{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T06:59:50Z","timestamp":1781593190748,"version":"3.54.5"},"reference-count":36,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"22","license":[{"start":{"date-parts":[[2021,5,31]],"date-time":"2021-05-31T00:00:00Z","timestamp":1622419200000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2021,5,31]]},"abstract":"<jats:sec>\n                    <jats:title>BACKGROUND<\/jats:title>\n                    <jats:p>Management of gunshot wounds to the spine with subsequent spinal cord injury is a controversial topic among spine surgeons. Possible complications of retained intradural bullets include delayed neurological deficits, spinal instability, and lead toxicity. The authors\u2019 purpose is to review the potential complications of retained intraspinal bullets and the surgical indications for intraspinal bullet removal.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>OBSERVATIONS<\/jats:title>\n                    <jats:p>The authors describe a case of a patient who developed cauda equina symptoms following a gunshot wound to the lumbar spine with a migrating retained intraspinal bullet. Because of neurological changes, the patient underwent surgical removal of the bullet. At the postoperative clinic visit 2 weeks following bullet removal, the patient reported resolution of her symptoms.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>LESSONS<\/jats:title>\n                    <jats:p>Gunshot wounds to the spine are challenging cases. The decision to proceed with surgical management in the event of retained bullet fragments is multifactorial and relies heavily on the patient\u2019s neurological status. A current review of the literature suggests that, in cases of cauda equina injuries and the development of neurological deficits in patients with retained intraspinal fragments, there is benefit from surgical decompression and bullet removal. Careful preoperative planning is required, and consideration of spinal alignment with positional changes is crucial.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/case21132","type":"journal-article","created":{"date-parts":[[2021,5,31]],"date-time":"2021-05-31T03:02:47Z","timestamp":1622430167000},"source":"Crossref","is-referenced-by-count":4,"title":["Surgical removal of a migrating intraspinal bullet: illustrative case"],"prefix":"10.3171","volume":"1","author":[{"given":"Daniel","family":"de los Cobos","sequence":"first","affiliation":[{"name":"Departments of Orthopaedic Surgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexa","family":"Powers","sequence":"additional","affiliation":[{"name":"Departments of Orthopaedic Surgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathan P.","family":"Behrens","sequence":"additional","affiliation":[{"name":"Departments of Orthopaedic Surgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tobias A.","family":"Mattei","sequence":"additional","affiliation":[{"name":"Neurosurgery, Saint Louis University School of Medicine, St. Louis, Missouri"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pooria","family":"Salari","sequence":"additional","affiliation":[{"name":"Departments of Orthopaedic Surgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"key":"b1","series-title":"2019 Annual Statistical Report\u2014Complete Public Version","unstructured":"National Spinal Cord Injury Statistical Center, University of Alabama at Birmingham. 2019 Annual Statistical Report\u2014Complete Public Version. National Spinal Cord Injury Statistical Center, University of Alabama at Birmingham."