The patient was admitted to Shmaisani hospital 08-April-2009 with history of gun shoot 20-March-2009 with paraplegia below L3 more dense in the left and cauda equina syndrome with loss of sphenteric functions and sensation. The patient progressed pulmonary embolism 2 days before transfer from KHMC which was treated accordingly.

On examination: there is slight movement of right L5 territory with complete paralysis of all nerve roots below L3.

There was rupture of the medial collateral ligament of the right knee and posterior crociate ligament which was repaired  14-April-2009.

CT-scan of the L2-4 showed the shrapnels inside the cauda equina behind L2 and 3 levels.

Laminectomy of L2 and 3 was performed. The patient due to anticoagulation with clexan which was stopped three days ago, had gross bleeding tendency, that the epidural fat was oozing all the time. Using image-intensifier the big metallic fragment was explored which partially extradural and partially intradural and was removed fro the left side.  Inspection of the dural wall showed that it had many tears and there were only two rootlets avulsed as vision permit. The dural defect was extended inferior and the other fragment was looked for. Using image-intensifier this shrapnel was setting between the rootlets, which were adherent. It was necessary to split the rootlets so as to reach the shrapnel and to remove it so that not to perform surgical trauma to these anatomically preserved rootlets. All the stage of the operation were performed using IOM ISIS and the DNS did not show any response even with high currents reaching up to 10 mA.

Most of the rootlets were anatomically preserved but swollen and contused. It was impossible to perform closure of the dura, for what Tachyseal was used to cover the area and aided with surgicel over it. Water-tight closure of muscles.

Smooth postoperative recovery with slight deterioration of the already compromised right L5 root.

The patient had not only shrapnels, but also bony fragments hidden between the rootlets of the cauda equina. This early surgery was necessary to remove compression and clearing the area of dirt.

In the future if another surgery is planned, then it will be clear that the rootlets are not to blame of.