Neurogenic claudication, a delayed complication of a retained bullet

A case report is presented of a 31-year-old man who visited the authors' neurosurgical department in 1993, complaining of neurogenic claudication. History revealed a gunshot incident 11 years ago, with a bullet left in situ.

To determine whether to operate on patients who have a bullet in situ near the spinal cord without initial neurologic deficits.

In the literature, only four publications report an epidural chronic inflammatory mass as a reaction to a retained bullet, thereby causing delayed neurologic symptoms. Previous to this report, only one case is described of a patient with a bullet lodged in the paravertebral musculature.

Clinically, the patient had pain radiating from his lower back to both his thighs, provoked by walking, standing, and the Valsalva maneuver. Comparison of radiographs made in 1990 and in 1993 showed the lead bullet still completely intact in 1990, whereas in 1993, a partial disintegration and displacement of the bullet, causing a chronic inflammatory reaction (extraspinal and intraspinal), as well as cyst formation, was seen. Particularly notable was the radiographic feature of a sort of "fallen leaf sign" at the level of L5-S1.

The preoperative complaints were still absent 1 year after surgery.

It is argued that with regard to a retained bullet in the vicinity of the spinal canal, the presence or absence of neurologic symptoms should be the guide for further diagnostic procedures. Only if a neurologic deficit develops, which is possible after many years, should surgical intervention be considered, depending on the severity and type of the deficit, as presented in this case report.