Massachusetts General Hospital, Boston, MA, USA.
Pain Physician. 2013 Mar-Apr;16(2):E103-6.
We are reporting on the implantation of a spinal cord stimulator to treat intractable radicular pain following a retained bullet fragment in the spinal canal. Such retained fragments are associated with risks including pain, neurological deficit, infection, toxic effects, and migration. Our patient was a young man with radicular pain and history of a gunshot entering the abdomen. Computed tomography of the spine had revealed a nearly complete bullet in the right paracentral canal at L4, partially extending into the lateral recess. He presented 17 months after his injury with gradually worsening pain and parasthesias radiating from the back to the whole right leg and foot. There was no weakness. As the patient had failed conservative therapy, procedural options were considered. In this case, the potential benefits of epidural steroid injection by any approach might not have outweighed risks of infection, related to foreign body and local steroid, or possible migration due to mechanical forces during injection. As he may well need repeated epidural steroid injections to manage his pain, this increases his risk for infection. A percutaneous trial spinal cord stimulation lead was placed, with epidural entry well away from the bullet. After good results, a permanent system was implanted. There was no evidence of infection or migration, and excellent pain relief was achieved. Bullets and other foreign bodies retained in the spinal canal can cause progressive neurologic symptoms through reactive tissue formation and compression. Spinal cord stimulation can relieve radicular pain while avoiding risks associated with altering the location of the offending foreign body.
我们报告了一例脊髓刺激器植入术，用于治疗椎管内残留弹片引起的顽固性神经根痛。这些残留的弹片会带来疼痛、神经功能缺损、感染、毒性作用和迁移等风险。我们的患者是一名年轻男性，因腹部中弹，有神经根痛和病史。脊柱 CT 显示 L4 右侧旁中央管内有一枚几乎完整的子弹，部分延伸至侧隐窝。他在受伤后 17 个月出现逐渐加重的疼痛和从背部放射到整个右腿和脚的感觉异常。没有无力。由于患者保守治疗失败，考虑了手术方案。在这种情况下，任何方法的硬膜外类固醇注射的潜在益处可能都不及感染的风险，这与异物和局部类固醇有关，或由于注射过程中的机械力而导致的可能迁移。由于他可能需要反复硬膜外类固醇注射来控制疼痛，这会增加他感染的风险。我们先放置了经皮试验性脊髓刺激导线，硬膜外进入点远离弹片。结果良好后，植入了永久性系统。没有感染或迁移的证据，并且获得了极佳的疼痛缓解效果。子弹和其他残留在椎管内的异物可通过反应性组织形成和压迫引起进行性神经症状。脊髓刺激可以缓解神经根痛，同时避免改变致病异物位置带来的风险。
