Gunshot wounds to the spine are becoming more prevalent, especially in urban areas. Neurologic injury can occur even if the projectile does not penetrate the spinal canal. Initial treatment should consist of stabilizing the patient's medical condition followed by a careful neurologic examination. Spinal stability can be determined from plain radiographs and CT scan, with the overwhelming majority of injuries being stable. Retained bullets rarely cause problems of delayed infection, late neurologic decline, or lead toxicity, eliminating the need for prophylactic bullet removal; however, in the thoracolumbar spine, removal of bullet fragments lodged within the spinal canal has been shown to significantly improve neurologic recovery.