A 21-year-old male sustained a single gunshot wound with entry over the left scapula. At the scene, the emergency medical response personnel found him on the ground alert, unable to move his legs, and noting pain all over his body. He was hemodynamically stable in the field. Ground ambulance immobilized the neck with a cervical collar and brought him to a local level 1 trauma center. At arrival to the trauma bay, he had a Glasgow coma scale score of 15. He was primarily complaining of bilateral hand numbness. On further examination, he had no motor or sensory function present in the lower extremities. In the upper extremities, sensation was present but diminished from T1 and above, with no sensation below T1. Motor function in the upper extremities was graded 3 (based on ASIA impairment scale) in all the key muscles on the right and only grade 2 on the left in the deltoid and biceps muscles with no motor further distal. Next, he was taken to the computed tomography (CT) suite for imaging of the head, neck, and thorax. Imaging, from the CT scan, revealed bullet tract through the posterior lateral left upper hemithorax, left scapular body, left lung apex, and base of left neck with bullet fragments terminating in the C6 vertebral body. Initial studies showed no acute intracranial abnormalities; however, there were fractures of the left C5 and C7 transverse foramina and processes and left C6 vertebral body and lamina fractures with bony and bullet fragments in the left aspect of the spinal canal at the C6 level (). As a result, there was a dense left epidural hematoma within the spinal canal at C2 through C7 levels. At the time, CT neck angiogram showed that the left extracranial vertebral artery was occluded, beyond 1 cm from its origin. Subsequently, the patient underwent angiography to further assess the cerebral vascular supply. On the angiogram, occlusion of the proximal portion of the left vertebral artery was noted with reconstitution in the distal portion of the artery near the occipitocervical junction (). No contrast extravasation from the left vertebral artery was noted. Patency was noted in the right vertebral artery and bilateral common, internal, and external carotid arteries. Vascular surgery specialists, after conducting and reviewing the angiogram, determined that no further intervention was required as the right vertebral artery along with bilateral internal carotid arteries was patent.\nFollowing the imaging studies and angiogram, the patient was admitted to the surgical intensive care unit (SICU) for continuous neurologic and hemodynamic control and observation. On the next hospital day, the patient was optimized by the vascular surgery team and the surgical intensive care unit trauma team and was deemed stable to proceed forward with surgical intervention of the spine. Given the spinal cord injury and preparation for spinal surgery, anticoagulation was not started prior to reporting to the operating room. The goals of the surgery were to decompress the cervical spinal cord and to provide stability to the spinal column.\nThe patient received a successful awake fiber-optic intubation with protection of the cervical spine and then general anesthesia was induced. Via a standard left sided Smith-Robinson approach, anterior cervical corpectomy of C6 and anterior cervical decompression were performed within C5–C7. Bony and bullet fragments were removed from within the canal and following decompression, and while avoiding excessive distraction, the anterior column was reconstructed using an appropriately sized interbody cage device packed with autologous bone graft. Anterior cervical plate and screws were used to provide stability to the cage-graft construct and maintain the proper cervical alignment (). Following the procedure, the patient remained intubated for airway edema concerns. The sedation was weaned after transporting the patient to the SICU from the operative suite; however, he remained unarousable. Given the neurologic change in the patient status, an emergent head CT scan was conducted and showed an acute basilar infarct.\nHead and neck CT angiogram were subsequently performed and showed new basilar artery segmental occlusion consistent with migration of a thrombus from the distal left vertebral artery. Both neurology and neurosurgery teams recommended hyperosmolar treatment, as the patient was not considered a good candidate for revascularization. Twelve hours later, repeat head CT scan showed progressive hydrocephalus and brainstem and cerebellar infarcts with impending herniation (). The patient was subsequently diagnosed with brain death and, with consent from his family, care was withdrawn.
A 20-year old male presented to the Emergency Department having been accidentally shot in the neck, by a friend using a 0.22 calibre air rifle, at a distance of approximately three metres. He complained of neck stiffness and pain on swallowing. Examination revealed an entry wound 1 cm below the level of the thyroid notch to the left of the midline, figure . A tense, non-pulsatile haematoma was evident deep to the entry wound. No bleeding or surgical emphysema were present. His voice was hoarse, although flexible endoscopic examination showed no pharyngeal or laryngeal abnormality. Cervical spine radiographs demonstrated an airgun pellet antero-lateral to the transverse process of C6, with a surrounding 6 cm diameter radiopacity consistent with haematoma and no deviation of the trachea, figure .\nPrimary resuscitation was uneventful, and the patient was taken to theatre within four hours for exploration of the wound and evacuation of the haematoma. Upon evacuation of the haematoma extensive haemorrhage developed from a defect in the anterior wall of the external carotid artery, which required rapid access and surgical repair. The airgun pellet was localised using image intensification and successfully retrieved from the paraspinous muscles, figure .\nThe pellet tract traversed the left lobe of the thyroid gland and the carotid sheath, impacting on the antero-medial aspect of the external carotid artery, just above the bifurcation, figure . It further traversed the paraspinous muscles and embedded immediately anterior to the transverse process of the sixth cervical vertebrae, at a depth of 8 cm from the skin entry wound.\nInitial recovery was uneventful, however at follow-up it was clear that the patient had Horner's syndrome from injury to the left cervical sympathetic chain and carotid arteries.