},{"issue":"408","key":"b2","series-title":"Clin Orthop Relat Res","doi-asserted-by":"publisher","first-page":"115","DOI":"10.1097\/00003086-200303000-00013","article-title":"Current treatment of gunshot wounds to the spine","author":"Kitchel SH","year":"2003","unstructured":"Kitchel SH. Current treatment of gunshot wounds to the spine. Clin Orthop Relat Res. 2003;(408):115\u2013119.10.1097\/00003086-200303000-00013"},{"issue":"408","key":"b3","series-title":"Clin Orthop Relat Res","doi-asserted-by":"publisher","first-page":"120","DOI":"10.1097\/00003086-200303000-00014","article-title":"Spinal cord injuries from gunshot wounds to the spine","author":"Waters RL","year":"2003","unstructured":"Waters RL, Sie IH. Spinal cord injuries from gunshot wounds to the spine. Clin Orthop Relat Res. 2003;(408):120\u2013125.10.1097\/00003086-200303000-00014"},{"issue":"7","key":"b4","series-title":"Spinal Cord","doi-asserted-by":"publisher","first-page":"504","DOI":"10.1038\/sc.2014.56","article-title":"Gunshot injuries in the spine","volume":"52","author":"de Barros Filho TE","year":"2014","unstructured":"de Barros Filho TE, Cristante AF, Marcon RM,  Gunshot injuries in the spine. Spinal Cord. 2014;52(7):504\u2013510.10.1038\/sc.2014.56"},{"issue":"12","key":"b5","series-title":"J Clin Neurosci","doi-asserted-by":"publisher","first-page":"1630","DOI":"10.1016\/j.jocn.2011.02.047","article-title":"How bullet trajectory affects outcomes of civilian gunshot injury to the spine","volume":"18","author":"Chittiboina P","year":"2011","unstructured":"Chittiboina P, Banerjee AD, Zhang S,  How bullet trajectory affects outcomes of civilian gunshot injury to the spine. J Clin Neurosci. 2011;18(12):1630\u20131633.10.1016\/j.jocn.2011.02.047"},{"issue":"12","key":"b6","series-title":"Clin Orthop Relat Res","doi-asserted-by":"publisher","first-page":"3945","DOI":"10.1007\/s11999-013-2901-2","article-title":"Civilian gunshot injuries of the spinal cord: a systematic review of the current literature","volume":"471","author":"Sidhu GS","year":"2013","unstructured":"Sidhu GS, Ghag A, Prokuski V,  Civilian gunshot injuries of the spinal cord: a systematic review of the current literature. Clin Orthop Relat Res. 2013;471(12):3945\u20133955.10.1007\/s11999-013-2901-2"},{"key":"b7","series-title":"Injury","doi-asserted-by":"publisher","first-page":"SA7","DOI":"10.1016\/S0020-1383(98)00098-9","article-title":"Gunshot wounds to the spine","volume":"29","author":"Isiklar ZU","year":"1998","unstructured":"Isiklar ZU, Lindsey RW. Gunshot wounds to the spine. Injury. 1998;29(suppl 1):SA7\u2013SA12.10.1016\/S0020-1383(98)00098-9"},{"issue":"2","key":"b8","series-title":"Spine J","doi-asserted-by":"publisher","first-page":"230","DOI":"10.1016\/S1529-9430(03)00178-5","article-title":"Gunshot wounds to the spine","volume":"4","author":"Bono CM","year":"2004","unstructured":"Bono CM, Heary RF. Gunshot wounds to the spine. Spine J. 2004;4(2):230\u2013240.10.1016\/S1529-9430(03)00178-5"},{"issue":"8","key":"b9","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"934","DOI":"10.1097\/00007632-199108000-00012","article-title":"The effects of removal of bullet fragments retained in the spinal canal. A collaborative study by the National Spinal Cord Injury Model Systems","volume":"16","author":"Waters RL","year":"1991","unstructured":"Waters RL, Adkins RH. The effects of removal of bullet fragments retained in the spinal canal. A collaborative study by the National Spinal Cord Injury Model Systems. Spine (Phila Pa 1976). 1991;16(8):934\u2013939.10.1097\/00007632-199108000-00012"},{"key":"b10","series-title":"Eur Spine J","doi-asserted-by":"publisher","first-page":"128","DOI":"10.1007\/s00586-016-4913-6","article-title":"Migratory low velocity intradural lumbosacral spinal bullet causing cauda equina syndrome: report of a case and review of literature","volume":"26","author":"Baldawa S","year":"2017","unstructured":"Baldawa S, Shivpuje V. Migratory low velocity intradural lumbosacral spinal bullet causing cauda equina syndrome: report of a case and review of literature. Eur Spine J. 2017;26(suppl 1):128\u2013135.10.1007\/s00586-016-4913-6"},{"issue":"7","key":"b11","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"450","DOI":"10.1097\/BRS.0000000000000797","article-title":"An update on civilian spinal gunshot wounds: treatment, neurological recovery, and complications","volume":"40","author":"Bumpass DB","year":"2015","unstructured":"Bumpass DB, Buchowski JM, Park A,  An update on civilian spinal gunshot wounds: treatment, neurological recovery, and complications. Spine (Phila Pa 1976). 