Nonmissile penetrating spinal injury

Case report and review of the literature

Restricted access

✓ Nonmissile penetrating spinal injuries (NMPSIs) are rare, even among the population of patients treated in large trauma centers. Patients who present with retained foreign body fragments due to stabbings represent an even smaller subset of NMPSI, and their optimal management is unclear.

The authors report the case of a 42-year-old man who presented to the University of California at Davis Medical Center with a retained knife blade after suffering a stab wound to the lower thoracic spine. They discuss this case in the context of a literature review and propose management options for patients with NMPSIs in whom fragments are retained.

A search of PubMed was undertaken for articles published between 1950 and 2006; the authors found 21 case reports and eight case series in the English-language literature but discovered no published guidelines on the management of cases of NMPSI with retained fragments.

After clinicians undertake appropriate initial trauma evaluation and resuscitation, they should obtain plain x-ray films and computerized tomography scans to delineate the anatomical details of the retained foreign body in relation to the stab wound. Neurosurgical consultation should be undertaken in all patients with an NMPSI, whether or not foreign body fragments are present. Surgical removal of a retained foreign body is generally recommended in these patients because the fragments may lead to a worse neurological outcome. Perioperative antibiotic therapy may be beneficial, but the result depends on the nature of the penetrating agent. There is no documentation in the literature to support the use of steroid agents in patients with NMPSIs.

Abbreviations used in this paper: CSF = cerebral spinal fluid; CT = computerized tomography; MR = magnetic resonance; MVA = motor vehicle accident; NMPSI = nonmissile penetrating spinal injury; SCI = spinal cord injury; VB = vertebral body.

Article Information

Address reprint requests to: Dongwoo John Chang, M.D., F.R.C.S.(C), Department of Neurological Surgery, University of California at Davis Medical Center, 4860 Y Street, Suite 3740, Sacramento, California 95817. email: dongwoo.chang@ucdmc.ucdavis.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Scout film from a CT scan revealing an 11.5-cm retained knife blade at the T-10 vertebra. The blade appears to enter the VB at the left inferior endplate and lie with its tip at the right superior endplate.

  • View in gallery

    Sequential noncontrast axial bone-window CT scans obtained through the T-10 VB revealing a retained knife blade entering at the left pedicle and traversing in a caudal direction through the VB. There is approximately 2 mm of central canal encroachment by the convex surface of the knife blade. There is no evidence of intraspinal hematoma on tissue windows.

  • View in gallery

    A and B: Three-dimensional reconstructed CT scans revealing a knife blade entering the T-10 VB at the left lower end-plate in a trajectory parallel and adjacent to the 11th rib. C: Three-dimensional reconstructed CT scan (caudocranial perspective) obtained at the T11–12 interspace. The convex knife blade surface is visualized in the central canal as an irregular artifact (arrow).

  • View in gallery

    Photograph showing the retained knife blade after surgical removal.

References

  • 1

    Adams RFAnslow PTalbot K: Screwdriver headache: a case of traumatic intracranial hypotension. Clin Radiol 56:6766802001

  • 2

    Adornato DCCollis JS: Stab wounds of the spinal cord. Int Surg 57:1471501972

  • 3

    Bill JH: Notes on arrow wounds. (With three wood cuts.). Am J Med Sci 44:3653871862

  • 4

    Bouderka MAAl Harrar RBouaggad AHarti ABarrou HBenaguida M: Tétraplégies consécutives à une plaie cervicale par arme blanche. Ann Fr Anesth Reanim 16:58601997

    • Search Google Scholar
    • Export Citation
  • 5

    Carey MEBrain and spinal wounds caused by missiles. Long D: Current Therapy in Neurological Surgery. 1985–1986 TorontoBC Decker1985. 114116

    • Search Google Scholar
    • Export Citation
  • 6

    Castillo RKahn EA: Asymptomatic transfixion of spinal cord by a knife blade. Report of a case. J Neurosurg 7:1791821950

  • 7

    Connell RAGraham CAMunro PT: Is spinal immobilisation necessary for all patients sustaining isolated penetrating trauma?. Injury 34:9129142003

    • Search Google Scholar
    • Export Citation
  • 8

    Fung CFNg TH: Delayed myelopathy after a stab wound with a retained intraspinal foreign body: case report. J Trauma 32:5395411992

    • Search Google Scholar
    • Export Citation
  • 9

    Groen RJMKafiluddin EAHamburger HLVeldhuizen EJFH: Spinal cord injury with a stingray spine. Acta Neurochir (Wien) 144:5075082002

