Operative Management of a Sacral Gunshot Injury via Minimally Invasive Techniques and Instrumentation

Abstract

Gunshot wounds to the spine account for 13% to 17% of all gunshot injuries and occur predominantly in the thoracic region. Minimally invasive spine surgery procedures implementing serial muscle dilation and the use of a tubular retracting system with a working channel minimize soft tissue trauma, facilitate less bony and soft tissue resection, decrease blood loss, minimize scarring and improve cosmesis, decrease hospitalization, and reduce postoperative pain and narcotic usage in comparison to more open, traditional approaches. Although minimally invasive spine surgery techniques and instrumentation have gained considerable attention, their application in the management of gunshot injuries to the sacrum has not been reported. The following is a brief case report of a 21-year-old male who sustained a gunshot injury to the sacrum who was managed operatively via minimally invasive spine surgery techniques and instrumentation.

Keywords: Gunshot wound; Minimally invasive; Sacral; Spine; Surgery; Trauma.

Fig. 1

Preoperative imaging. (A) Anteroposterior and (B) lateral plain radiographs illustrating the lumbosacral and sacral location of the bullet fragments secondary to a gunshot injury. (C) Axial and (D) sagittal computed tomography imaging noting the anterior right-sided location of the bullet fragment at the level of S2 (arrow).

Fig. 2

Intraoperative minimally invasive approach. (A) Demonstration of the right-sided sacral location of the gunshot wound. (B, C) Application of serial muscle dilators at the site of the sacral gunshot wound. (D) Intraoperative lateral fluoroscopic image of application of muscle dilators to the sacrum. (E, F) Application of the tubular retractor and secured working channel (note the visualization of the projectile in Fig. 2F).

Fig. 3

(A) Intraoperative removal of bullet fragment with a shodded pituitary rongeur through the working channel. (B) Intraoperative illustration of the size of the removed bullet fragment.

Fig. 4

One-month postoperative (A) axial and (B) sagittal computed tomography images illustrating the sacral defect following the surgical removal of bone and bullet fragments.