Retained bullet in the cervical spinal canal and the associated surgical management conundrum: case report and review of the literature

INTRODUCTION: Gunshot wounds (GSW) to the cervical spine remain uncommon. Surgery often does not yield significant neurological improvement and the decision to utilize surgery depends on a number of factors. We describe the case of a 28 year-old male suffering a complete spinal cord injury (SCI) secondary to a bullet lodged in the cervical spinal canal. We present the unique radiological findings and review the indications for and utility of spine surgery for cervical GSW. CASE PRESENTATION: The patient was a 28 year-old male involved in a motor vehicle accident immediately after sustaining a gunshot wound to the cervical spine. Neurologic exam revealed a complete SCI at the C4 level. CT scan revealed a retained bullet in the spinal canal at the C4/5 level without vascular injury or unstable vertebral fracture. He was managed nonoperatively, however, he remained ventilator dependent and ultimately expired secondary to cardiac arrest from a suspected pulmonary embolism. DISCUSSION: We present a case of complete SCI secondary to a retained bullet in the cervical spine. These cases can be managed both operatively and nonoperatively. Given the high risk of morbidity and overall poor neurological recovery after surgical intervention for SCI secondary to GSW, physicians must understand the appropriate indications for surgical intervention. These indications include, but are not limited to, progressive neurological deficit, cerebrospinal fluid leak, spinal instability, and acute lead toxicity.