Luis M Tumialán1, Raymond R Walkup, Sanjay K Gupta. 1. Emory University School of Medicine, Grady Memorial Hospital, Department of Neurosurgery, Atlanta, GA, USA. ltumial@emory.edu
Abstract
BACKGROUND CONTEXT: In victims of gunshot wounds with retained bullet fragments in the central nervous system, delayed neurological deficit may result from copper-induced neurotoxicity. The mainstay of therapy involves surgical exploration and retrieval of fragments. PURPOSE: A patient who presented with delayed neurological deficit after a transperitoneal gunshot wound is presented. STUDY DESIGN: Technical report. METHODS: A 25-year-old male, who was the victim of a transperitoneal gunshot wound with a copper-jacketed bullet, presented several weeks after recovering from his abdominal injury. The patient presented with a worsening radiculopathy in the L5 distribution and progressive dorsiflexion weakness. Subsequent imaging demonstrated a bullet lodged lateral to the L5-S1 neural foramina. RESULTS: A minimally invasive approach with the use of a tubular retractor was used to retrieve the retained bullet. The lateral location of the bullet, the proximity of the nerve root to the bullet, and the limited visualization of the operative field from a minimally invasive approach, placed the nerve root at increased risk. Intraoperative myelography and electrophysiological monitoring were used to locate the nerve root in relation to the bullet and guide the extraction of the bullet. Postoperatively, the patient had complete resolution of his preoperative symptoms. CONCLUSIONS: In cases where proximity to neural structures and limited visualization of bony landmarks may increase the risk of injury when extracting a foreign body, intraoperative myelography and electrophysiological monitoring are valuable adjuncts to further elucidate the surgical anatomy for a minimally invasive approach.
BACKGROUND CONTEXT: In victims of gunshot wounds with retained bullet fragments in the central nervous system, delayed neurological deficit may result from copper-induced neurotoxicity. The mainstay of therapy involves surgical exploration and retrieval of fragments. PURPOSE: A patient who presented with delayed neurological deficit after a transperitoneal gunshot wound is presented. STUDY DESIGN: Technical report. METHODS: A 25-year-old male, who was the victim of a transperitoneal gunshot wound with a copper-jacketed bullet, presented several weeks after recovering from his abdominal injury. The patient presented with a worsening radiculopathy in the L5 distribution and progressive dorsiflexion weakness. Subsequent imaging demonstrated a bullet lodged lateral to the L5-S1 neural foramina. RESULTS: A minimally invasive approach with the use of a tubular retractor was used to retrieve the retained bullet. The lateral location of the bullet, the proximity of the nerve root to the bullet, and the limited visualization of the operative field from a minimally invasive approach, placed the nerve root at increased risk. Intraoperative myelography and electrophysiological monitoring were used to locate the nerve root in relation to the bullet and guide the extraction of the bullet. Postoperatively, the patient had complete resolution of his preoperative symptoms. CONCLUSIONS: In cases where proximity to neural structures and limited visualization of bony landmarks may increase the risk of injury when extracting a foreign body, intraoperative myelography and electrophysiological monitoring are valuable adjuncts to further elucidate the surgical anatomy for a minimally invasive approach.