2015;40(7):450\u2013461.10.1097\/BRS.0000000000000797"},{"key":"b12","series-title":"World Neurosurg","doi-asserted-by":"publisher","first-page":"62","DOI":"10.1016\/j.wneu.2019.07.151","article-title":"Removal of migrating lumbar spine bullet: case report and surgical video","volume":"131","author":"Siddiqui MI","year":"2019","unstructured":"Siddiqui MI, Hawksworth SA, Sun DY. Removal of migrating lumbar spine bullet: case report and surgical video. World Neurosurg. 2019;131:62\u201364.10.1016\/j.wneu.2019.07.151"},{"issue":"10","key":"b13","series-title":"Spine J","doi-asserted-by":"publisher","first-page":"e5","DOI":"10.1016\/j.spinee.2009.06.009","article-title":"Neurogenic claudication and radiculopathy as delayed presentations of retained spinal bullet","volume":"9","author":"Ajmal S","year":"2009","unstructured":"Ajmal S, Enam SA, Shamim MS. Neurogenic claudication and radiculopathy as delayed presentations of retained spinal bullet. Spine J. 2009;9(10):e5\u2013e8.10.1016\/j.spinee.2009.06.009"},{"key":"b14","series-title":"J Clin Neurosci","doi-asserted-by":"publisher","first-page":"185","DOI":"10.1016\/j.jocn.2016.01.008","article-title":"Migrating bullet in the thecal sac at the level of the conus medullaris without neurological deficit","volume":"29","author":"Koban O","year":"2016","unstructured":"Koban O, \u00c7al H, Ek\u015fi M\u015e,  Migrating bullet in the thecal sac at the level of the conus medullaris without neurological deficit. J Clin Neurosci. 2016;29:185\u2013188.10.1016\/j.jocn.2016.01.008"},{"issue":"2","key":"b15","series-title":"Spine J","doi-asserted-by":"publisher","first-page":"404","DOI":"10.1016\/j.spinee.2006.10.025","article-title":"Intrathecal migratory foreign body without neurological deficit after a gunshot wound","volume":"8","author":"Ben-Galim P","year":"2008","unstructured":"Ben-Galim P, Reitman CA. Intrathecal migratory foreign body without neurological deficit after a gunshot wound. Spine J. 2008;8(2):404\u2013407.10.1016\/j.spinee.2006.10.025"},{"issue":"8","key":"b16","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"910","DOI":"10.1097\/00007632-199704150-00015","article-title":"Neurogenic claudication, a delayed complication of a retained bullet","volume":"22","author":"Kuijlen JM","year":"1997","unstructured":"Kuijlen JM, Herpers MJ, Beuls EA. Neurogenic claudication, a delayed complication of a retained bullet. Spine (Phila Pa 1976). 1997;22(8):910\u2013914.10.1097\/00007632-199704150-00015"},{"issue":"3","key":"b17","series-title":"Ann Surg","doi-asserted-by":"publisher","first-page":"305","DOI":"10.1097\/00000658-198203000-00010","article-title":"Lead poisoning from retained bullets. Pathogenesis, diagnosis, and management","volume":"195","author":"Linden MA","year":"1982","unstructured":"Linden MA, Manton WI, Stewart RM,  Lead poisoning from retained bullets. Pathogenesis, diagnosis, and management. Ann Surg. 1982;195(3):305\u2013313.10.1097\/00000658-198203000-00010"},{"key":"b18","series-title":"World Neurosurg","doi-asserted-by":"publisher","first-page":"377","DOI":"10.1016\/j.wneu.2020.05.112","article-title":"Lead toxicity from intradiscal retained bullet fragment: management considerations and recommendations","volume":"141","author":"Towner JE","year":"2020","unstructured":"Towner JE, Pieters TA, Maurer PK. Lead toxicity from intradiscal retained bullet fragment: management considerations and recommendations. World Neurosurg. 2020;141:377\u2013382.10.1016\/j.wneu.2020.05.112"},{"key":"b1","series-title":"2019 Annual Statistical Report\u2014Complete Public Version","unstructured":"National Spinal Cord Injury Statistical Center, University of Alabama at Birmingham. 2019 Annual Statistical Report\u2014Complete Public Version. National Spinal Cord Injury Statistical Center, University of Alabama at Birmingham."