gunshot wounds to the spine account for approximately 13 to 17% of all spinal cord injuries each year5 ) .
spinal cord injury after gunshot usually results in complete injury , such as paraplegia , which is highly associated with thermal tissue injury34 ) . however , neurological deficits can be variable , ranging from radiculopathy to spinal cord injury .
although neurological deficits might be absent initially , most patients eventually develop deficits that require surgical intervention6 ) .
we describe a rare case of delayed onset of neurological symptoms after a bullet injury to the flank ; the bullet migrated and became lodged in the spinal canal .
we also review the relevant literature and compare the current case with other clinical case reports .
a 30-year - old man presented to our outpatient clinic with radiating pain both legs .
the pain in both legs was aggravated with walking and relieved with rest , symptoms typical of neurogenic claudication .
the patient reported that he had been shot in the left lateral side of the back on 1 year ago .
we determined on physical examination that the wound on the left flank had already healed ( fig .
1 ) . at the time that he was shot , the patient had no other complaints , except for pain at the entrance wound . at that time of gun shut , he had to have absolute bed rest and conservative treatment because of a liver injury caused by the gunshot .
after several months of treatment , his liver was healed enough to ambulate and walk ; however , he needed a cane to walk .
after he started walking , he began to experience continuous radiating pain on both lower extremities . on neurologic examination ,
dorsiflexion of the ankle and big toe on the right leg revealed mild motor weakness ( grade iv ) .
the patient also complained of numbness on the right lower limb ; however , patellar and achilles reflexes were normal . on admission ,
other laboratory findings were normal . a mild degree of voiding difficulty was detected , although that symptom did not bother the patient .
plain radiographs revealed a round , radiopaque mass in the spinal canal at the l3 - 4 level ( fig .
non - contrast reconstructed ct images of the lumbar spine were taken after admission , which revealed that the bullet - shaped mass was within the spinal canal , pointing cephalic at the l3 - 4 interspace ( fig .
the bullet within the spinal canal was located in the intradural space , compressing the nerve root ( fig .
because of his claudication and pain , we decided to surgically remove the bullet from the spinal canal .
with the patient prone on a wilson frame , fluoroscopic guidance was used to plan an incision over the l3 - 4 spinous process .
the l3 lamina was carefully and completely removed with a drill , and a dural incision was made .
both intraoperative and postoperative motor - evoked potential and somatosensory - evoked potential were normal .
the patient ambulated the day after surgery and reported that the radicular pain and claudicating pain were greatly improved .
he was discharged 1 week after surgery . on his follow - up visit at 4 weeks , the pain had nearly resolved , and oral medications , including pain killers , were completely stopped .
he showed definitive improvement in motor power of the right leg ; however , independent ambulation without a cane was not achieved .
the annual incidence of spinal cord injuries is 10.4 and 83 per million people , and the most common cause of spinal cord injuries is motor vehicle accident910 ) .
spinal cord injuries due to gunshot wounds are very rare , and the absence of acute neurological symptoms after gunshot - related spinal injury is even rarer .
our case report is particularly interesting because intradural localization and our patient developed radiating pain in both lower extremities 1 year after the initial injury . in additions ; to our knowledge , only a few cases with similar characteristics have been reported27 ) .
most bullet injuries are accompanied by acute neurologic symptoms , and if initially the patient might be neurologically intact fortunately , neurological symptoms gradually appear over time .
there are two possible explanations for the delayed appearance of neurological symptoms in the literatures : first , compression of the spinal cord or the thecal sac and impingement of the nerve root as a result of migration of the bullet and second , reactionary epidural fibrosis . according to a paper by ajmal et al.1 ) , there have been only 7 reported cases of delayed neurological symptoms caused by epidural fibrosis after gunshot injury .
first , our patient developed radiating pain in both lower extremities 1 year after the initial injury , and the cause was thought to be epidural fibrosis due to the injury itself .
second , it is unique that our case is intradural bullet injury . in the surgical field , there was a significant inflammatory response in the area where the bullet was lodged .
however , since serial images were unavailable , we could not compare images taken when the patient incurred the injury with the images taken in our clinic ; as a result , we were unable to completely exclude true bullet migration or potential stenosis because of degenerative changes .
we presumed that bullet might enter the body of left flank , which would be the level of thoraco - lumbar junction ( fig .
1 ) , because of the entrance skin wound . after penetrating skin on left flank of thoraco - lumbar junction
, bullet might penetrate the vertebra and dura , which was finally found with adhesion on l3 - 4 level .
we assumed that bullet might be located at intradural thoraco - lumbar junction at first injury , which migrated on l3 - 4 level after ambulation .
after migration on l3 - 4 level , bullet was stuck to l3 - 4 level , because of its size and diameter . and epidural fibrosis and intra dural adhesion might follow .
when determining the surgical treatment for patients with bullet injury , surgeons should assess neurological damage and abnormalities , instability , the position of bony fragments , age , and systemic complaints .
ajmal et al.1 ) opposed surgical removal of intraspinal bullets because the injury is caused neurological deficit in the end , but surgical treatment should be considered when patients have instability and neurological damage or abnormalities , whether delayed or immediate . in an acute setting ,
the indications for exploration include , but are not limited to , cerebrospinal fluid leak , infection , and partial or progressive deficits .
risk of bullet migration and development of fibrosis and stenosis over time should be considered in other patients .
these patients should therefore be informed about late complications if a decision is made to manage them conservatively .
regular follow - ups with radiographs may also be required to monitor bullet migration18 ) .
in contrast , ben - galim and reitman2 ) recommend early surgical intervention even if the patient has no neurological symptoms initially because of the risk that neurological deficits will develop as a result of intrathecal bullet migration and inflammatory reaction . in our case , after healing of the internal organs , the patient began walking with a cane , after walking he discovered that he had continuous radiating pain in both lower extremities .
we presumed that a claudication patient needed bed rest for healing of internal organ injury , which masked the walking symptom of claudication and radicular pain .
we decided on surgical treatment because the patient had neurologic abnormalities and neurological symptom aggravation .
after surgery , he showed definite improvement of motor power in the right leg ; however , independent ambulation without a cane was not achieved .
firstly we found the inflammatory changes in surgical field , however we missed taking pictures .
, we could not find and get the initial radiology of initial gun shot , which would be the good evidence of the pathophysiology in this case , whether symptom develop form migration of bullet or inflammation , however we presumed that both would be related with symptom .
we documented an extremely rare case of intradural location of a bullet , which was treated surgically with a satisfactory outcome .
we need to be cautious , if you see the non - symptomatic gunshot patients without penetration of bullet , which means absence of outlet of bullet . from current case and reviews of literatures ,
we need to think about possibility of intradural migration of bullet or chronic inflammation and adhesion to surrounding tissue .
 bullet injuries to the spine may cause injury to the anatomical structures with or without neurologic deterioration . 
 most bullet injuries are acute , resulting from direct injury . however , 
 in rare cases , delayed injury may occur , resulting in claudication . 
 we report a case of intradural bullet at the l3 - 4 level with radiculopathy in a 30-year - old male . after surgical removal , radicular and claudicating pain 
 were improved significantly , and motor power of the right leg also improved . 
 we report the case of intradural bullet , which resulted in delayed radiculopathy . 