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CASE REPORT Korean J Spine 7(4):261-264, 2010

Transection of the Spinal Cord Following Anterior Cervical Stab : A Case Report

Chang-Min Park1, Dae-Yong Kim2, Ju Ho Jeong2, Yong-Seok Park2

1Department of , 2Neurosurgery, School of Medicine, Kosin University, Busan, Korea

Stab to the neck with transection of the cervical spinal cord and complete paraplegia in combination with penet- rating injury to the trachea and esophagus are extremely uncommon, and optimal treatment remains unclear. We report an unusual case of stab of the anterior neck with a penetrating injury to the trachea and esophagus and transection of the spinal cord at the C7-T1 level. Tracheoplasty and esophageal primary suture were performed by the thoracic . We regularly followed up the patient with the cervical spinal lesion, because there was neither definite mechanical spinal instability nor CSF leakage. Moreover, there was a possibility of the aggravation of mediastinitis. The postoperative course of the patient was uneventful without a CSF leak or a wound infection. Nineteen months after the operation, the patient had no complain of nuchal pain or the limitation of motion of the neck. There was no definite cervical instability. However, no neurological improvement has been reported either.

Key Words: Stab woundㆍCervical spinal cordㆍParaplegia

INTRODUCTION CASE REPORT

There have been a few reports of spinal cord due A 60-year-old man in a drunken state was attacked and to an unusual direction of a knife wound4). Stab injuries usually injured by a fruit knife. The 1.5 cm wound was located trans- occur in the posterior aspect of the cervical and upper thoracic versely on the lower anterior neck 1.5 cm above the sternal spines in association with spinal cord injuries, which are more notch, without any significant active . At the scene, commonly found in their incomplete form. The standard treat- he was found to be alert and in no respiratory failure, with ment of such cases is still controversial due to the lack of repor- the knife removed in the lower cervical area. At the emergency ted cases7). Furthermore, cases of cervical spinal cord injuries department, his blood pressure was 100/50 mmHg, and oxygen in combination with penetrating injury to the trachea and saturation was 93.4%. No movement of the lower extremities esophagus following cervical stab injuries are extremely rare. was seen or reported. A good carotid pulse was presented bila- Therefore, the diagnosis and treatment of such cases are diffi- terally, and no bruits were heard. Breath sound was not decrea- cult and pose a challenge to surgeons. We report herein the sed in lung, and chest radiographs revealed no abnormal fin- case of a 60 year-old man who had a transection of the cervical dings such as atelectasis. The patient sustained an incomplete spinal cord at the C7-T1 level associated with paraplegia follo- cord lesion with flaccid paraplegia but minimal preservation wing a transverse anterior cervical stab injury that penetrated of pain (pin-prick) and temperature sensation on the left lower the trachea and esophagus. A review of the literature has also extremity, which was regarded as grade B by the Frankel classi- been included. fication, and with a motor score of 25 out of 50 on both sides. There was an evidence of the deep hyperreflexia of the lower limbs. Sacral sensation and bladder/bowel functions were also ● Received: Dec 8, 2010 ● Accepted: Dec 24, 2010 not spared. ● Published: Dec 28, 2010 Simple radiographs of the cervical spine showed no bony Corresponding Author: Dae-Yong Kim, M.D. abnormality or obvious emphysema. Computed tomographic Department of Neurosurgery, Kosin University Gospel , 34 Amnam-dong, Suh-gu, Busan 602-702, Korea (CT) scans of the neck demonstrated multiple emphysema and Tel: +82-51-990-6705, Fax: +82-51-990-3042 the trace of the stab wound in the anterior neck space, without E-mail: [email protected]

Korean J Spine 7(4) December 2010 261 CM Park, et al.

Fig. 1. Computed tomographic scan of the neck showing multiple emphysema (A) and a trajectory of stab wound (B) in the anterior neck space, without obvious or foreign bodies, which were suggestive of a penetration of the trachea and esophagus.

Fig. 3. Intraoperative photograph showing nearly transected trachea and esophagus.

