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.

Keywords: Foreign body; Gunshot wound; Laminectomy; Recovery of function; Spinal cord injury.

Fig. 1

Computed tomography scan of the spine shows the fragment in an intra-canicular position at the T9-10 level in the axial (A), coronal (B) and sagittal (C) planes.

Fig. 2

Intraoperative microscope pictures showing the extended traumatic durotomy through the T9 laminectomy defect and the silver hue of the bullet lying on the dorsal column (A). (B) Shows the bullet being extracted gently.

Fig. 3

Postoperative magnetic resonance imaging of the T-spine, shows a large (extending longitudinally about 2 levels [from lower-T8 to upper T10]) intramedullary T2 signal (A, B) without associated T1 signal (C) change consistent with spinal cord contusion and no obvious persistent cerebrospinal fluid leak or on-going spinal cord compression.