When the bullet moves! Surgical caveats from a migrant intraspinal bullet

Rarely, spinal gunshot injuries result in migrating intraspinal bullets. Use of MRI is controversial and other radiographic imaging might mimic an extradural bullet, even though it is intradural and migratory. Here, we present a case of spinal missile injury resulting in an intraoperatively mobile intradural bullet. The challenges faced during diagnosis and surgical removal are described. We also show that intraoperative ultrasonography may be useful in clarifying whether the bullet is intradural. A 32-year-old male presented with weakness and paraesthesia in his right leg following an accidental gunshot injury to his spine. Facet joint destruction and an intraspinal bullet were detected. Immediate surgical removal and transpedicular instrumentation was performed. The surgical procedure was complicated by lack of an identifying dural perforation at the bullet entry point and a gliding bullet inside the spinal canal during surgery. Gliding of the bullet was caused by the pushing effect of the bone rongeur and further gliding was avoided by performing the next laminectomy with an electric drill. Where other modalities indicated for a possible extradural location, intraoperative USG clearly showed the intradural position of the bullet and provided clear images without major artifacts. Surgical treatment of a mobile intradural bullet is challenging and open to surprises. Location of the bullet may shift as result of surgical procedure itself. Laminectomy should be performed with a power drill. Where fluoroscopy was inadequate and MRI not available, intraoperative USG proved useful in ascertaining the intradural versus extradural position of the bullet and allowed for a tailored dural opening.