Minimally Invasive Management of Civilian Gunshot Wounds to the Lumbar Spine: A Case Series and Technical Report

Abstract

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.

Case Report: Full-Endoscopic Surgery for Bullet Wounds of the Spine: A Report of Three Cases

“…Gunshot wounds of the spine and spinal cord in peacetime and wartime make 10-21% of all spinal injuries (7-9). In 2014 in the United States, 16.8% (33,594 people) of deaths from injuries were associated with damaging effects of firearms (10). Males aged 15-34 years are more likely to be affected by this type of injury (various authors, 78-91%), 10-24.5% are lumbar spine injuries, of which penetrating injuries make about 14% (9,(11)(12)(13)(14).…”

“…The necessity of removal of a wounding body in uncomplicated non-penetrating gunshot wounds of the spine, especially in the late period, is still open for discussion. Experts differ on the toxic effects of lead when a wounding body remains for a long time (10,20); however, there is no doubt that a foreign body must be removed in cases of purulent-inflammatory complications (21).…”

“…There are some published reports on the microsurgical removal of a wounding body through a tube retractor through a posterior access along the optimal trajectory. This method proved to be very efficient in terms of regression of neurological dysfunctions and prevention of infectious complications in a spine gunshot wound (10,22).…”

Percutaneous transforaminal endoscopic removal of a foreign body of the lumbar spine

“…Учитывая, что в отечественной и зарубежной литературе нет сведений о выполнении подобного рода операций, успех вмешательства не был гарантирован. До настоящего времени опубликовано единственное клиническое наблюдение эндоскопического удаления ранящего снаряда из просвета позвоночного канала интерламинарным доступом [12], что не является полной аналогией настоящего вмешательства.…”

Resolution of cauda equina syndrome after surgical extraction of lumbar intrathecal bullet

“…[ 2 , 4 , 6 ] The literature suggests the following indications for surgery; CES attributed to persistent neural compression, CSF leak, mechanical instability, bullet migration resulting in new neurological deficits, and the concern for lead poisoning. [ 1 , 2 , 4 , 5 ] Having performed this study, we would add the following variables to the list; the type/severity of the neurological deficit, the duration between injury and presentation, involvement of the lumbosacral plexus, the injury type (e.g., weapon type [civilian vs. military]), bullet trajectory (e.g., transferred kinetic energy), and specific imaging findings.…”