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    Gunshot wound, bullet, remove or not.

    I just received an email describing the following case and asking what should be done.
    A person's 19-year old nephew has been shot at T2 with the bullet lodged in the spine "without any vertebral damage. He may have an anatomic transcetion (sic) at this level. The bullet entered at his right shoulder (a high velocity bullet) and entered transversely at the T2 level. These are my questions and concerns:"

    1. "Initially [the nephew's] condition was table and he was moved from ICU to the floor. They suspected colon on intenstinal (sic) damage from another bullet but he was cleared from this after 48 hours. However, this was indeed the case, and he went into renal failure and emergency surgery was performed... An iliostomy was performed and he is now relatively stable in ICU."

    2. "His neurosurgeon... does not want to remove the bullet. I consulted [another doctor] and he thinks that we should remove the bullet. The surgeon... thinks that the cord may not be stable after excision..."

    3. "I want to know if [the nephew] would be a candidate for any of the clinical trials you have mentioned. He would probably be excluded from the proneuron because of the gunshot wound. But what if they removed the bullet and tried the macrophage injection?"

    4. "What about Estim that also must be done in 2 weeks? Would he be a candidate? Any suggestion here?"

    5. "Finally, is there any place that you could recommend where both procedures could be done? (Bullet removal and experimental treatment.) We would be willing to go anywhere."
    The decision to remove a bullet is of course a clinical one and must be based on a careful risk-benefit analysis. There are risks to surgery and one should consider the stability of spinal cord, as well as the timing of surgery. However, there are ways to stabilize the spinal column after surgery and early operation to remove bullets are easier. After 1-2 weeks, scar tissue forms and it may be more difficult to remove the bullet.

    As you know, the presence of a bullet may impede tissue repair and recovery, and may lead to future complications such as development of neuropathic pain, migration of the bullet to cause further damage, and inflammation. I assume that because your nephew's injury involves gunshot wounds, that he did not receive methylprednisolone (high-dose steroid) shortly after his injury. However, it may be a reasonable consideration to use methylprednisolone at the time of surgery, to minimize damage to the spinal cord during the removal of the bullet.

    If his current surgeon is not willing to do the operation, you should seek another expert opinion on this matter. Doctors who have experience in the treatment of gunshot wounds of the spinal cord believe that removal of the bullet may be helpful. I would suggest that you contact Dr. Bob Waters at Ranchos Los Amigos in Downey California to see if you can get his opinion.

    Many centers routinely remove bullets in the spinal canal and I don't think that the complication rates from such surgery are higher than from other types of surgery, particularly if the spinal cord injury is severe. MRI scans are often misleading when trying to determine whether spinal cord "transection" has occurred and this diagnosis should be made after clear visualization of the spinal cord.

    Regarding experimental therapies, I would suggest that none of the current clinical trials are offering therapies that would be suitable for your nephew at this time. There are a number of clinical trials for more chronic spinal cord injury and there will be plenty of time for your nephew to participate in these later. Your first consideration should be to get him stabilized and rehabilitated as soon as possible. With regard to his rehabilitation and e-stimulation and other approaches, many studies have suggested that there is no difference in rehabilitation and recovery of patients from gunshot wounds compared to other trauma to the spinal cord.

    I am posting this to CareCure Community site (http://sciwire.com, with names and locations didacted) to encourage other people who may have had similar experiences, to post their experience and recommendations. Below are some medical literature references, including an abstract containing Dr. Water's email address.

    Wise.

    • Waters RL and Sie IH (2003). Spinal cord injuries from gunshot wounds to the spine. Clin Orthop. 120-5. Rancho Los Amigos National Rehabilitation Center, Downey, CA 90242, USA. rwaters@dhs.co.la.ca.us. Although vehicular trauma traditionally has accounted for the majority of spinal cord injuries, gunshot wounds are the second most common cause. Furthermore, the proportion of spinal cord injuries caused by gunshot wounds are increasing although the proportion of injuries caused by high-speed vehicular trauma is decreasing. Gunshot wounds to the spine commonly are thought to be stable injuries. There is, however, a potential for instability if the bullet passes transversely through the spinal canal and fractures pedicles and facets. Injuries to the thoracic region of the spine are the most common, followed by the thoracolumbar area and the cervical spine. Completeness of injury is related to the anatomic region. Patients with incomplete injuries and patients with injuries in the thoracolumbar region have the greatest improvement in motor function. Approximately (1/4) of individuals are able to ambulate 1 year after injury. Surgical decompression of bullets from the spinal canal has been shown to improve neurologic recovery below the T12 level. Improvement of neurologic recovery after bullet removal has not been shown in other regions of the spine. Rare instances of late neurologic decline because of retained bullet fragments have been documented.

    • Kitchel SH (2003). Current treatment of gunshot wounds to the spine. Clin Orthop. 115-9. Orthopedic Spine Associates, Eugene, OR 97401, USA. The incidence of spinal cord injury from gunshot wounds in penetrating trauma continues to increase with the violent nature of society. This particularly is true in urban areas, as is found with other violent crime. Either the direct path of the bullet or the concussive effects cause injury to the spine and spinal column. Thorough patient evaluation and appropriate radiographic studies will provide the keys to treatment of these patients. Criteria are given for treatment related to neurologic findings and progressive neurologic evaluation. Infection related to missiles penetrating through the alimentary tract and then lodging in the spine is a relatively rare complication and appropriate standards for debridement and fragment removal are discussed. Principles of treatment in all missile injuries to the spine evolve around spine stability, aggressive rehabilitation, and preservation of neurologic function.

