View of the patient's back and bullet entry point. The bullet lodged in the left side of her chest. to the left lung through 14 cm of fatty tissue. She instantly felt numbness and weakness in her legs and fell to the floor. At a local hospital she was found to have a left hemopneumothorax. A chest tube was placed and antibiotics were administered. Three days later the patient was transferred to Kaiser Permanente Medical Center, Los Angeles, for further care. On examination she was an alert, obese young woman with a paraparesis that was much worse on the left side (3/5) than on the right side (4/5). Strength in the arms was normal. The left plantar response was extensor, the right flexor. Pain and temperature sensation were decreased on the right side below T8. Touch and position sensation were normal, but vibratory sensation was decreased bilaterally at the ankles. Rectal sphincter tone was decreased. Coordination and examination of the cranial nerves were normal. She was unable to sit or stand without support.
X rays showed multiple bullet fragments along the 8th posterior left rib .
??PA and lateral views?? of the thoracic spine show a bullet with its multiple fragments seen along the 8th posterior rib. Some metal fragments are seen overlying the posterior 8th vertebral body. The lateral films appear to show the bullet overlying the posterior elements of the 8th vertebra. No destroyed vertebral body was specifically identified. 2-18-93. A bullet with multiple fragments appeared to be overlaying the posterior element of the 8th vertebra. There were no fractures.
A computed tomogram with intrathecal contrast media was performed and confirmed that there were no bullet fragments in the spinal canal. There was mild enlargement of the spinal cord from T8 through T10 .
CT scan of the thoracic spine with intrathecal contrast. The spinal chord is intact, is normal in size at T6, but shows mild enlargement from T8 through T10. The spinal cord returns to normal size at T11. No metal fragments or fracture are seen within either the spinal cord or the neural foramina. 2-19-93. There was no evidence of spinal cord or nerve root compression. Bullet fragments were present outside the T8-9 neural foramina. .
Two views of a CT scan with intrathecal contrast at T8 of the thoracic spine. Multiple small bullet fragments are seen adjacent to and within the the T neural foramen on the left side. No bullet fragments are seen within the spinal canal. 4-7-93.
The patient was diagnosed to have Brown Sequard-plus (BB-plus) syndrome[12] and was treated with physiotherapy. At discharge from the hospital 16 days after the accident the patient was able to sit independently and take several steps with a walker and two people maximum assistance. After three weeks of intensive inpatient rehabilitation at a spinal cord injury center, the patient was able to walk 50 feet independently with a walker. She subsequently showed gradual improvement while receiving outpatient physical therapy. At six months after the injury she had almost completely recovered full neurologic function, except for mild residual diminished pain and temperature sensation on the right side below T8, which did not interfere with her activities. She was able to walk independently, and had normal bladder and bowel function. A repeat CT scan eight months after the accident
CT-thoracic spine with intrathecal contrast. This image is compared to the previous thoracic CT with intrathecal contrast . There is no evidence of swelling of the spinal cord. The spinal cord is normal in size from T through T. There is no evidence of displacement of the spinal cord in lateral, ventral or dorsal projections. 10-28-93. showed no evidence of cord swelling. In fact, it was normal in size from T6 through T10. This correlated well with the patient's recovery. Bullet fragments were still present in the paraspinous region at the level of T8 and T9 on the left, with a single small bullet fragment present in the T8-9 neural foramen on the left. Bullet fragments remained unchanged in position. Finally, 29 months after the accident there remained small residual sensory and proprioceptive deficit in the right lower extremity and a slight weakness of the left lower extremity, but, otherwise, the patient leads a completely normal life.