Mobile Intradural Bullet: A Problem on so Many Levels

Introduction: We present the case of an 18-year-old man who presented to emergency room having been shot. He was managed as per the Advanced Trauma Life Support protocol and his primary survey was unremarkable. He had a contaminated entry wound in his left loin although there were no signs of an exit wound. No other injuries were identified.

Methods: Computed tomography revealed a bullet within the spinal canal at the level of the first sacral vertebra. There was no neurological deficit on clinical examination of the lower limbs.

He was admitted for observation and several hours later started complaining of scrotal numbness. All other neurology was spared.

He was managed surgically with the aim of debriding the entry wound and retrieving the bullet. Intraoperatively the level of the bullet was marked with the image intensifier. With the patient prone, a posterior midline incision was performed, followed by a laminectomy of S1. The dura was identified and protected, although no bullet was located. There was no evidence of injury to the dura at this level.

Results: Repeat fluoroscopy demonstrated that the bullet had migrated cranially, and was located level with the superior end plate of the L5 vertebral body. Laminectomy of L5 therefore had to be performed followed by a controlled durotomy, following which the bullet was finally retrieved from among the cauda equina.

Postoperatively the patient recovered well and was discharged 3 days later, independently mobile with no neurological deficit.

Conclusion: There have been very few reports in the literature of traumatic mobile intradural foreign bodies. Our case raises awareness of this scenario and highlights the need for careful operative planning, including the possibility that laminectomies at multiple levels may be required, as well as a durotomy for foreign body retrieval.