    • Putzke JD, Richards JS and Devivo MJ (2001). Gunshot versus nongunshot spinal cord injury: acute care and rehabilitation outcomes. Am J Phys Med Rehabil. 80: 366-70; quiz 371-3, 387. Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, USA. OBJECTIVE: To examine the impact of gunshot-caused spinal cord injury on acute and rehabilitative care outcome using a case control design. DESIGN: Two groups (i.e., gunshot- vs. nongunshot-caused spinal cord injury) of 212 individuals were matched case-for-case on age (i.e., within 10 yr), education, gender, race, marital status, primary occupation, impairment level, and Model System region. Outcome measures included length of hospital stay, functional status (FIM), treatment charges, and home discharge rates. RESULTS: The two groups did not differ in the length of stay during acute and rehabilitative care, charges during rehabilitative care, or postrehabilitation discharge placement. Several significant between-group differences in treatment procedures were noted (e.g., prevalence of spinal surgery), which may, in part, account for the higher acute-care charges among those persons with nongunshot-caused spinal cord injury. CONCLUSION: Once an individual is stabilized and admitted for rehabilitative care, gunshot etiology of spinal cord injury seems largely unrelated to the initial rehabilitation outcome.

    [This message was edited by Wise Young on 02-27-04 at 07:23 AM.]

    #2
    About two weeks after I was shot I also had an option on whether the bullet could be removed or they could leave it in. I thought that the bullet was causing all of the problems and I told the doctors to remove it. I was also on a ventilator and I was unable to talk. The bullet was removed and the neurosurgeon said that the cord looked good. He also did a laminectomy and I have two or three small lead fragments of the bullet that are still in my neck. I don't think that the surgery made any difference in my recovery. I am glad that this large lead projectile is out.

    PN
    The test of success is not what you do when you are on top. Success is how high you bounce when you hit the bottom
    --General George Patton

    Complex problems need to be solved collectively.
    ––Paul Nussbaum
    usc87.blogspot.com

    Comment


      #3
      PN,
      Thank you for your experience. My nephew is now 10 days post bullet lodged into T2. We have consulted several neurosurgeons on bullet removal with various responses. Right now my nephew's medical status is not stable as he fights infection from injuries to various organs and has now had two surgeries to repair damage to his intestines and duodeum. The family has decided to remove the bullet as soon as he can tolerate another surgery. I will update his progress.

      Danni

      Comment


        #4
        Danni,

        I clearly understand about consulting with different neurosurgeons. I wish your nephew well and please feel free to contact me by e-mail.

        Good luck!

        PN
        The test of success is not what you do when you are on top. Success is how high you bounce when you hit the bottom
        --General George Patton

        Complex problems need to be solved collectively.
        ––Paul Nussbaum
        usc87.blogspot.com

        Comment


          #5
          i was also shot in back severl times and "no bullet removel' which caused severl yrs of unessasery pain which hampered pt now one removed to great relief but pt start now verry hard and late.
          Brian

          Comment


            #6
            Hi Brian,

            I am glad that you are now out of pain but am at a loss for all your years of suffering.

            Good luck!
            The test of success is not what you do when you are on top. Success is how high you bounce when you hit the bottom
            --General George Patton

            Complex problems need to be solved collectively.
            ––Paul Nussbaum
            usc87.blogspot.com

            Comment


              #7
              thanks for the thought but i deal with lots of cronic pain from the waist down but that is another deal. but best wishes in your sitation.
              Brian

              Comment


                #8
                I was shot 2.5 years ago. The bullet (9mm short) is still lodged in my C6 vertebra. I'm a C6 incomplete, and in the 2.5 year period I've been able to regain 70 to 80% of my mobility back, to the point that I'm going to Project Walk in March to get to walk again. I've been fortunate, I only have very mild neuropathic pain in my hands, but only when I'm tired. I've got full range of movement in my neck and it's very stable. The reason why my neurosurgeon didn't want to remove it was, the fusion would restrict my movement and with the procedure there was a possibility of further damage.
                Mind over Matter
                Nothing ventured, Nothing gained!

                Comment


                  #9
                  I was shot at the T2 / T3 level in 1978. back then and in the hospital where I was treated, the University of Vermont, the standard procedure seemed to be stabilize and leave the bullet alone / no removal.

                  I was shot 4 times and they removed the other three but left the one by my spine. If I was injured and had the choice today and was medically stable (as I was throughout initial injury) I would say go for it and have bullet removed.

                  Each circumstance is unique.
                  Hoping your nephew stabilizes and improves.

                  Edited to say neuropathic pain has also been a major problem for me. Definitely effects quality of life.
                  Last edited by ChesBay; 4 Feb 2007, 3:29 PM.

                  Comment


                    #10
                    The bullet injured me at L1, L2 level and I had my first operation in 1991. But the surgeon missed the tip of the bullet which had seperated and therefore I had another operation in 1993 to remove it. After it was removed I was able to move my right leg but still can't put any weight on it. I have neuropathic pain which is sometimes unbearable.

                    Comment


                      #11
                      Brian, my apologies. I thought you were pain-free after the removal of the bullet. I deal with pain daily and nothing is normal. I read an article about 10 years ago (maybe longer) in the LA Times titled "Anatomy of a Bullet." Bullet wounds are very destructive and painful because they ricochet off bone, tear into flesh and a low-speed projectile may do more damage than a bullet traveling at high speed. I wish I had a solution for this pain but I don't.
                      The test of success is not what you do when you are on top. Success is how high you bounce when you hit the bottom
                      --General George Patton

                      Complex problems need to be solved collectively.
                      ––Paul Nussbaum
                      usc87.blogspot.com

                      Comment

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