Hit Me with Your Best Shot: Complex Lumbosacral Plexopathy Secondary to Gunshot Wound

Case Diagnosis: 20-year-old female with right lower extremity weakness after gunshot wound who was found to have an extensive lumbosacral plexopathy diagnosed by NCS/EMG.

Case Description or Program Description: A 20-year-old female presented as a level 1 trauma after sustaining a gunshot wound while working her shift at a local coffee shop. In the trauma bay, there was a single entrance wound in the RLQ of her abdomen. She complained of numbness to her right leg and pelvic x-ray confirmed a retained bullet. FAST exam revealed free fluid prompting emergent exploratory laparotomy. During her hospital stay, she developed worsening pain, numbness and weakness to the right lower extremity. Unfortunately, she was unable to undergo MRI due to the retained bullet, therefore electrodiagnostic studies were recommended.

Setting: Outpatient EMG clinic

Assessment/Results: Roughly one month after her hospitalization, the patient presented to our PM&R outpatient clinic for NCS/EMG. The patient was ambulatory with a rolling walker, however she continued to have pronounced pain and weakness in her right leg particularly with hip flexion, knee extension, and dorsiflexion. Based on our electrodiagnostic findings, we found that our patient had an extensive right lumbosacral plexopathy with the greatest severity affecting the femoral, obturator and sciatic nerve.

Discussion (relevance): Although our patient’s history and physical exam provided us with a likely diagnosis of a plexopathy, we were unable to confirm this diagnosis with MRI imaging due to the retained bullet her pelvis. Our electrodiagnostic studies helped us to determine the location and extent of injury to her peripheral nerves. The information from our studies also provided the patient with a prognosis and likelihood of recovery.

Conclusions: Our patient's EMG study revealed volitional MUAP activity to all the muscles tested in her right leg. Therefore, we concluded that there was no evidence of complete denervation/neurotmesis. We educated the patient that although her length of recovery time may be prolonged, her prognosis was favorable for regeneration of the damaged nerves and muscle reinnervation. We recommended that she continue outpatient physical therapy to gradually improve function overtime.