Case 3-1: A migrating lumbar bullet
A 19-year-old man suffered multiple gunshot wounds involving his eye, mandible, thigh, and lower back.
Lumbar x-ray. WA = bullet lodged in the L2-L3 disc space, WDA = spinal canal
Lumbar x-ray. WA = bullet migrated into the spinal canal, WDA = spinal canal
The patient was awake, oriented, and in moderate painful distress. His left eye had an obvious penetrating injury, and his left lower mandible was swollen with intraoral bleeding. The thigh wound appeared to be a through-and-through injury. He had a single wound to his lower back, with decreased strength in his left lower extremity.
Penetrating injuries to the airway, eye, brain, spinal cord, thorax, and abdomen
Given the patient’s presentation with two wounds to the head and neck with intraoral bleeding, rapid sequence intubation was performed with etomidate and succinylcholine. Multiple computed tomography (CT) scans demonstrated a subdural and intraparenchymal brain hemorrhage and a penetrating mandibular bone injury. A lateral lumbar spine radiograph demonstrated a bullet lodged in the L2-L3 intervertebral disk space.
The patient had a complicated hospital course, initially undergoing decompression of his subdural hematoma. At the time of discharge, he was awake and alert. He lost his eye and was discharged with incomplete left lower extremity motor deficits. He returned 1 month later with increasing back and radicular pain. Repeat lumbar imaging demonstrated that the bullet originally in the L2-L3 disc interspace had migrated posteriorly into the central spinal canal. He underwent bullet removal using fluoroscopy.
Bullets can migrate immediately at the time of the initial penetrating injury, such as embolizing from the femoral vein into the pulmonary artery.
Bullets can migrate subsequent to the initial event, as in the case presented.
Bullets can migrate into more unfavorable positions, including central nervous system, joints, and cardiovascular and pulmonary structures, necessitating delayed removal.
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