Migration of a swallowed needle into the cervical spine: case report

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  • Division of Neurosurgery, Department of Surgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Foreign body migration into the cervical spine is rare. Only 3 prior reports of needle migration into the cervical spine exist in the literature. Here, the authors report one such case, where the migrated needle narrowly avoided the thecal sac and vertebral artery. To the authors’ knowledge, this is the first report of a migrated swallowed foreign body in the cervical spine.

Foreign body migration into the cervical spine is rare. Only 3 prior reports of needle migration into the cervical spine exist in the literature. Here, the authors report one such case, where the migrated needle narrowly avoided the thecal sac and vertebral artery. To the authors’ knowledge, this is the first report of a migrated swallowed foreign body in the cervical spine.

Foreign body ingestion is a common issue in pediatric patients. Swallowed foreign bodies can present usually with dysfunction of any portion of the gastrointestinal tract. Migration of a swallowed foreign body into the vertebral column is rare, with no prior cases reported by the authors. Other foreign bodies have rarely been reported in the cervical spine.1–8 Here, we report the first case of a swallowed sewing needle migrating into the cervical spine.

Case Report

A 16-year-old previously healthy girl presented to the emergency department at a local hospital with neck discomfort after eating a bowl of fish-shaped crackers. After a short assessment and head and neck examination, the patient was sent home with reassurance. Over the next 3 days, her discomfort became increasingly worse and she developed odynophagia and hoarseness. She was taken to the nearest major hospital by her parents. There, plain radiographs of the neck were obtained and demonstrated a foreign body anteriorly entering the vertebral column (Fig. 1). Cervical spine CT scanning and CTA were performed and demonstrated a needle-shaped object entering the left C4–5 interspace, passing medial to the vertebral artery with no violation of the vertebral artery (Fig. 2). Our neurosurgical unit was contacted, and the patient was transferred for further assessment.

FIG. 1.
FIG. 1.

Plain anteroposterior (A) and lateral (B) radiographs showing the presence of a metallic foreign body entering the cervical spine.

FIG. 2.
FIG. 2.

Axial (A) and sagittal (B) CT scans showing the needle entering the C4–5 interspace medial to the vertebral artery.

The patient denied any radiculopathic symptoms, tingling, weakness, or bladder and bowel issues. She did not report difficulty with secretions or drooling. She denied intentional ingestion, stating that she had just been snacking on the crackers. Possible psychiatric causes of foreign body ingestion were excluded after discussion with the patient and her family. We did not obtain a formal psychiatry consult, but a social worker did see the patient and agreed that self-harm was unlikely. On examination, the patient had stable vital signs, was not in respiratory distress, and was neurologically intact.

The decision was made to surgically remove the needle. The pediatric general surgery team was consulted preoperatively because of the transpharyngeal route taken by the needle. The patient was taken to the operating room for a left-sided standard anterior cervical exposure for removal of the needle. Intubation proceeded without issue. Anterior cervical spine exposure was performed in the standard fashion. Fluoroscopy was used to confirm the correct level. After insertion of the trimline retractors, the operative microscope was brought in to explore the field for the foreign body. The needle was visualized and removed (Fig. 3) without violation of spinal structures. There was no fluid leakage after removal of the foreign body, so hemostasis was achieved and the wound was closed. No involvement of general surgery was needed during the operation. Postoperatively, CTA was performed, which confirmed that there was no arterial injury. The patient was started on antibiotic prophylaxis with ciprofloxacin and metronidazole as per the suggestion of the pediatric general surgery team. The patient was discharged on postoperative day 1 on oral antibiotics for a 7-day course with no complications.

FIG. 3.
FIG. 3.

Photograph of the needle with a ruler for scale. Figure is available in color online only.

The patient was seen for follow-up 6 weeks postoperatively. She was doing well, with no infectious or neurological complications. Her odynophagia and hoarseness had resolved. She was not booked for further follow-up.

Discussion

Swallowing foreign bodies is common in children. Only approximately 1% of ingestions require surgical intervention.9 The most common complications of needle ingestion are duodenal and cecal perforation. Unusual needle migrations, including to the lung,10 the aortic arch,11 the pericardium,12 the thyroid,13 and the anterior lumbar spine,14 have been reported.

Cervical foreign bodies are rare, with only a few reports in the literature. These include a nail from a nail gun,5 a chopstick,7 and a pocketknife blade.8 A sublaminar wire has been reported after unexpectedly migrating transdurally to an intramedullary position.3 Two reports describe sewing needles as foreign bodies,2,6 and 3 further reports describe acupuncture needles as foreign bodies in the cervical spine.1,4 In each of these reports, the object was inserted forcefully into the neck either anteriorly or posteriorly. We were unable to find prior reports of swallowed foreign bodies migrating into the cervical spine.

