Resolution of cauda equina syndrome after surgical extraction of lumbar intrathecal bullet

Background: Gunshot wound (GSW) injuries to the spinal column are correlated with potentially severe neurological damage. Here, we describe a GSW to the thoracolumbar junction (e.g., T12/L1 level) which resulted in a cauda equina syndrome that resolved once the bullet was removed. Case Description: A 29-year-old male presented with a T12-L1 GSW; the bullet traversed the right chest and liver, entered the spinal canal at T12, and then settled at L1. He experienced excruciating burning pain in the right lower extremity/perineum and had urinary retention. On neurological examination, he exhibited severe weakness of the right iliopsoas/quadriceps (2/5) and extensor hallucis longus (1/5) which had decreased sensation in the right lower extremity in all dermatomes and urinary retention. The myelogram showed the bullet lodged intrathecally at L1; it compressed the cauda equina. Immediately after, the bullet was extracted and at 8 weeks follow-up, the patient’s right-sided motor function normalized, the sensory findings improved, and the sphincteric dysfunction resolved; the only residual deficit was minimal residual numbness in the L2-L5 distributions. Conclusion: Twenty percent of penetrating spinal column injuries are attributed to GSW s. The location of these injuries best determines the neurological damage and degree of recovery. Since patients with incomplete cauda equina syndromes have favorable prognoses, removal of bullets involving the T12-S1 levels may prove beneficial.