Endoscopic Bulletectomy for Lumbar Spine Gunshot Wounds: A Minimally Invasive Solution for Chronic Lead Toxicity

Introduction: Gunshot wounds (GSW) encompass 13-21% of all spinal cord injuries across the US, with 39.7% involving the lumbar spine. Surgical removal of residual bullet fragments has been largely controversial across the literature, yet management should be individualized to the patient. Indications for removal include but are not limited to neurological deterioration, vertebral instability, infection, dural involvement, and metal toxicity. Herein, we introduce a uniportal endoscopic bulletectomy technique for the treatment of lead toxicity via tandem removal of the endoscopic set and foreign body.

Methods: This is a case of an 18-year-old female who presented after a right paralumbar GSW with RLE subjective weakness but no incontinence or saddle anesthesia. Radiographic workup demonstrated a retained bullet within the L1-2 intervertebral space and a right L2 pedicle comminuted fracture with no overt instability. The entry wound was located 3.5 cm right off midline at L3, traversing the right paraspinous muscles near the right L2/3 neural foramen without invading the spinal canal. No neurosurgical intervention was indicated and the patient was discharged in a brace. However, after 2 months, her serum lead levels elevated from < 0.1 to 12 mcg/dL, notably exceeding the WHO environmental exposure limit of < 5 mcg/dL. Thus, surgical removal was recommended.

Results: A uniportal endoscopic bulletectomy was performed using a 10mm working channel via a trans-Kambin approach for L1/2 discectomy and drilling of the L2 superior endplate to create an extraction cavity. Residual scar tissue surrounding the fragment was adequately dissected. Since conventional endoscopic instruments were too small for bullet retrieval, laparoscopic gator graspers were used to grasp the bullet before tandem removal with the cannula at the incision site. No perioperative complications occurred, and the total operative time was 62 minutes with an EBL of 5 mL. Postoperatively, the patient experienced complete resolution of her RLE weakness and ambulated well independently.

Conclusion : While surgical bullet removal is largely debated, there is a relative indication when concerns exist for chronic lead toxicity, especially in younger patients. We propose our endoscopic bulletectomy technique, using laparoscopic gator graspers for tandem removal, as a valuable addition to the surgical arsenal of minimally invasive GSW management.