In the USA, low velocity gunshot injuries (GSI) account for 13% of all urban spinal injuries, and they have become the second leading cause of all spinal cord injuries. The initial clinical evaluation should assess vascular, visceral, and/or neurological injury. Early imaging studies are required with computerized tomography in addition to plain radiographs to assess accurately the location and extent of the bone injury. The role of steroids is unclear, and if given, should be administered to GSI patients with complete or partial neurological deficit who present within eight hours of injury. The indications for prophylactic antibiotics have not been well established and although recommended, these are deemed essential only in patients with associated visceral perforation. Early surgical exploration is most appropriate to address associated vascular or visceral injury, while spinal decompression does not appear to influence neurological recovery. The majority of GSI spine fractures are stable; instability is usually due to ill-advised decompression of cervical spine GSI. Retained bullet fragments are rarely problematic; lead toxicity can occur due to missile contact with the synovial fluid, disc space, or contact with a pseudocyst.