    • Search Google Scholar
    • Export Citation
  • 10

    Guillain GGarcin R: Le syndrome de Brown-Sequard d’origine traumatique. Ann Med Interne 29:3613851931

  • 11

    Harmit SSinghal VBansal VP: Intraspinal, extradural stab injury of the spine without neurologic deficit. A case report. Int Orthop 9:2772781985

    • Search Google Scholar
    • Export Citation
  • 12

    Heary RFVaccaro ARMesa JJBalderston RA: Thoracolumbar infections in penetrating injuries to the spine. Orthop Clin North Am 27:69811996

    • Search Google Scholar
    • Export Citation
  • 13

    Hecimovic IVrankovic DRubin OMaksimovic ZRukovanjski M: Transoral missile removal from the anterior C1 region following transpharyngeal missile wound. Arch Orthop Trauma Surg 119:3403431999

    • Search Google Scholar
    • Export Citation
  • 14

    Horowitz MDDove DBEismont FJGreen BA: Impalement injuries. J Trauma 25:9149161985

  • 15

    Jallo GI: Neurosurgical management of penetrating spinal injury. Surg Neurol 47:3283301997

  • 16

    Jones FDWoosley RE: Delayed myelopathy secondary to retained intraspinal metallic fragment. Case report. J Neurosurg 55:9799821981

    • Search Google Scholar
    • Export Citation
  • 17

    Jones WA: Old stab wounds of the spinal cord with subsequent widespread pigmentation of the spinal cord and base of the brain. JAMA 121:100410061943

    • Search Google Scholar
    • Export Citation
  • 18

    Karger BSudhues HBrinkmann B: Arrow wounds: major stimulus in the history of surgery. World J Surg 25:155015552001

  • 19

    Karim NONabors MWGolocovsky MCooney FD: Spontaneous migration of a bullet in the spinal subarachnoid space causing delayed radicular symptoms. Neurosurgery 18:971001986

    • Search Google Scholar
    • Export Citation
  • 20

    Karlins NLMarmolya GSnow N: Computed tomography for the evaluation of knife impalement injuries: case report. J Trauma 32:6676681992

    • Search Google Scholar
    • Export Citation
  • 21

    Kitchel SH: Current treatment of gunshot wounds to the spine. Clin Orthop Relat Res 408:1151192003

  • 22

    Kulkarni AVBhandari MStiver SReddy K: Delayed presentation of spinal stab wound: case report and review of the literature. J Emerg Med 18:2092132000

    • Search Google Scholar
    • Export Citation
  • 23

    Levy MLGans WWijesinghe HSSooHoo WEAdkins RHStillerman CB: Use of methylprednisolone as an adjunct in the management of patients with penetrating spinal cord injury: outcome analysis. Neurosurgery 39:114111481996

    • Search Google Scholar
    • Export Citation
  • 24

    Lipschitz R: Associated injuries and complications of stab wounds of the spinal cord. Paraplegia 5:75821967

  • 25

    Lipschitz RBlock J: Stab wounds of the spinal cord. Lancet 2:1691721962

  • 26

    Manzone PDomenech VForlino D: Stab injury of the spinal cord surgically treated. J Spinal Disord 14:2642672001

  • 27

    McCarron MOFlynn PAPang KAHawkings SA: Traumatic Brown-Séquard–plus syndrome. Arch Neurol 58:147014722001

  • 28

    McFadden JR: Tissue reactions to standard neurosurgical metallic implants. J Neurosurg 36:5986031972

  • 29

    Meltzer HSKim PJOzgur BMLevy ML: Vertebral body granuloma of the cervical region after pencil injury. Neurosurgery 54:152715302004

    • Search Google Scholar
    • Export Citation
  • 30

    Miller CAPenetrating wounds of the spine. Wilkins RRengachary S: Neurosurgery New YorkMcGraw Hill1985. 17461748

  • 31

    Moyed SShanmuganathan KMirvis SEBethel ARothman M: MR imaging of penetrating spinal trauma. AJR Am J Roentgenol 173:138713911999

    • Search Google Scholar
    • Export Citation
  • 32

    O’Neill SMcKinstry CSMaguire SM: Unusual stab injury of the spinal cord. Spinal Cord 42:4294302004

  • 33

    Ott KTarlov ECrowell RPapadakis N: Retained intracranial metallic foreign bodies. Report of two cases. J Neurosurg 44:80831976

