Cephalad Migration of Intradural Bullet from Thoracic Spine to Cervical Spine

Background: There are few reported instances of intraspinal migration of a bullet fragment. The majority of these migrations occur caudally, typically below the level of T10. Even fewer cases demonstrate cephalad migration from the sacral spine to the lumbar spine. We report here for the first time a case of a cephalad migration intradurally from the thoracic spine to cervical spine. Case Description: A 31-year old man presented to the emergency department with a suspected spinal cord injury following a GSW sustained to the left shoulder. A penetrating gunshot injury to the thoracic spine at the level of T2 was observed, and CT angiography revealed a cephalad migration of the bullet fragment to the level of C6. The patient had marked weakness of the bilateral upper extremities, with paraplegia of the lower extremities. There was a sensory deficit beginning at a level 1 cm below the clavicle, as well as a decrease in rectal tone. We performed a laminectomy at C6 with dural incision and removal of the main bullet fragment. Following the surgery, significant improvement in strength and sensation in the bilateral upper extremities was noted, but paraplegia and sensory loss below the level of T2 persisted. Conclusions: In this report, we review the previously reported cases in which intraspinal migration of bullets have occurred, and discuss the unique finding in this study of cephalad migration of a bullet within the dura. In addition, we detail considerations in the management of such injuries.