Operative Management of a Sacral Gunshot Injury via Minimally Invasive Techniques and Instrumentation
The patient was a 21-year-old male who sustained multiple gunshot injuries to his lumbosacral region. The patient's initial history and examination revealed three posterior entry wounds in the lumbar spine without exit wounds, full motor strength in bilateral lower extremity, normal sensory examination of bilateral lower extremity, and symmetrical reflexes. Plain radiographic imaging demonstrated multiple projectiles in the soft tissue of the lumbosacral region with one projectile lodged within the anterior body of S2 ().\nThe patient was admitted, evaluated and assessed by the trauma surgery team for local wound care, oral antibiotics and routine outpatient follow-up. He was subsequently discharged 3 days after admission. The patient returned to the Emergency Department at the University of Virginia 48 hours after discharge with complaint of erectile dysfunction and now a five-day history of constipation. The orthopaedic spine surgery service was consulted due to the concern of evolving neurologic symptoms. Upon evaluation by the spine service, the examination revealed subtle findings consistent with a S2-S4 nerve root dysfunction. This included perianal numbness, present but weak rectal tone, and weak volitional contraction. The bulbocavernous reflex was intact. There was no subjective or objective motor weakness in either extremity and reflexes were symmetric.\nComputed tomography (CT) scans confirmed a right-sided entry wound with an oblique trajectory through the right S2 lamina traversing the spinal canal and lodging within the anterior aspect of the S2 sacral body (). There were no associated injuries to the vasculature, solid or hollow viscera of the abdomen or pelvis, or evidence of a hematoma or other mass effect within the spinal canal. Based on these findings, there was concern that direct nerve root injury may have occurred, or to a lesser degree, a cauda equina syndrome from an external compressive lesion. Surgical intervention was performed in the attempt to re-establish function, decompress the neural structures, and remove the projectile and any associated fragments.\nGeneral endotracheal anesthesia was administered, and routine preoperative antibiotics consisting of 1 g of Cefazolin were administered. The two cephalad bullet wounds were lodged within the soft tissue. These underwent local wound management with irrigation and debridement and left in place. Attention was then directed to the third and most caudal projectile (). The projectile was carefully correlated with the intraoperative fluoroscopy to determine the location of the ideal skin incision, () which was sequentially widened with larger dilators () (Depuy Spine, Raynham, MA, USA) at the level of the projectile ().\nA microscope was then brought into the surgical field. A decompressive laminectomy was performed at S1-S3 bilaterally. The right sacral nerve root was transected with free proximal and distal ends. Left sacral nerve roots appeared intact, but injured due to the high-energy injury of the projectile. Several bone fragments and bullet fragments within the canal were removed. The bullet projectile was found in the anterior sacrum and carefully extracted with a shodded pituitary rongeur through the working channel ().\nDue to the muscle sparring surgical approach, there was nominal blood loss during surgical access. The estimated blood loss was under 25 mL. No drains were required and the incision was closed with a simple running fascial stitch and interrupted nylon skin suture. The final working portal was 21 mm in length. No intraoperative complications were noted.\nAt 1-month follow-up, the patient had regained perianal sensation and partial return of bowel function as well as continence; however, he did require the occasional use of stool softners for regularity. He never required digital disimpaction. Furthermore, he regained the ability to obtain an erection, however ejaculation remained somewhat problematic. The gunshot wound healed without incidence. Motor examination of his lower extremities remains full with improvement of the heel numbness of the left lateral heel. CT imaging noted complete removal of the gunshot bullet with no associated complications (). Phone conversations with the patient and family at 10 months have noted an improvement only in bowel function. The remaining sexual dysfunction and sensation have plateaued.