Chapter 3: Central Nervous System

Case 3-1: A migrating lumbar bullet

Patient Presentation

A 19-year-old man suffered multiple gunshot wounds involving his eye, mandible, thigh, and lower back.

Clinical Presentation

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.

Differential Dx

• Penetrating injuries to the airway, eye, brain, spinal cord, thorax, and abdomen

Emergency Care

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.

Outcome

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.

Key Learning Points

• 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.

Further Reading

Case 3-2: ...