Case Report

Ann Rehabil Med 2013;37(1):118-122

pISSN: 2234-0645 • eISSN: 2234-0653
http://dx.doi.org/10.5535/arm.2013.37.1.118 Annals of Rehabilitation Medicine

A Case Report of Spinal Cord Injury Patient

From a High Velocity Gunshot Wound
to the Lumbar Spine
Juyong Kim, MD, Je Ho Kim, MD, Moon Suk Bang, MD

Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, Korea

We report on operational and rehabilitation management, as well as the outcome, of a patient who with sustained
spinal cord injury from a high velocity gunshot wound to the lumbar spine. More specifically, a patient with a
gunshot wound to the spine is more likely to sustain a complete injury and have a poor prognosis. As such, there
should be concerns regarding associated and extended injuries related to bullet fragmentation as well as the
possibility of long-term sequelae.

Keywords Gunshot wound, Spinal cord injury, Forensic ballistics

INTRODUCTION the two groups, nonmilitary gunshot wounds tend to

result from low velocity weapons. However, injuries from
Gunshot wound is one of the leading causes of spinal high velocity weapons among the civilian population
cord injuries in the world, accounting for 13% to 43% of have recently been on the rise. Overall, cases of gunshot
such injuries [1]. In addition, spinal cord injuries follow- wounds to the spine are relatively rare in Korea, except
ing gunshot wounds show a higher incidence of complete for the veterans of the Korean War and the Vietnam War.
injury with worse outcomes than that resulting from In Korea, there was only one case report on a patient with
blunt trauma [2]. spinal cord injury due to a low velocity gunshot wound
Generally, gunshot wounds are divided into two cat- to the thoracic spine [3]. Here, we describe the first case
egories—those resulting from high velocity weapons typi- of a Korean man with spinal cord injury caused by a high
cally used for military purposes; and wounds from low- velocity gunshot wound.
velocity weapons such as pistols and handguns. Between
CASE REPORT
Received November 10, 2010; Accepted April 25, 2012
Corresponding author: Moon Suk Bang
Department of Rehabilitation Medicine, Seoul National University
A 40-year-old man became paraplegic after a gunshot
College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea wound to the lumbar spine. The injury occurred when
Tel: +82-2-2072-2925, Fax: +82-2-743-7473, E-mail: [email protected]
he came under fire during a shooting rampage while he
This is an open-access article distributed under the terms of the Creative was abroad. The perpetrator had fired an AR-15 rifle Ar-
Commons Attribution Non-Commercial License (http://creativecommons.
org/licenses/by-nc/3.0) which permits unrestricted noncommercial use, maLite Model 15 (Colt Inc., Hartford, CT, USA), and the
distribution, and reproduction in any medium, provided the original work is
properly cited. bullet went through the victim’s back. After the incident,
Copyright © 2013 by Korean Academy of Rehabilitation Medicine his bilateral lower limbs showed no muscle contraction
 Spinal Cord Injury From a Gunshot Wound to the Spine

with sensory loss. The patient underwent explorative the largest fragments was lodged in the T12-L1 disc. An-
laparotomy and was diagnosed with injuries to the spinal other large fragment was located between the right verte-
cord and aorta. He was transferred to our hospital on the bral body and aorta at the level of the renal arteries (Fig.
second post-traumatic day. A computed tomography (CT) 2). Apart from bowel contusion, there was no evidence of
scan revealed a burst fracture of the first lumbar vertebra, intra-abdominal trauma such as active bleeding or bowel
resulting from penetration by a bullet from the gunshot perforation on the patient’s CT images.
through the right paraspinal muscles and L1-2 interver-
tebral disc (Fig. 1). The bullet was fragmented, and one of

Fig. 3. Photograph of a bullet fragment in the T12-L1 disc

space.

Fig. 1. Preoperative 3-dimentional reconstructed com-

puted tomography shows a burst fracture of the first lum-
bar vertebra.

Fig. 2. Preoperative simple X-ray of the spine shows 2 Fig. 4. Postoperative 3-dimentional computed tomogra-
large bullet fragments: 1) T12-L1 disc level, a 0.8-cm phy of the spine shows posterior fixation of T11-L3 and
sized bullet fragment and 2) prevertebral space of L1, a remnant bullet fragments in the spinal canal of the L1
1.0-cm sized bullet fragment. level (A, lateral view; B, anteroposterior view).

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Juyong Kim, et al.

