Management of penetrating cervical injuries is challenging. The weapon may be withdrawn
or may be intact, and its removal may add to neurologic deficit. Immobilization of
spine and careful transportation are important. Penetrating cervical spine injuries
are most commonly caused by gunshots; penetrating trauma with other objects is relatively
rare.[1]
Case 1
A 12-year-old boy was injured in the neck by a javelin while playing. The javelin
was removed immediately, and he was sent to a local hospital where the wound was debrided
and sutured. The child was referred 8 days after injury to our center. On examination,
there was a sutured laceration in the posterior cervical region. He had spasticity
in all four limbs, power 4/5 in both upper limbs with moderate grip weakness in right
hand. Lower limb power was 3/5 on right and 5/5 on left side. Bilateral triceps reflexes
were absent, and all reflexes in lower limbs were exaggerated with upgoing plantars
and absent abdominal reflex. He had 50% sensory loss to all modalities up to T8 level.
Computed tomography (CT) of the cervical spine revealed a C6 lamina fracture on the
right side with bone fragments in the spinal canal ([Fig. 1A, B]). Magnetic resonance imaging (MRI) showed a cord contusion at C6 level ([Fig. 1C, D]). The patient's C6 vertebra was operated by right-sided hemilaminectomy of the C6
vertebra with r emoval of bony fragments impinging on the cord and foreign bodies
in the form of hair, and dust in the subcutaneous tissue was done. There was no dural
rent. Antibiotics (injection ceftriaxone 100 mg/kg/d q12h and injection amikacin 15
mg/kg/d q12h) were given for 1 week till the time of suture removal after surgery.
Steroids were not used intra- or postoperatively. Postoperatively, the patient showed
improvement in the motor response from 3/5 to 4+/5 in the right lower limb and he
could walk with support ([Fig. 1E] and [F]). There was improvement in the right hand grip up to 80%.
Fig. 1 (A) Axial CT of the cervical spine showing C6 lamina fracture right side with canal
compromise. (B) Sagittal CT cervical spine showing C6 lamina fracture with bone fragments in spinal
canal. (C) Axial T2WI MRI showing fractured bone fragment impinging on thecal sac at C6 with
cord contusion. (D) Sagittal T2WI MRI showing fractured bone fragment impinging on thecal sac at C6
with cord contusion. (E) Close view of surgical wound postoperatively. (F) Patient regained significant power postoperatively and could walk with support.
MRI, magnetic resonance imaging.
Case 2
A 42-year-old man ([Fig. 2A]) had history of assault by an ice pick on left side of the neck. Following incidence
the patient was not able to move his left-sided upper and lower limbs. On examination,
there was small puncture wound of size 4 mm on left lateral side of the neck ([Fig. 2B]). There was no active bleed or discharge; localized tenderness was present. On examination,
tone was increased on left upper and lower limbs. Power was 0/5 across all joints
in the left lower limb and upper limb, and power was 4+/5 across all joints in the
right upper limb and lower limb. Deep tendon reflexes were exaggerated. Plantar reflex
was extensor bilaterally. Sensory loss was present to touch and pain up to T8 level.
Fig. 2 (A) Profile photo of the patient. (B) Close view of puncture wound site on left side of neck. (C) Axial T2WI MRI s/o cord contusion at C3 level. (D) Sagittal T2WI MRI showing cord contusion at C3 level. MRI, magnetic resonance imaging.
X-ray and CT of the cervical spine were normal. MRI of the cervical spine was done,
which was suggestive of cord contusion at C3 level ([Fig. 2C, D]). The patient was managed conservatively. Entry site did not show any signs of infection
at presentation and also during the period of hospital stay. Only antibiotics were
administered for 7 days (injection ceftriaxone 100 mg/kg/d IV q12h and injection amikacin
15 mg/kg/d IV q12h), and no wound debridement was deemed necessary. Steroids were
not given. There was improvement in the power, 5/5 across all joints in right upper
and lower limbs, and it was 2/5 across shoulder, 3/5 across elbow, and 3/5 across
all joints in lower limbs.
Most of the penetrating spinal injuries consist of gunshot injuries. Cervicothoracic
spinal involvement is most common. Penetrating cervical injuries with other objects
are relatively rare[1] and are usually associated with assault. These injuries are mostly reported in younger
men, and the weapon is typically knife (incidence: 72–84%).[2] Penetrating injuries with other objects are even rarer. In the largest series from
South Africa, assault with axes, screwdriver, bicycle, spokes, garden forks, sickles,
and sharpened broomsticks have been reported.[2] Assailants typically aim for the neck or chest, and the cervicothoracic region is
within the natural sweep of attacker's arm. Laterally directed horizontal stab can
cause complete transaction of the cord as can pass between the two vertebrae, but
stab from behind usually produces incomplete cord damage.[3] Immediate damage is caused by primary neural injury, vascular injury, injury caused
by in-driven foreign bodies, and bone fragments. Secondary damage may be caused by
retained weapon, infection, edema, and cerebro-spinal fluid (CSF) leak. According
to literature, prophylactic antibiotics should be given, but the duration to which
they should be continued is controversial. The agent should be chosen depending on
antibiotic policy in each institution, site of injury, associated viscous perforation
(lungs, bowel, etc.), and degree of contamination by the penetrating object. Viscous
injuries are more associated with lumbar or thoracic region penetrating trauma. These
may require more extensive management such as thorough peritoneal lavage, wound debridement,
diverting colostomies, etc. In such cases, antibiotic coverage may be indicated for
a prolonged period of time.[4] The duration of antibiotics extended for a period of 7 to 14 days reduces rate of
infection as compared with 48 to 72 hours.[5]
Heary et al[6] advocated that steroids do not offer any significant advantage in penetrating injuries
to the spine and thus must be avoided. The risk of immune compromise and subsequent
infection is much higher than any other expected benefit.
Indications for surgery include progressive neurodeficit, CSF leak, radiologic evidence
of neural compression by retained foreign body, bone fragment, or soft tissue. Thakur
et al treated 81% of nonmissile penetrating spinal injuries cases by doing surgical
exploration with dural repair and removal of foreign body or simple exploration and
irrigation.[7] However, others report no difference in outcome following surgical management in
patients with complete or incomplete spinal injury.[8] Karlins et al have shown improvement in patients even with delayed intervention.[9]
Gold standard procedure includes surgical decompression with laminectomy, removal
of the foreign object in the original trajectory path, and repair of the dural tear.
We conclude that nonmissile penetrating spinal injuries are a rare cause of penetrating
cervical cord injuries. In properly selected patients, surgery can offer good neurologic
outcome even in delayed cases.
