BACKGROUND Treatment of penetrating gunshot wounds (GSW) to the spine remains controversial. The decision to operate is often based on surgeon preference and experience. We present a case series of 7 patients who underwent minimally invasive thoracolumbar/sacral decompression and bullet removal at a level 1 trauma center. OBJECTIVE To describe the use of minimally invasive techniques to achieve decompression and bullet removal for GSW to the spine. METHODS From 2010 to 2017, 7 patients with spinal GSW underwent minimally invasive decompression and bullet removal at an academic level 1 trauma center. RESULTS Patient ages ranged from 20 to 55 yr (mean: 31 yr). The mechanisms of injury were GSW to the abdomen/pelvis (n = 6) and direct GSW to the spine (n = 1). Based on the neurological examination, the injuries were characterized as complete (n = 1) or incomplete (n = 6). Decompression and bullet removal were performed using a tubular retractor system. All patients with incomplete injuries who had postdischarge follow-up demonstrated some neurologic recovery. There were no postoperative wound infections, cerebrospinal fluid (CSF) fistulas, or other complications related to the procedure. CONCLUSION Minimally invasive decompression and bullet removal is a safe technique that may help reduce the risk of postoperative infections and CSF fistulas in patients with GSW to the lumbar spine compared to the standard open technique. This approach appears to be particularly beneficial in patients with incomplete injuries and neuropathic pain refractory to medical treatment.
Historically, the surgical management of gunshot wounds to the spine has been controversial. Repair of a persistent cerebrospinal fluid (CSF) leak is a generally agreed upon indication. The management of such CSF leaks typically involves lumbar drainage or direct surgical repair. Here, the authors report two cases of CSF diversion with an external ventricular drain (EVD) in patients with cervical gunshot wounds. Both patients had spinal canal obliteration or physiologic myelographic block at or below the level of injury. To the best of the author’s knowledge, these are the first two reports of successful EVD treatment of persistent CSF leaks related cervical gunshot wounds. The authors also propose a CSF treatment algorithm for cervical gunshot wounds that includes EVD.
<b><i>Introduction:</i></b> Cavernous malformations in the pediatric population are exceedingly rare, especially in infants. Giant cavernous malformations (GCM) are even more rare and have a diameter >4 cm. The onset of symptoms predominantly occurs in adulthood, but the rate of hemorrhage is significantly higher in the pediatric population. Similar to non-GCM, GCM can be misidentified as tumors on imaging due to their tumefactive pattern with edema. Here, we present a rare case of a right frontotemporal GCM in a 2-month-old girl, the youngest recorded case in the existing literature. <b><i>Case Presentation:</i></b> A previously healthy 2-month-old girl presented to the emergency department following an increasing frequency of seizure-like activity that began 3 days prior to presentation. Magnetic resonance imaging of the brain with and without contrast characterized a large (5.8 × 4.3 × 4.2 cm) heterogeneous lesion of the right temporal lobe with diffuse scattered blood products of various ages seen throughout the lesion. She underwent a right-sided craniotomy where a gross total excision was achieved. Pathology confirmed the diagnoses of a GCM. The patient’s seizures subsequently resolved, and she continues to do well postoperatively. <b><i>Discussion/Conclusion:</i></b> GCM can be mistaken for tumors due to their large size, cystic nature, and surrounding edema, but a vascular lesion should always remain in the differential diagnosis before operating, even in infants. Surgery is generally recommended in patients that present with a symptomatic hemorrhage, recurrent hemorrhages, persistent seizures despite medical management, or progressively worsening neurological deficits if the GCM is in a safe location. It has been shown that 70–99% of patients undergoing surgery with successful removal of the GCM can achieve seizure freedom 2 years postoperatively. Complete surgical excision of this infant’s GCM was successful in treating her neurologic symptoms; therefore, pathological confirmation of this lesion is critical and should prompt a complete surgical excision.
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