Cauda equina syndrome caused by intradural migration of a bullet: A rare case presentation

Intradural migration of a bullet within the spinal canal represents an exceptionally uncommon clinical scenario and carries the potential for progressive or delayed neurological decline. Although such fragments may initially remain silent, their subsequent movement within the spinal canal can create significant diagnostic and therapeutic challenges. In this report, we present an unusual and instructive case of cauda equina syndrome that developed secondary to the delayed caudal migration of an intradural bullet fragment. We further provide a detailed discussion of the diagnostic evaluation, surgical management, and clinical decision-making considerations associated with this condition. A 32-year-old male patient sustained a gunshot injury in 2022. Initial imaging demonstrated that the bullet had penetrated the spinal canal and become lodged intradurally at the L1-L2 level, although the patient exhibited no neurological deficits at that time. He was, therefore, managed conservatively with routine follow-up. Approximately 2.5 years later, the patient presented with the sudden onset of bilateral lower extremity weakness, progressive gait impairment, and new-onset urinary incontinence. Computed tomography revealed that the intradural bullet fragment had migrated caudally to the S2 vertebral level, resulting in significant compres-sion of the cauda equina nerve roots. Urgent surgical intervention was undertaken, consisting of a partial bilateral laminectomy at the S1-S2 level and microsurgical extraction of the bullet. Postoperative neurological recovery was substantial, with marked improvement in motor function and complete resolution of urinary symptoms. Although intradural bullet fragments may initially appear clinically insignificant in patients who present without neurological deficits, delayed migration poses a serious risk for the development of cauda equina syndrome and other potentially irreversible complications. This case highlights the importance of maintaining a high index of suspicion and considering early prophylactic surgical extraction when intradural localization is identified, even in neurologically intact individuals. Early intervention may prevent severe late complications such as neurological deterioration, infectious sequelae arising from contaminated missile tracts, and possible lead toxicity related to chronic intradural exposure.