},{"issue":"408","key":"b2","series-title":"Clin Orthop Relat Res","doi-asserted-by":"publisher","first-page":"115","DOI":"10.1097\/00003086-200303000-00013","article-title":"Current treatment of gunshot wounds to the spine","author":"Kitchel SH","year":"2003","unstructured":"Kitchel SH. Current treatment of gunshot wounds to the spine. Clin Orthop Relat Res. 2003;(408):115\u2013119.10.1097\/00003086-200303000-00013"},{"issue":"408","key":"b3","series-title":"Clin Orthop Relat Res","doi-asserted-by":"publisher","first-page":"120","DOI":"10.1097\/00003086-200303000-00014","article-title":"Spinal cord injuries from gunshot wounds to the spine","author":"Waters RL","year":"2003","unstructured":"Waters RL, Sie IH. Spinal cord injuries from gunshot wounds to the spine. Clin Orthop Relat Res. 2003;(408):120\u2013125.10.1097\/00003086-200303000-00014"},{"issue":"7","key":"b4","series-title":"Spinal Cord","doi-asserted-by":"publisher","first-page":"504","DOI":"10.1038\/sc.2014.56","article-title":"Gunshot injuries in the spine","volume":"52","author":"de Barros Filho TE","year":"2014","unstructured":"de Barros Filho TE, Cristante AF, Marcon RM,  Gunshot injuries in the spine. Spinal Cord. 2014;52(7):504\u2013510.10.1038\/sc.2014.56"},{"issue":"12","key":"b5","series-title":"J Clin Neurosci","doi-asserted-by":"publisher","first-page":"1630","DOI":"10.1016\/j.jocn.2011.02.047","article-title":"How bullet trajectory affects outcomes of civilian gunshot injury to the spine","volume":"18","author":"Chittiboina P","year":"2011","unstructured":"Chittiboina P, Banerjee AD, Zhang S,  How bullet trajectory affects outcomes of civilian gunshot injury to the spine. J Clin Neurosci. 2011;18(12):1630\u20131633.10.1016\/j.jocn.2011.02.047"},{"issue":"12","key":"b6","series-title":"Clin Orthop Relat Res","doi-asserted-by":"publisher","first-page":"3945","DOI":"10.1007\/s11999-013-2901-2","article-title":"Civilian gunshot injuries of the spinal cord: a systematic review of the current literature","volume":"471","author":"Sidhu GS","year":"2013","unstructured":"Sidhu GS, Ghag A, Prokuski V,  Civilian gunshot injuries of the spinal cord: a systematic review of the current literature. Clin Orthop Relat Res. 2013;471(12):3945\u20133955.10.1007\/s11999-013-2901-2"},{"key":"b7","series-title":"Injury","doi-asserted-by":"publisher","first-page":"SA7","DOI":"10.1016\/S0020-1383(98)00098-9","article-title":"Gunshot wounds to the spine","volume":"29","author":"Isiklar ZU","year":"1998","unstructured":"Isiklar ZU, Lindsey RW. Gunshot wounds to the spine. Injury. 1998;29(suppl 1):SA7\u2013SA12.10.1016\/S0020-1383(98)00098-9"},{"issue":"2","key":"b8","series-title":"Spine J","doi-asserted-by":"publisher","first-page":"230","DOI":"10.1016\/S1529-9430(03)00178-5","article-title":"Gunshot wounds to the spine","volume":"4","author":"Bono CM","year":"2004","unstructured":"Bono CM, Heary RF. Gunshot wounds to the spine. Spine J. 2004;4(2):230\u2013240.10.1016\/S1529-9430(03)00178-5"},{"issue":"8","key":"b9","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"934","DOI":"10.1097\/00007632-199108000-00012","article-title":"The effects of removal of bullet fragments retained in the spinal canal. A collaborative study by the National Spinal Cord Injury Model Systems","volume":"16","author":"Waters RL","year":"1991","unstructured":"Waters RL, Adkins RH. The effects of removal of bullet fragments retained in the spinal canal. A collaborative study by the National Spinal Cord Injury Model Systems. Spine (Phila Pa 1976). 1991;16(8):934\u2013939.10.1097\/00007632-199108000-00012"},{"key":"b10","series-title":"Eur Spine J","doi-asserted-by":"publisher","first-page":"128","DOI":"10.1007\/s00586-016-4913-6","article-title":"Migratory low velocity intradural lumbosacral spinal bullet causing cauda equina syndrome: report of a case and review of literature","volume":"26","author":"Baldawa S","year":"2017","unstructured":"Baldawa S, Shivpuje V. Migratory low velocity intradural lumbosacral spinal bullet causing cauda equina syndrome: report of a case and review of literature. Eur Spine J. 2017;26(suppl 1):128\u2013135.10.1007\/s00586-016-4913-6"},{"issue":"7","key":"b11","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"450","DOI":"10.1097\/BRS.0000000000000797","article-title":"An update on civilian spinal gunshot wounds: treatment, neurological recovery, and complications","volume":"40","author":"Bumpass DB","year":"2015","unstructured":"Bumpass DB, Buchowski JM, Park A,  An update on civilian spinal gunshot wounds: treatment, neurological recovery, and complications. Spine (Phila Pa 1976). 