Cervical spinal cord bullet fragment removal using a minimally invasive surgical approach: a case report

Journal of Medical Case Reports

Richard G Fessler¹  Justin S Smith²  Koichi Sugimoto¹  Zachary A Smith¹  Cort D Lawton¹ 

[1]Department of Neurological Surgery, Northwestern University, 676 N. St. Clair Street, Suite 2210, Chicago, IL 60661, USA

[2]Neurological Surgery, UVA Spine Center, 415 Ray C. Hunt Dr., Charlottesville, VA 22903, USA

关键词: Spinal cord;    Minimally invasive spine surgery;    Intramedullary;    Gunshot wound;    Bullet;   

Others  :  1195570
DOI  :  10.1186/1752-1947-6-235

 received in 2012-01-19, accepted in 2012-05-09,  发布年份 2012

【 摘 要 】

Introduction

We present a case of penetrating gunshot injury to the high-cervical spinal cord and describe a minimally invasive approach used for removal of the bullet fragment. We present this report to demonstrate technical feasibility of a minimally invasive approach to projectile removal.

Case presentation

An 18-year-old African-American man presented to our hospital with a penetrating gunshot injury to the high-cervical spine. The bullet lodged in the spinal cord at the C1 level and rendered our patient quadriplegic and dependent on a ventilator. For personal and forensic reasons, our patient and his family requested removal of the bullet fragment almost one year following the injury. Given the significant comorbidity associated with quadriplegia and ventilator dependency, a minimally invasive approach was used to limit the peri-operative complication risk and expedite recovery. Using a minimally invasive expandable retractor system and the aid of a microscope, the posterior arch of C1 was removed, the dura was opened, and the bullet fragment was successfully removed from the spinal cord.

Conclusions

Here we describe a minimally invasive procedure demonstrating the technical feasibility of removing an intramedullary foreign object from the high-cervical spine. We do not suggest that the availability of minimally invasive procedures should lower the threshold or expand the indications for the removal of bullet fragments in the spinal canal. Rather, our objective is to expand the indications for minimally invasive procedures in an effort to reduce the morbidity and mortality associated with spinal procedures. In addition, this report may help to highlight the feasibility of this approach.

【 授权许可】

   
2012 Lawton et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

【 参考文献 】

• [1]Bono CM, Heary RF: Gunshot wounds to the spine. Spine J 2004, 4:230-240.
• [2]Tindel NL, Marcillo AE, Tay BK, Bunge RP, Eismont FJ: The effect of surgically implanted bullet fragments on the spinal cord in a rabbit model. J Bone Joint Surg Am 2001, 83:A:884-A:890.
• [3]Kahraman S, Gonul E, Kayali H, Sirin S, Duz B, Beduk A, Timurkaynak E: Retrospective analysis of spinal missile injuries. Neurosurg Rev 2004, 27:42-45.
• [4]Waters RL, Sie IH: Spinal cord injuries from gunshot wounds to the spine. Clin Orthop Relat Res 2003, 408:120-125.
• [5]Waters RL, Adkins RH: The effects of removal of bullet fragments retained in the spinal canal. A collaborative study by the National Spinal Cord Injury Model Systems. Spine 1991, 16:934-939.
• [6]Fessler RG, Khoo LT: Minimally invasive cervical microendoscopic foraminotomy: an initial clinical experience. Neurosurgery 2002, 51:S37-S45.
• [7]Gala VC, Voyadzis JM, Burkes A, Fessler RG: Outcomes following minimally invasive resection of intradural-extramedullary spinal tumors. [http://2007.cns.org/AbstractPop2.aspx?ID=1318 webcite]
• [8]Isaacs RE, Podichetty VK, Sandhu FA, Santiago P, Spears JD, Aaronson O, Kelly K, Hrubes M, Fessler RG: Thoracic microendoscopic discectomy: a human cadaver study. Spine 2005, 30:1226-1231.
• [9]Isaacs RE, Podichetty VK, Santiago P, Sandhu FA, Spears J, Kelly K, Rice L, Fessler RG: Minimally invasive microendoscopy-assisted transforaminal lumbar interbody fusion with instrumentation. J Neurosurg Spine 2005, 3:98-105.
• [10]Khoo LT, Fessler RG: Microendoscopic decompressive laminotomy for the treatment of lumbar stenosis. Neurosurgery 2002, 51:S146-S154.
• [11]Le H, Sandhu FA, Fessler RG: Clinical outcomes after minimal-access surgery for recurrent lumbar disc herniation. Neurosurg Focus 2003, 15:E12.
• [12]Ogden AT, Fessler RG: Minimally invasive resection of intramedullary ependymoma: a case report and literature review. Neurosurgery 2009, 65:E1203-E1204.
• [13]Tredway TL, Santiago P, Hrubes MR, Song JK, Christie SD, Fessler RG: Minimally invasive resection of intradural-extramedullary spinal neoplasms. Neurosurgery 2006, 58:ONS52-ONS58.
• [14]Simpson RK, Venger BH, Narayan RK: Treatment of acute penetrating injuries of the spine: a retrospective analysis. J Trauma 1989, 29:42-46.
• [15]Perez-Cruet MJ, Foley KT, Isaacs RE, Rice-Wyllie L, Wellington R, Smith MM, Fessler RG: Microendoscopic lumbar discectomy: technical note. Neurosurgery 2002, 51:S129-S136.
• [16]Rosen DS, O’Toole JE, Eichholz KM, Hrubes M, Huo D, Sandhu FA, Fessler RG: Minimally invasive lumbar spinal decompression in the elderly: outcomes of 50 patients aged 75years and older. Neurosurgery 2007, 60:503-509.
• [17]Hsieh PC, Koski TR, Sciubba DM, Moller DJ, O’Shaughnessy BA, Li KW, Gokaslan ZL, Ondra SL, Fessler RG, Liu JC: Maximizing the potential of minimally invasive spine surgery in complex spinal disorders. Neurosurg Focus 2008, 25:E19.
• [18]Ogden AT, Eichholz K, O’Toole J, Smith JS, Gala V, Voyadzis JM, Sugimoto K, Song J, Fessler RG: Cadaveric evaluation of minimally invasive posterolateral thoracic corpectomy: a comparison of 3 approaches. J Spinal Disord Tech 2009, 22:524-529.
• [19]Smith JS, Ogden AT, Fessler RG: Minimally invasive posterior thoracic fusion. Neurosurg Focus 2008, 25:E9.
• [20]Vasudevan RR, Galvan G, Pait GT, Villavicencio AT, Bulsara KR: Muscle splitting approach with METRx™ system for removal of intrathecal bullet fragment: a case report. J Trauma 2007, 62:1290-1291.
• [21]Tumialan LM, Walkup RR, Gupta SK: Minimally invasive retrieval of a bullet from the L5-S1 neural foramina after transperitoneal gunshot wound. Spine J 2009, 9:169-173.