Fig. 2. Sagittal T1-weighted (A) and T2-weighted (B) magnetic reso- nance imaging of the cervical spine showing an air pocket in the anterior portion of the disc and a transection of the spinal cord at the C7-T1 level, with discontinuity of the anterior and posterior Fig. 4. Follow-up MR imaging (19 months after the operation) sho- dural layers. No definite epidural or subdural hematomas are seen. wing a spinal cord transected between C7 and T1 without a pseu- domeningocele, spinal abscess or syrinx. any obvious or , which suggested a penetration of the trachea and esophagus (Fig. 1). Magnetic significant cerebrospinal fluid leak. However, there was no resonance (MR) imaging of the cervical spine showed an air definite mechanical spinal instability at that point in time. pocket in the anterior portion of the disc and linear high and Regular follow up of the patient with the cervical lesion was low signal intensities of the spinal cord between the C7 and T1 decided, because there was neither definite mechanical spinal with a discontinuity of the anterior and posterior dura layers, instability nor CSF leakage was found and also there was a without any definite epidural or subdural hematoma on sagittal possibility of the aggravation of mediastinitis. After the , T2WI and T1WI, which suggested a transection of the cervical due to the lack of efficacy and the potential harm of steroid cord (Fig. 2). Under a clinical diagnosis of anterior spinal in regard to and infection, steroid therapy was injury, identification of the anterior spinal artery injury using not used. Prophylactic intravenous antibiotics were given for noninvasive CT and MR angiograms was tried, but neither 14 days. The patient was maintained on a endotracheal tube for could detect the anterior spinal artery technically. 6 days, and thereafter the tube was successfully extubated. An exploration was performed first by the thoracic surgeons. The postoperative course of the patient was uneventful without Nearly transected trachea and esophagus were detected(Fig. CSF leakage or wound infection. 3). There was a mild mediastinitis without any significant active Nineteen months after the operation, follow-up MR ima- bleeding. The wound was carefully irrigated. Tracheoplasty and ging showed a spinal cord transected between C7 and T1 without primary suture of the esophageal wound were performed. In a pseudomeningocele, spinal abscess or syrinx (Fig. 4). There the cervical spine, there was an approximately 12 mm lacera- was no definite cervical instability on simple stress X-rays. No tion of anterior longitudinal ligament and disc without any obstruction and stricture of the trachea and esophagus on

262 Korean J Spine 7(4) December 2010 Cervical Cord Stab Injury esophagogram were also found. There was no sequelae in the penetrating traumas. Therefore, steroid therapy is generally trachea or the esophagus. The patient did not complain of not recommended due to the lack of definitive evidence and nuchal pain or limitation of motion of neck. However, no its detrimental effects on wound healing and risks of infection. neurological improvement was reported. Our patient did not receive steroid therapy because there was a possibility of a delay in wound healing and a lack of definitive DISCUSSION evidence. Prophylactic antibiotic therapy is recommended, and the antibiotics are selected depending on the injured region of the body and the local hospital sensitivities. The tetanus The cervical spinal cord is relatively safe from immunization status of the patient should be identified, and injury because it is protected by the cervical vertebra. About tetanus prophylaxis is performed if needed. two-thirds of patients with spinal cord injuries show a partial Reconstructive procedures of combined tracheo-esophageal cord injury such as incomplete Brown-Sequard Syndrome rather injuries, especially total transection of both, represent a major than complete injury. A plausible explanation for this may be challenge in general thoracic and trauma surgery6). Delay of that when the spine is attacked from behind, a knife blade esophageal repair for over 24 hours increases a morbidity and goes around the spinous process to the space between the 8) mortality. So the definitive treatment must be performed within laminae with subsequent preservation of the spinal cord . Cases 24 hours after the injury. Recently, one-stage reconstructions of esophageal and spinal cord injuries following cervical penet- 3,9) with restoration of continuity of both the trachea and esopha- rating injury are extremely rare . In our case, it is thought gus (with closure of both stomas) are recommended11). There that a knife blade, which was directed anteroposteriorly almost is much controversy regarding surgical exploration of stab at the midline and parallel to the C7-T1 disc space, penetrated injuries of the spine and spinal cord1). A selective approach the trachea and esophagus and transected the spinal cord. Our has been developed in , with clearly identified case was very rare, where the bony structure did not protect indicators for surgical intervention: when (1) foreign bodies the spinal cord. are retained in the wound, (2) persistent CSF leakage, (3) fin- Simple radiographs and CT scans are mandatory for the dings of spinal cord compression, and (4) sepsis has occurred confirmation of bony injuries, retained foreign bodies and due to epidural abscess or granuloma in a late stage8). Persis- signs of spinal instability. MR imaging is the choice of modality tent CSF leakage should be treated with a dural repair using for the diagnosis of and bleeding within patches. Platz et al.9) performed a sealing procedure with the spinal cord. Spinal cord transection and dural laceration patches using fibrin glue and local muscle flaps. When dural were identified using MR images in our case. A neurological lacerations occur at the anterior and posterior aspects as in examination revealed that our case had a complete paraplegia, our case, persistent CSF leakage requires both anterior and but pain (pin-prick) and temperature sensation were minimally posterior approaches. Fortunately in our case, CSF leakage preserved. This result suggests that the right lateral spinothala- spontaneously stopped without any treatment. mic tract was minimally preserved despite the injury. When If new symptoms, such as pain, develop, MR imaging is vascular injuries are suspected by the trajectory of the knife necessary to identify the occurrence of posttraumatic syrinx10). blade, imaging studies are necessary because arterial occlusion, Delayed myelopathy, cord abscess, or symptomatic pseudome- arteriovenous fistula or false aneurysm can occur in associa- 2) ningocele have not been infrequently reported in cases of tion with a stab wound to the spine . In our case, considering retained intraspinal metallic fragments2,5,7,14). In our case, follow- the trajectory of the knife blade and the transection of the up MR imaging did not reveal the aforementioned findings. cervical spinal cord, injuries of the anterior spinal artery which To the best of our knowledge, there have been no cases of passes through the anterior median fissure was suspected. spinal instability after a non-missile penetrating injury of the However, we could not confirm the injury to the anterior spine. However, if spinal instability is suspected, flexion/exten- spinal artery using MR and CT angiography. Cervical MR sion radiographs are needed to identify the instability. Altho- imaging and CT did not reveal intradural hemorrhage. Based ugh in our case, delayed spinal instability due to partial inju- on those findings, it was thought that there was no injury ries to the anterior longitudinal ligament and disc was suspe- to the anterior spinal artery. A possible explanation may be cted, the instability was not detected on the 19-month follow- that the spinal artery avoided injury while the back of the up stress view. The reason for this may be that a portion of knife was displacing it. the intact anterior longitudinal ligament and annulus fibrosus For the treatment of spinal cord damage provoked by knife maintains the stability to some extent. However, it is thought penetration, megadose methylprednisolone would be consi- that instability may occur after long-term follow-up. There- dered, there is still some controversy regarding its efficacy in fore, regular follow-ups with flexion/extension radiographs