Anatomically, the location of the needle in our report is similar to that of a previously reported sewing needle.2 In that case, the needle entered posteriorly and ran anterolaterally between the dura mater and vertebral artery. In our case, the needle passed medial to the vertebral artery though the neural foramen. In addition, that needle had been in situ for 2 years prior to intervention. It is likely that the CSF leakage reported by the authors was due to local inflammation and scarring around the foreign body due to the time from injury. Primary duraplasty in their case prevented chronic CSF leak or formation of fistula.

Our patient fortunately had no complications. Other reports of a cervical foreign body have described dural tears,6 CSF leak,2 subarachnoid hemorrhage,1 radiculopathy,1,8 spinal cord injury,4 and the need for extensive dissection.7 These other cases were complicated by the length of time the object was in situ,2,6 the force of insertion of the object,7 or the size8 or location1,4 of the object. The transesophageal entry of the foreign body in the current report did present unique challenges in terms of infection risk and intubation. Due to the entry through the gastrointestinal tract, which is not sterile, we elected to use antibiotic prophylaxis in concordance with prior reports.7

A careful social history was important in this case. In several of the prior cases of cervical foreign bodies, there has been a psychiatric component to the case. In our case, the patient steadfastly denied intentional ingestion of the needle in question. Our social work team assessed the patient and agreed that there was no component of self-harm. Swallowed needles are very infrequently used as a method of self-harm.15 Only two prior cases of self-harm leading to a cervical foreign body have been reported.2,7

Conclusions

We present the first report of a migrated swallowed foreign body into the cervical spine. Our patient had no complications. In patients with foreign body ingestion, adequate workup should be done to exclude uncommon complications. Migration of foreign bodies to neighboring structures should be considered as a possibility. Based on the location of the needle in this case, preoperative vascular imaging and attention to intraoperative CSF leakage are important considerations. Antibiotics based on a transesophageal route were felt to be indicated.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: both authors. Acquisition of data: Persad. Drafting the article: Persad. Critically revising the article: both authors. Reviewed submitted version of manuscript: both authors. Approved the final version of the manuscript on behalf of both authors: Vitali.

References

  • 1

    Anderson DW, Datta M. The self-pith. AJNR Am J Neuroradiol. 2007;28(4):714715.

  • 2

    Arizumi F, Inoue Sh, Tachibana T, et al. A sewing needle in contact with the cervical dura mater and vertebral artery: a case report. Medicine (Baltimore). 2016;95(52):e5764.

    • Search Google Scholar
    • Export Citation
  • 3

    Fraser AB, Sen C, Casden AM, et al. Cervical transdural intramedullary migration of a sublaminar wire. A complication of cervical fixation. Spine (Phila Pa 1976). 1994;19(4):456459.

    • Search Google Scholar
    • Export Citation
  • 4

    Murata K, Nishio A, Nishikawa M, et al. Subarachnoid hemorrhage and spinal root injury caused by acupuncture needle—case report. Neurol Med Chir (Tokyo). 1990;30(12):956959.

    • Search Google Scholar
    • Export Citation
  • 5

    Nathoo N, Sarkar A, Varma G, Mendel E. Nail-gun injury of the cervical spine: simple technique for removal of a barbed nail. J Neurosurg Spine. 2011;15(1):6063.

    • Search Google Scholar
    • Export Citation
  • 6

    Silvestro C, Cocito L, Pisani R. Delayed effects of a migrated foreign body (sewing needle) in the cervical spine: a case report. Spine (Phila Pa 1976). 2001;26(5):578579.

    • Search Google Scholar
    • Export Citation
  • 7

    Yamaguchi S, Eguchi K, Takeda M, et al. Penetrating injury of the upper cervical spine by a chopstick—case report. Neurol Med Chir (Tokyo). 2007;47(7):328330.

    • Search Google Scholar
    • Export Citation
  • 8

    Zaldivar-Jolissaint JF, Bobinski L, Van Dommelen Y, et al. Delayed presentation of deep penetrating trauma to the subaxial cervical spine. Eur Spine J. 2015;24(suppl 4):S540S543.

    • Search Google Scholar
    • Export Citation
  • 9

    Webb WA. Management of foreign bodies of the upper gastrointestinal tract: update. Gastrointest Endosc. 1995;41(1):3951.

  • 10

    Ozkan Z, Kement M, Kargı AB, et al. An interesting journey of an ingested needle: a case report and review of the literature on extra-abdominal migration of ingested foreign bodies. J Cardiothorac Surg. 2011;6:77.

    • Search Google Scholar
    • Export Citation
  • 11

    Macchi V, Porzionato A, Bardini R, et al. Rupture of ascending aorta secondary to esophageal perforation by fish bone. J Forensic Sci. 2008;53(5):11811184.

    • Search Google Scholar
    • Export Citation
  • 12

    Cekirdekci A, Ayan E, Ilkay E, Yildirim H. Cardiac tamponade caused by an ingested sewing needle. A case report. J Cardiovasc Surg (Torino). 2003;44(6):745746.

    • Search Google Scholar
    • Export Citation
  • 13

    Chen CY, Peng JP. Esophageal fish bone migration induced thyroid abscess: case report and review of the literature. Am J Otolaryngol. 2011;32(3):253255.

