help to highlight the feasibility of this approach.

Figure 1

Radiographic imaging of a retained bullet fragment in the high-cervical spine. Sagittal (A) and axial (B) computed tomography (CT) images show the relationship of the fragment (designated by *) to the arch of C1 and the dens of C2. Note the fracture of the right posterior arch of C1 (arrow).

Figure 2

(A) Photograph of the extracted bullet fragment and (B) photograph of our patient’s neck in the prone position, demonstrating the post-operative skin incision and the site of bullet penetration.