Endoscopic percutaneous extraction of a retained bullet fragment in the lumbar spine for lead toxicity management: illustrative case.

Background: It is often common practice to leave gunshot wound (GSW) bullet fragments in the spinal column given the morbidity of surgical removal. When extraction is indicated, the least invasive approach is favored to preserve surrounding neurovascular structures, particularly in cases without focal neurological deficits. This report highlights a percutaneous endoscopic technique for the retrieval of a retained bullet causing lead toxicity.

Observations: The authors present the case of an 18-year-old female who presented for a GSW bullet lodged within her lumbar spine, who was neurologically intact with no overt instability. Outpatient follow-up was concerning for elevating blood lead serum levels of 12 μg/dL, which exceeded WHO guidelines of < 5 μg/dL. She underwent endoscopic removal of the bullet with no complications and subsequent improvement of her lead levels.

Lessons: Endoscopic techniques present a promising approach for removing bullets from the spine, with reduced tissue trauma, improved visualization, and shorter recovery times compared with traditional open or minimally invasive surgery. In cases of retained bullet fragments with no focal deficit, migration, or instability, conservative management with serial lead monitoring is recommended. However, when surgical removal is indicated from lead toxicity, endoscopic extraction of foreign bullets can be considered as an effective, yet less invasive alternative to open or minimally invasive surgical procedures. https://thejns.org/doi/10.3171/CASE2538.