The patient underwent L1 decompressive laminectomy, The patient complained of severe neuropathic pain
partial corpectomy, removal of the bullet and T11-L3 in the bilateral lower extremities (visual analogue scale
posterior fixation. The dura in the level of the first lumbar [VAS], 7 to 8). Neuropathic pain was characterized by
vertebra was severely damaged, and most parts of the tingling and squeezing, which were aggravated at night.
cauda equina were severed from the conus medullaris. Although transcutaneous electrical nerve stimulation
A 0.8-cm bullet fragment at the T12-L1 disc level was re- (TENS) and many kinds of analgesics including gabapen-
moved (Fig. 3). Subsequently, a rupture of the abdominal tin (900 mg/day), pregabalin (450 mg/day), amitriptyline
aorta was treated by a vascular surgeon. A 1.0-cm bullet (25 mg/day), clonazepam (1 mg/day), oxycodone (20 mg/
fragment just anterior to the first lumbar vertebral body day), and fentanyl patch (50 μg/hr) were tried simultane-
was also removed. However, massive bleeding occurred ously and alternatively, he continued to suffer from pain
following removal, so aorta graft interposition with that waxed and waned in the range of 4 to 8 on the VAS.
polytetrafluoroethylene was performed after resection On the 55th post-traumatic day, he performed parallel-
of the aorta between the renal artery and the superior bar (p-bar) gait with both knee-ankle-foot orthosis
mesenteric artery. A possibility of a second insult to the (KAFO), in parallel with the Walking Index for Spinal
spinal cord due to infarction caused by massive bleed- Cord Injury (WISCI) level 1. On the 90th post-traumatic
ing was considered, although it could not be confirmed. day, he managed axillary crutch gait with both KAFO in
A postoperative spinal CT scan revealed multiple bone the p-bar. Seven months after the trauma, however, there
remnants and bullet fragments in the L1-2 intervertebral was no recovery in the neurological level of his injury ac-
disc and spinal canal space (Fig. 4). cording to neurologic examinations including the manual
The patient subsequently began range of motion exer- muscle test and sensory exam compared with the initial
cise at bedside on the 13th post-traumatic day and tilting evaluation. Moreover, the patient’s endurance and sta-
table exercise in the gym on the 18th day. bility of gait function remained poor to the point that he
On the 39th post-traumatic day, the patient was trans- could only manage the p-bar gait for 2 cycles and crutch
ferred to the Department of Rehabilitation. His neuro- gait for one quarter of a cycle in the p-bar (WISCI level
logical level of injury was determined as T12 according 3). He showed no significant improvement in the activi-
to the American Spinal Injury Association Impairment ties of daily living, measured by the Korean Spinal Cord
Scale (AIS)-A. Sensory examination revealed sensory loss Independence Measure (KSCIM) score over the course
in L2 and below. The manual muscle test showed grade 0 from the 39th to the 81st post-traumatic day (from 32 to
in all the muscles of the bilateral lower limbs. Deep ten- 35 points). Improvement was shown in bathing, dressing
don reflexes of the bilateral knees and ankle joints were and motion in bed.
decreased and muscle tones of bilateral lower extremities
were flaccid. The bulbocavernosus reflex was absent. His DISCUSSION
bladder and bowel sense decreased, and urodynamic ex-
amination revealed detrusor areflexia with coordinated In the present report, we described a patient with inju-
sphincter. ries to the spinal cord and aortic wall from a high velocity
On the 53th post-traumatic day, the patient underwent gunshot wound. Such injuries usually occur in soldiers
an electromyographic study. No responses were observed and involve wounds from gunshots fired at speeds greater
in motor nerve conduction study, H reflex, F wave, so- than 2,000—3,000 feet per second, whereas low velocity
matosensory evoked potential and bulbocavernosus re- injuries result from gunshots at 1,000—2,000 feet per sec-
flex. The sensory nerve conduction study showed a nor- ond. The characteristics of high velocity gunshot injury
mal value. Needle electromyography of all the muscles of are comminuted fractures, devitalized soft tissue, and
the bilateral lower extremities showed severe to profound periosteal stripping. The extent of bullet fragmentation
abnormal spontaneous activities with no motor unit ac- also increases concomitantly with velocity, resulting in
tion potential. The results were compatible with polyra- more severe destruction due to the wider range of dam-
diculopathy or the anterior horn cell lesion below L1, and age to tissue compared to low velocity gunshot wounds
there was no evidence of reinnervation. [4]. Consequently, high velocity gunshots correlate with

