Bullet fragment [Neurosurgery Wiki]

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====== Bullet fragment ======

There are few reported instances of [[intraspinal]] [[migration]] of a [[bullet]] fragment. The majority of these migrations occur caudally, typically below the level of T10. Even fewer cases demonstrate cephalad migration from the [[sacral spine]] to the [[lumbar spine]]. 

Todnem et al., from the Department of Neurosurgery, Medical College of [[Georgia]] at [[Augusta]] University, reported for the first time a case of a cephalad migration [[intradural]]ly from the [[thoracic spine]] to [[cervical spine]].

A 31-year old [[man]] presented to the [[Emergency Department]] (ED) with a suspected [[spinal cord injury]] following a [[gunshot wound]] (GSW) sustained to the left [[shoulder]]. A penetrating [[gunshot]] [[injury]] to the [[thoracic spine]] at the level of T2 was observed, and [[CT angiography]] revealed a cephalad migration of the bullet fragment to the level of C6. The patient had marked [[weakness]] of the bilateral upper extremities, with [[paraplegia]] of the lower extremities. There was a [[sensory deficit]] beginning at a level 1 cm below the [[clavicle]], as well as a decrease in rectal tone. 

They performed a [[laminectomy]] at C6 with dural incision and removal of the main bullet fragment. Following the surgery, significant improvement in strength and sensation in the bilateral upper extremities was noted, but paraplegia and [[sensory loss]] below the level of T2 persisted.

In this report, they review the previously reported cases in which intraspinal migration of bullets have occurred, and discuss the unique finding in this study of cephald migration of a bullet within the dura. Additionally, they detail considerations in the management of such injuries
((Todnem N, Hardigan T, Banerjee C, Alleyne CH Jr. Cephalad migration of an
intradural bullet from the thoracic spine to the cervical spine: A case report.
World Neurosurg. 2018 Jul 20. pii: S1878-8750(18)31414-1. doi:
10.1016/j.wneu.2018.06.198. [Epub ahead of print] PubMed PMID: 30036715.
)).
----
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 May;62(5):1290-1. PubMed PMID: 17495741.