Mobile intrathecal bullet causing delayed radicular symptoms.

A 27-year-old man who was intoxicated came to the emergency department after he accidentally shot himself in the abdomen with a .25 caliber pistol. The physical examination revealed an entry wound in the right midabdomen and surrounding powder burns on the skin. No exit wound was found. The patient was in stable condition . After a laparotomy for repair of small bowel and mesentery, the patient began complaining of numbness of and discomfort in the left leg and foot. Neurologic examination showed deficits in the distribution of the sacral nerves, with loss of sensation in the lower left leg, urinary urgency, and no feeling around the anus. Abdominal radiographs obtained at the time showed a metallic density (the bullet) within the spinal canal just above the S1-S2 interspace (Figs. 1A and 1 B). Some cortical disruption of the vertebral end plates around the T11-T12 disk suggested that that might have been the site of entry. A myelogram/CT was performed to ascertain whether the bullet was intradural (Fig . 1C). Under fluoroscopy, the bullet was seen to move around within the thecal sac. The sac was intact up to the L2L31evel. Because of the patient's symptoms, removal of the bullet was thought to be indicated, and a sacral laminectomy was performed. When the dura was opened, the bullet had migrated upward. The dural incision was extended until the bullet was encountered. The bullet was removed, and the patient improved clinically.