Korean J Spine 7(4) December 2010 263 CM Park, et al. are needed to confirm the result. junction. Neurosurgery 17:930-936, 1985 Although some investigators have demonstrated that the 3. English GM, Hsu SF, Edgar R, Gibson-Eccles M: Oesophageal improvement rate of neurological deficits is lower in patients trauma in patients with spinal cord injury. Paraplegia 30:903- 912, 1992 with incomplete spinal cord injuries after stab wounds to the 13) 12) 4. Han SR, Yoon SW, Yee GT, Sohn MJ, Whang CJ: An unusual spine , this assertion has not yet been accepted . Our patient stab injury of the cervical spinal cord: A case report. Kor J showed incomplete spinal cord injury with minimally preser- Spine 2:184-187, 2005 ved pain and temperature sensation in the left lower extre- 5. Jones FD, Woosley RE: Delayed myelopathy secondary to mity, but muscular weakness and sensory deficits did not retained intraspinal metallic fragment: Case report. J Neuro- improve even after 19 months. A possible explanation for this surg 55:979-982, 1981 may be that the entire spinal cord except the partial lateral 6. Kim DH, Yoo BH, Kim HY: Complete transsection of the spinothalamic tract was transected, and thus there was no trachea by . Korean J Thorac Cardiovasc Surg 40:79-82, 2007 possibility of recovery. 7. Pal HK, Bhatty GB, Deb S, Mishra S: Traumatic pseudome- ningocele at cranio-vertebral junction following stab injury. CONCLUSION Injury 29:142-143, 1998 8. Peacock WJ, Shrosbree RD, Key AG: A review of 450 stab- wounds of the spinal cord. S Afr Med J 51:961-964, 1977 We report herein a 60-year-old man who committed ante- 9. Platz A, Kossmann T, Payne B, Trentz O: Stab wounds to the rior cervical stab injury by himself and then showed a transe- neck with partial transsection of the spinal cord and penetra- ction of the cervical spinal cord following a penetrating injury ting injury to the esophagus. J Trauma 54:612-614, 2003 to the trachea and esophagus through the C7-T1 disc space. 10. Sett P, Crockard HA: The value of magnetic resonance ima- Tracheoplasty and primary suture of the esophageal wound ging (MRI) in the follow up management of spinal injury. Para- plegia 29:396-410, 1991 were successfully performed. There were neither CSF leakage, 11. Sokolov VV, Bagirov MM: Reconstructive surgery for com- spinal instability, pseudomeningocele, spinal abscess nor syrinx bined tracheo-esophageal injuries and their sequelae. Eur J for the 19 months follow up. However, there was no neurolo- Cardiothorac Surg 20:1025-1029, 2001 gical improvement due to the transection of the almost entire 12. Velmahoos GC, Degiannis E, Hart K, Souter I, Saadia R: Chan- cervical spinal cord. Long-term follow-up is necessary because ging profiles in spinal cord injuries and risk factors influen- of a possible delay of instability. cing recovery after penetrating injuries. J Trauma 28:334-337, 1995 13. Waters RL, Sie I, Adkins RH, Yakura JS: Motor recovery follo- REFERENCES wing spinal cord injury caused by stab wounds: A multicenter study. Paraplegia 33:98-101, 1995 14. Wright RL: Intramedullary spinal cord abscess: Report of a 1. Criado E, Oller D, Fulghum J: Delayed diagnosis of a foreign case secondary to stab wound with good recovery following body in the spinal canal. South Med J 83:332-333, 1990 operation. J Neurosurg 23:208-210, 1965 2. de Villiers JC, Grant AR: Stab wounds at the craniocervical

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