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 Spinal Cord Injury From a Gunshot Wound to the Spine

higher mortality and morbidity than low velocity gun- typical for a patient suffering from a complete spinal cord
shots [5]. injury.
The AR-15 rifle is a high velocity weapon; its bullet can Magnetic resonance imaging (MRI) is generally regard-
reach speeds of up to 3,200 feet per second. Accordingly, ed as the best method for assessing ordinary spinal cord
our patient suffered from a burst fracture of the first injuries. However, the strong magnet used in the proce-
lumbar vertebra due to the high power exuded by the dure can cause bullet migration and lead to additional
weapon, which resulted in complete paraplegia and se- neurologic damage. Finitsis et al. [10] have retrospective-
vere neuropathic pain as well as an aortic injury resulting ly reported that the use of MRI on patients with retained
from an impacted bullet fragment in the posterior wall of metallic ballistic fragments in the spinal region can yield
the abdominal aorta. Furthermore, multiple remnants of more information than other imaging techniques. The
bullet fragments lodged in the T12-L1 disc and L1 prever- study further asserted that no untoward effects were seen
tebral areas could not be removed. [10]. Nevertheless, the safety of MRI technology has yet to
There have been articles describing whether surgery be proven by any prospective controlled scientific study
can produce neurologic benefits. For example, Stauffer et [1]. In the present case, we decided not to perform MRI
al. [6] demonstrated that no neurological difference was on the patient since a bullet fragment lodged in his spinal
observed in either surgery or nonoperative management canal could easily migrate to other regions.
for complete or incomplete spinal cord injuries. Both In conclusion, spinal cord injury patients caused by
groups had similar rates of causalgia [6]. To deal with le- high velocity gunshot wounds have relatively poor prog-
sions associated with intracanal bullets, Waters and Ad- nosis due to worse neurological improvement. There-
kins [7] reported a statistically significant improvement fore, careful evaluations of gunshot wound patients are
in motor function after surgical removal and decompres- required by physiatrists, especially in terms of gunshot
sion from the T12 to L4 levels, in comparison with non- velocity, lesion of injury and presence of remnant bullets
operative management. Although fractures resulting from or other accompanying injuries for proper goal setting for
gunshot wounds are usually not unstable and rarely re- rehabilitation and management.
quire stabilization [1], our patient had a burst fracture of
the first lumbar vertebra due to high energy from the bul- CONFLICT OF INTEREST
let, requiring operation. Furthermore, some case reports
have supported that bullet migration can cause neural No potential conflict of interest relevant to this article
deficits lasting from several months to years after a gun- was reported.
shot injury [1]. In the present case, multiple remnants of
bullet fragments in the spinal canal may potentially lead REFERENCES
to a continuous, diffuse inflammatory reaction, hinder-
ing neurologic recovery [1]. Therefore, even with proper 1. Bono CM, Heary RF. Gunshot wounds to the spine.
operative management, there still exists a possibility of Spine J 2004;4:230-40.
long term negative effects associated with residual frag- 2. Kaufman HH, Pait TG. Gunshot wounds to the spine.
ments of the bullet. Contemp Neurosurg 1993;15:1-6.
In the past, the gunshot etiology of spinal cord inju- 3. Lim SJ, Kim YT, Ha HG. An operative case of air-gun-
ries was unrelated to the measurements of pain and the shot wound to the thoracic spine. J Korean Neurosurg
Functional Independence Measure (FIM) scores [8,9]. Soc 1997;26:584-8.
However, complete lesions are more common in spinal 4. Bartlett CS. Clinical update: gunshot wound ballistics.
cord injuries caused by gunshots than other etiologies Clin Orthop Relat Res 2003;(408):28-57.
[2]. The patient had a complete injury in the levels of the 5. Ordog GJ, Wasserberger J, Prakash A, Balasubrama-
conus medullaris and cauda equina along with sustained niam S. Civilian gunshot wounds: determinants of
extensive wounds, all of which caused him to suffer se- injury. J Trauma 1987;27:943-7.
vere neuropathic pain. The neurologic outcome of this 6. Stauffer ES, Wood RW, Kelly EG. Gunshot wounds of
case, which involved a complete lesion, was poor, as is the spine: the effects of laminectomy. J Bone Joint

www.e-arm.org 121
Juyong Kim, et al.

Surg Am 1979;61:389-92. 9. Waters RL, Adkins RH, Sie I, Cressy J. Postrehabili-

7. Waters RL, Adkins RH. The effects of removal of bullet tation outcomes after spinal cord injury caused by
fragments retained in the spinal canal: a collaborative firearms and motor vehicle crash among ethnically
study by the National Spinal Cord Injury Model Sys- diverse groups. Arch Phys Med Rehabil 1998;79:1237-
tems. Spine (Phila Pa 1976) 1991;16:934-9. 43.
8. Putzke JD, Richards JS, Devivo MJ. Gunshot ver- 10. Finitsis SN, Falcone S, Green BA. MR of the spine in
sus nongunshot spinal cord injury: acute care and the presence of metallic bullet fragments: is the bene-
rehabilitation outcomes. Am J Phys Med Rehabil fit worth the risk? AJNR Am J Neuroradiol 1999;20:354-
2001;80:366-70. 6.

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