    • Search Google Scholar
    • Export Citation
  • 14

    Ozsunar Y, Tali ET, Kilic K. Unusual migration of a foreign body from the gut to a vertebral body. Neuroradiology. 1998;40(10):673674.

    • Search Google Scholar
    • Export Citation
  • 15

    Shahmansouri N, Shirzad M, Zeraatiannejad Davani S, Heidari F. An atypical suicide attempt: self-inflicted intra-cardiac injury with sewing needle. Iran J Psychiatry Behav Sci. 2014;8(4):8082.

    • Search Google Scholar
    • Export Citation

Contributor Notes

Correspondence Aleksander Michal Vitali: University of Saskatchewan, Royal University Hospital, Saskatoon, SK, Canada. alex.vitali@usask.ca.

INCLUDE WHEN CITING Published online April 3, 2020; DOI: 10.3171/2020.1.PEDS19590.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • View in gallery

    Plain anteroposterior (A) and lateral (B) radiographs showing the presence of a metallic foreign body entering the cervical spine.

  • View in gallery

    Axial (A) and sagittal (B) CT scans showing the needle entering the C4–5 interspace medial to the vertebral artery.

  • View in gallery

    Photograph of the needle with a ruler for scale. Figure is available in color online only.

  • 1

    Anderson DW, Datta M. The self-pith. AJNR Am J Neuroradiol. 2007;28(4):714715.

  • 2

    Arizumi F, Inoue Sh, Tachibana T, et al. A sewing needle in contact with the cervical dura mater and vertebral artery: a case report. Medicine (Baltimore). 2016;95(52):e5764.

    • Search Google Scholar
    • Export Citation
  • 3

    Fraser AB, Sen C, Casden AM, et al. Cervical transdural intramedullary migration of a sublaminar wire. A complication of cervical fixation. Spine (Phila Pa 1976). 1994;19(4):456459.

    • Search Google Scholar
    • Export Citation
  • 4

    Murata K, Nishio A, Nishikawa M, et al. Subarachnoid hemorrhage and spinal root injury caused by acupuncture needle—case report. Neurol Med Chir (Tokyo). 1990;30(12):956959.

    • Search Google Scholar
    • Export Citation
  • 5

    Nathoo N, Sarkar A, Varma G, Mendel E. Nail-gun injury of the cervical spine: simple technique for removal of a barbed nail. J Neurosurg Spine. 2011;15(1):6063.

    • Search Google Scholar
    • Export Citation
  • 6

    Silvestro C, Cocito L, Pisani R. Delayed effects of a migrated foreign body (sewing needle) in the cervical spine: a case report. Spine (Phila Pa 1976). 2001;26(5):578579.

    • Search Google Scholar
    • Export Citation
  • 7

    Yamaguchi S, Eguchi K, Takeda M, et al. Penetrating injury of the upper cervical spine by a chopstick—case report. Neurol Med Chir (Tokyo). 2007;47(7):328330.

    • Search Google Scholar
    • Export Citation
  • 8

    Zaldivar-Jolissaint JF, Bobinski L, Van Dommelen Y, et al. Delayed presentation of deep penetrating trauma to the subaxial cervical spine. Eur Spine J. 2015;24(suppl 4):S540S543.

    • Search Google Scholar
    • Export Citation
  • 9

    Webb WA. Management of foreign bodies of the upper gastrointestinal tract: update. Gastrointest Endosc. 1995;41(1):3951.

  • 10

    Ozkan Z, Kement M, Kargı AB, et al. An interesting journey of an ingested needle: a case report and review of the literature on extra-abdominal migration of ingested foreign bodies. J Cardiothorac Surg. 2011;6:77.

    • Search Google Scholar
    • Export Citation
  • 11

    Macchi V, Porzionato A, Bardini R, et al. Rupture of ascending aorta secondary to esophageal perforation by fish bone. J Forensic Sci. 2008;53(5):11811184.

    • Search Google Scholar
    • Export Citation
  • 12

    Cekirdekci A, Ayan E, Ilkay E, Yildirim H. Cardiac tamponade caused by an ingested sewing needle. A case report. J Cardiovasc Surg (Torino). 2003;44(6):745746.

    • Search Google Scholar
    • Export Citation
  • 13

    Chen CY, Peng JP. Esophageal fish bone migration induced thyroid abscess: case report and review of the literature. Am J Otolaryngol. 2011;32(3):253255.

    • Search Google Scholar
    • Export Citation
  • 14

    Ozsunar Y, Tali ET, Kilic K. Unusual migration of a foreign body from the gut to a vertebral body. Neuroradiology. 1998;40(10):673674.

    • Search Google Scholar
    • Export Citation
  • 15

    Shahmansouri N, Shirzad M, Zeraatiannejad Davani S, Heidari F. An atypical suicide attempt: self-inflicted intra-cardiac injury with sewing needle. Iran J Psychiatry Behav Sci. 2014;8(4):8082.

    • Search Google Scholar
    • Export Citation

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