2015;40(7):450\u2013461.10.1097\/BRS.0000000000000797"},{"key":"b12","series-title":"World Neurosurg","doi-asserted-by":"publisher","first-page":"62","DOI":"10.1016\/j.wneu.2019.07.151","article-title":"Removal of migrating lumbar spine bullet: case report and surgical video","volume":"131","author":"Siddiqui MI","year":"2019","unstructured":"Siddiqui MI, Hawksworth SA, Sun DY. Removal of migrating lumbar spine bullet: case report and surgical video. World Neurosurg. 2019;131:62\u201364.10.1016\/j.wneu.2019.07.151"},{"issue":"10","key":"b13","series-title":"Spine J","doi-asserted-by":"publisher","first-page":"e5","DOI":"10.1016\/j.spinee.2009.06.009","article-title":"Neurogenic claudication and radiculopathy as delayed presentations of retained spinal bullet","volume":"9","author":"Ajmal S","year":"2009","unstructured":"Ajmal S, Enam SA, Shamim MS. Neurogenic claudication and radiculopathy as delayed presentations of retained spinal bullet. Spine J. 2009;9(10):e5\u2013e8.10.1016\/j.spinee.2009.06.009"},{"key":"b14","series-title":"J Clin Neurosci","doi-asserted-by":"publisher","first-page":"185","DOI":"10.1016\/j.jocn.2016.01.008","article-title":"Migrating bullet in the thecal sac at the level of the conus medullaris without neurological deficit","volume":"29","author":"Koban O","year":"2016","unstructured":"Koban O, \u00c7al H, Ek\u015fi M\u015e,  Migrating bullet in the thecal sac at the level of the conus medullaris without neurological deficit. J Clin Neurosci. 2016;29:185\u2013188.10.1016\/j.jocn.2016.01.008"},{"issue":"2","key":"b15","series-title":"Spine J","doi-asserted-by":"publisher","first-page":"404","DOI":"10.1016\/j.spinee.2006.10.025","article-title":"Intrathecal migratory foreign body without neurological deficit after a gunshot wound","volume":"8","author":"Ben-Galim P","year":"2008","unstructured":"Ben-Galim P, Reitman CA. Intrathecal migratory foreign body without neurological deficit after a gunshot wound. Spine J. 2008;8(2):404\u2013407.10.1016\/j.spinee.2006.10.025"},{"issue":"8","key":"b16","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"910","DOI":"10.1097\/00007632-199704150-00015","article-title":"Neurogenic claudication, a delayed complication of a retained bullet","volume":"22","author":"Kuijlen JM","year":"1997","unstructured":"Kuijlen JM, Herpers MJ, Beuls EA. Neurogenic claudication, a delayed complication of a retained bullet. Spine (Phila Pa 1976). 1997;22(8):910\u2013914.10.1097\/00007632-199704150-00015"},{"issue":"3","key":"b17","series-title":"Ann Surg","doi-asserted-by":"publisher","first-page":"305","DOI":"10.1097\/00000658-198203000-00010","article-title":"Lead poisoning from retained bullets. Pathogenesis, diagnosis, and management","volume":"195","author":"Linden MA","year":"1982","unstructured":"Linden MA, Manton WI, Stewart RM,  Lead poisoning from retained bullets. Pathogenesis, diagnosis, and management. Ann Surg. 1982;195(3):305\u2013313.10.1097\/00000658-198203000-00010"},{"key":"b18","series-title":"World Neurosurg","doi-asserted-by":"publisher","first-page":"377","DOI":"10.1016\/j.wneu.2020.05.112","article-title":"Lead toxicity from intradiscal retained bullet fragment: management considerations and recommendations","volume":"141","author":"Towner JE","year":"2020","unstructured":"Towner JE, Pieters TA, Maurer PK. Lead toxicity from intradiscal retained bullet fragment: management considerations and recommendations. World Neurosurg. 2020;141:377\u2013382.10.1016\/j.wneu.2020.05.112"}],"container-title":["Journal of Neurosurgery: Case Lessons"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-case-lessons\/1\/22\/article-CASE21132.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-case-lessons\/1\/22\/article-CASE21132.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-case-lessons\/1\/22\/article-CASE21132.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,5]],"date-time":"2026-02-05T14:57:20Z","timestamp":1770303440000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-case-lessons\/1\/22\/article-CASE21132.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,5,31]]},"references-count":36,"journal-issue":{"issue":"22"},"URL":"https:\/\/doi.org\/10.3171\/case21132","relation":{},"ISSN":["2694-1902"],"issn-type":[{"value":"2694-1902","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,5,31]]}}}