Removal of Migrating Lumbar Spine Bullet: Case Report and Surgical Video.

BACKGROUND: Gunshot wounds to the spine are devastating injuries. Rarely, the bullet has been reported to migrate. Migration is associated with progressive neurologic deficits that often improve with bullet removal. The authors report a case of removal of a migrating lumbar spine bullet. This is supplemented by an operative video and a review of the literature. CASE DESCRIPTION: A 31-year-old man presented to the emergency department with multiple gunshot wounds and lower-extremity paresthesia. A ballistic injury occurred with an entry wound in the right posterior soft tissues, traversing the right paraspinal muscle and fracturing the left lumbar 5 pedicle and left lumbar 4 transverse process. The bullet was positioned within the spinal canal at the lumbar 3/4 interspace. His spinal injury was managed nonoperatively due to his traumatic injuries and findings of minimal neurologic deficit without cerebrospinal fluid leak. The patient returned to the neurosurgery clinic a year later and was found to have worsening low back pain, decreased sensation throughout the left leg, and radiating pain throughout the right leg. Imaging demonstrated the bullet had migrated caudally to the midlumbar 5 vertebral body. Given the patient's progressive symptoms and migration of the bullet fragment, informed consent was obtained for a laminectomy and removal of the intradural bullet fragment. CONCLUSIONS: Neurosurgical treatment for gunshot wounds remains controversial. Cauda equina or lumbosacral level wounds are often incomplete and may improve with surgical decompression and bullet removal. Migrating bullet fragments throughout the spine and brain lead to worsened neurologic function, which can be reversed by removal. Movement of the bullet during surgery should be expected, and intraoperative fluoroscopy and patient positioning can help to properly localize the bullet and aid in its removal.

Increased immune gene expression and immune cell infiltration in high-grade astrocytoma distinguish long-term from short-term survivors.

Survival in the majority of high-grade astrocytoma (HGA) patients is very poor, with only a rare population of long-term survivors. A better understanding of the biological factors associated with long-term survival in HGA would aid development of more effective therapy and survival prediction. Factors associated with long-term survival have not been extensively studied using unbiased genome-wide expression analyses. In the current study, gene expression microarray profiles of HGA from long-term survivors were interrogated for discovery of survival-associated biological factors. Ontology analyses revealed that increased expression of immune function-related genes was the predominant biological factor that positively correlated with longer survival. A notable T cell signature was present within this prognostic immune gene set. Using immune cell-specific gene classifiers, both T cell-associated and myeloid linage-associated genes were shown to be enriched in HGA from long-term versus short-term survivors. Association of immune function and cell-specific genes with survival was confirmed independently in a larger publicly available glioblastoma gene expression microarray data set. Histology was used to validate the results of microarray analyses in a larger cohort of long-term survivors of HGA. Multivariate analyses demonstrated that increased immune cell infiltration was a significant independent variable contributing to longer survival, as was Karnofsky/Lansky performance score. These data provide evidence of a prognostic anti-tumor adaptive immune response and rationale for future development of immunotherapy in HGA.