A Rare Penetrating Cervical Spine Injury by Scissors: A Case Report and Literature Review

A Rare Penetrating Cervical Spine Injury by Scissors: A Case Report and Literature Review

Corresponding author Dr. De-chun Wang, No.5 Donghai zhong Road, Qingdao Shandong, China, 266000, Tel: +86 18661809296; Email: dechun-w@163.com
Abstract

Penetrating neck injuries are frequent problems in an emergency. It represents approximately 5–10 % of all trauma cases that present to the emergency department [1, 2]. The neck region contains a high density of vital organ structures in a relatively small and unprotected anatomic region, making it one of the most vulnerable areas of the body for all types of injuries [3]. Management requires a logical approach with a swift assessment of the adequacy of airway and circulation and of the possible presence of any skeletal or neurological damage prior to operative intervention. We report a rare case with penetrating cervical spine injury by scissors.

Keywords: Cervical Spine Injury; Penetrating; Scissors
Case Report
A 78-year-old female patient was admitted to the emergency and trauma department after falling on scissors 2 hours earlier. Physical examination revealed a 2 cm horizontal sharp wound (Figure 1) getting hit on the right side of the neck on the level of the hyoid bone.
Figure 1
The handle of scissors was outside and the tip deeply stabbed in the neck. There was no active bleed at the time of examination. She was conscious, limited neck movement with central pain. Her vitals were stable. Her pulse rate was 80/min, blood pressure 90/60mmHg, regular respiration and she was maintaining oxygen saturation of 100%. Her power in the left upper and lower limbs was grade V, while in the right upper and lower limbs it was grade III. The sensation was present but diminished from C5 on the right side while the left was normal. Computed tomography (CT) of the cervical spine (Figure 2) revealed the tip lodged in the right half of canal at C5 vertebral level. Following the imaging studies and laboratory examinations, spinal surgery specialists determined to operate on the patient. We found the tip of scissors stabbed into the spine canal through the space between the carotid sheath and splanchnic fascia without no damage to great vessels, trachea, and esoph-anaesagus. Finally, we removed the foreign body. The patient was admitted to the intensive care unit (ICU) for an advanced observation and therapy.
Figure 2. (3D CT-scan)
One week later, the power of the right upper and lower limbs recovered to grade IV. She was transferred to the spinal surgery ward. The magic resonance imaging (MRI) of the cervical spine (Figure 3)revealed no compression on the cord. After 10 days’ follow-up, the patient was discharged (Figure 4).
Figure 3.
Figure 4. (Professor Wang and the woman)
Discussion
The penetrating injuries are defined as neck wounds that extend deep to the platysma. Penetrating injuries to neck with impacted foreign bodies are very challenging due to the proximity to vital structures and difficulties in accessing them for the removal. The complicated anatomy of the neck and the location of very important vital structures on a small surface make the evaluation of damage and indications for surgical intervention difficult [4]. In our opinions, four steps should be allowed to rescue the patients suffered from penetrating cervical spine injuries.
1. Emergency physicians, trauma surgeons, and anaesthesiologists should acquire a thorough knowledge of the anatomy of the neck.
The neck can be divided into three major zones for surgery:- Zone 1, below the cricoids to the thoracic inlet; zone 2, from the cricoids to the angle of the mandible; and zone 3, above the angle of the mandible. Zone 2 injuries are the most common injuries [5]. Zone 1 contains the major vascular structures of the subclavian artery and vein, jugular vein, and common carotid artery, as well as the esophagus, thyroid, and trachea. Zone 2 contains the common carotid artery, internal and external carotid arteries, jugular vein, larynx, hypopharynx, and cranial nerves X, XI, and XII. Zone 3 contains the internal and external carotid arteries, jugular vein, lateral pharynx, and cranial nerves VII, IX, X, XI, and XII [2].According to Ordog, mortality depends on the neck zone exposed to injury and the type of tool inflicting the injury [7]. It is very important to recognize the anatomy of the neck.
2. Prompt diagnosis based on physical laboratory and imaging examinations
Plane X-rays demonstrate major bony injuries and the foreign bodies including bullets. Dynamic X-rays can provide vital information about stability[8]. Doppler ultrasonography and computed tomography (CT) angiography are useful for detecting carotid and venous system injuries. Physical and Laboratory examinations can help surgeons to evaluate the liver and kidney functions. Prompt diagnosis based on laboratory and imaging examination is useful to therapy.

3. A logical approach to swift assessmentPatients should be examined according to general trauma principles. A primary survey should be performed consisting of checking and treating the airway, breathing, and circulation (ABC) . First and foremost the airway needs to be established and the cardio cerebral perfusion needs to be maintained. It is after this that a detailed evaluation of the site and severity of the wound needs to be done [6].The patients of PSIs should be resuscitated by the standard ATLS protocol (ABCDE) as in cases of other types of spinal injuries.

4. Cooperation from multi-departments and clear indications for surgery

Penetrating neck trauma poses a diagnostic and therapeutic dilemma to emergency physicians, trauma surgeons, and anaes thesiologists. It needs a cooperation from multi-departments. According to Rao PM, the indications for surgical interventions in neck injuries include [9]:
1. Active bleeding, hematoma or hemorrhagic shock,
2. Presence of blood in the respiratory and digestive tracts,
3. Respiratory failure, subcutaneous emphysema,
4. Neurological symptoms.
Conclusion
The neck region contains a high density of vital organ structures in a relatively small and unprotected anatomic region, making it one of the most vulnerable areas of the body for all types of injuries [10]. The universally accepted protocol is that these injuries need to be managed in a systematic manner. An early and fast diagnosis can determine indications for surgery and prevent severe fatal complications.
Competing interests
The authors declare no competing interests.
Authors’ contributions
All the authors have read and approved the final version of the manuscript.

References

1. Gupta B, Gulati A, Gupta D. A rare presentation of pellet injury in the neck. ISRN Surg. 2011, 2011: 306126.

2. Luntz M, Nusem S, Kronenberg J. Management of penetrating wounds of the neck. Eur Arch Otorhinolaryngol.1993, 250(7): 369–374.

3. Fischer JE, Bland KI, Callery MP. Mastery of surgery. Lippincott Williams & Wilkins; 2007.

4. Nason RW, Assuras GN, Gray PR, Lipschitz J, Burns CM. Penetratingneck injuries: analysis of experience from a Canadian trauma centre. Can J Surg. 2001, 44(2): 122–126.

5. Stiernberg CM, Jahrsdoerfer RA, Gillenwater A, Joe SA, Alcalen SV. Gunshot wounds to the head and neck. Arch Otolaryngol Head Neck Surg. 1992, 118(6): 592–597.

6. Broniatowski M, Tucker HM. Penetrating injuries of the neck. Emergency evaluation and management. Postgraduate Medicine. 1986, 80(1): 155–160.

7. Ordog GJ. Penetrating neck trauma. J Trauma. 1987, 27: 543–554.

8. Kumar A, Pandey PN, Ghani A, Jaiswal G. Penetrating spinal injuries and their management. J Craniovertebr Junction Spine. 2011, 2(2): 57–61.

9. Rao PM, Bhatti MF, Gaudino J, Ivatury RR, Aquarwal N et al. Penetrating injures of the neck: criteria for exploration. J Trauma.1983, 23(1): 47–49.

10. Fischer JE, Bland KI, Callery MP. Mastery of surgery. Lippincott Williams & Wilkins; 2007.

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