Expert’s comment concerning Grand Rounds case entitled “Lead toxicity and management of gunshot wounds in the lumbar spine” (by B. Rentfrow, R. Vaidya, C. Elia, A. Sethi doi:10.1007/s00586-013-2805-6)

Excerpt

I read with interest this case report [1] describing late-onset plumbism associated with gunshot wound (GSW) to the spine, with retained lead-based bullet fragments within the intervertebral disc space. I congratulate the authors on their well-written, interesting, detailed, and accurate discussion of the literature pertaining to GSW involving the spine. I particularly enjoyed their description of the various challenges that can be encountered in the treatment of projectile injuries to the spine and the indications for surgical intervention, which include the uncommon cases of spinal instability, the presence of neurological compression with progressive spinal cord injury, recalcitrant infection, and late-onset claudication, in addition to plumbism. The authors go on to describe the challenges that occur when having to address extensive scar formation in the epidural space and around the great vessels, both of which can be predictably encountered when addressing delayed onset plumbism secondary to a bullet fragment. Their case report also emphasizes the difficulties that can be anticipated when trying to remove all bullet fragments due to the potential for proximity and adherence to vital structures, and subsequently, the uncertainty involved in deciding on the need for additional surgery if serum lead levels remain elevated postoperatively or gradually increase again over time in the setting of residual bullet fragments. …