    • Search Google Scholar
    • Export Citation
  • 34

    Peacock WJShrosbree RDKey AG: A review of 450 stab wounds of the spinal cord. S Afr Med J 51:9619641977

  • 35

    Rand CWPatterson GH: Stab wounds of the spinal cord. Report of seven cases. Surg Gynec Obstet 48:6526611929

  • 36

    Romanick PCSmith TKKopaniky DROldfield D: Infection about the spine associated with low-velocity-missile injury to the abdomen. J Bone Joint Surg Am 67:119512011985

    • Search Google Scholar
    • Export Citation
  • 37

    Rubin GTallman DSagan LMelgar M: An unusual stab wound of the cervical spinal cord. Spine 26:4444472001

  • 38

    Schulz FColmant HJTrübner K: Penetrating spinal injury inflicted by screwdriver: unusual morphological findings. J Clin Forensic Med 2:1531551995

    • Search Google Scholar
    • Export Citation
  • 39

    Shellock FG: Radiofrequency energy-induced heating during MR procedures: a review. J Magn Reson Imag 12:30362000

  • 40

    Sights WPBye RJ: The fate of retained intracerebral shotgun pellets. An experimental study. J Neurosurg 33:6466531970

  • 41

    Simpson RKVenger BHNarayan RK: Treatment of acute penetrating injuries of the spine: a retrospective analysis. J Trauma 29:42461989

    • Search Google Scholar
    • Export Citation
  • 42

    Simsek OKilincer CSunar HHamamcioglu MKCanbaz SÇobanogl S: Surgical management of combined stab injury of the spinal cord and the aorta—case report. Neurol Med Chir (Tokyo) 44:2632652004

    • Search Google Scholar
    • Export Citation
  • 43

    Splavski BŠarić GVrankovic DGlavina KMuršić BBlagus G: Computed tomography of the spine as an important diagnostic tool in the management of war missile spinal trauma. Arch Orthop Trauma Surg 117:3603631998

    • Search Google Scholar
    • Export Citation
  • 44

    Splavski BVranković DJŠaricć GBlagus GMuršić BRukovansjki M: Early management of war missile spine and spinal cord injuries: experience with 21 cases. Injury 27:6997021996

    • Search Google Scholar
    • Export Citation
  • 45

    Stauffer ESWood RWKelly EG: Gunshot wounds of the spine: effects of laminectomy. J Bone Joint Surg Am 61:3893921979

  • 46

    Thakur RCKhosla VKKak VK: Non-missile penetrating injuries of the spine. Acta Neurochir (Wien) 113:1441481991

  • 47

    Tindall SCBierbrauer KBrain and spinal wounds caused by missiles. Long D: Current Therapy in Neurological Surgery-2 PhiladelphiaBC Decker1989. Vol 2:187189

    • Search Google Scholar
    • Export Citation
  • 48

    Tokushige JInokuchi AKawaguchi H: Impalement injuries involving the spinal canal. J Orthop Sci 5:6146172000

  • 49

    Velmahos GCDegiannis EHart KSouter ISaadia R: Changing profiles in spinal cord injuries and risk factors influencing recovery after penetrating injuries. J Trauma 38:3343371995

    • Search Google Scholar
    • Export Citation
  • 50

    Waters RLHu SSPenetrating injuries of the spinal cord: stab and gunshot injuries. Fryomoyer JDucker TBHadler NM: The Adult Spine: Principles and Practice New YorkRaven Press1991. Vol 1:815826

    • Search Google Scholar
    • Export Citation
  • 51

    Wohltmann CDFranklin GABoaz PWLuchette FAKearney PARichardson JD: A multicenter evaluation of whether gender dimorphism affects survival after trauma. Am J Surg 181:2973002001

    • Search Google Scholar
    • Export Citation
  • 52

    Wolf SM: Delayed traumatic myelopathy following transfixion of the spinal cord by a knife blade. Case report. J Neurosurg 38:2212251973

    • Search Google Scholar
    • Export Citation
  • 53

    Yashon DJane JAWhite RJ: Prognosis and management of spinal cord and cauda equina bullet injuries in sixty-five civilians. Case report. J Neurosurg 32:1631701970

    • Search Google Scholar
    • Export Citation

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 169 169 16
Full Text Views 91 85 0
PDF Downloads 73 53 0
EPUB Downloads 0 0 0

PubMed

Google Scholar