A 58-year-old Iranian man presented to our emergency department after an air gun shot injury. On admission, a penetrating wound in the left lateral region of zone II of his neck was detected. His vital signs were normal. His only complaint was slight odynophagia. No bleeding, hematoma, dysphonia or subcutaneous emphysema was noticeable. On further investigation, anteroposterior and lateral X-rays showed a hyperdense pellet in the left latera region of his neck (Figure ). A computed tomography scan confirmed the presence of the pellet at the level of the thyroid cartilage (Figure ).\nOur patient underwent a neck exploration using a hockey stick incision. After the primary incision of the skin and platysma, the carotid sheath was explored with no findings of note. An intraoperative X-ray of his neck, using control needle markers, revealed a tiny orifice of about 1.5mm on the left superior part of the thyroid cartilage. Extending the orifice to 1.5cm showed a pellet between the cartilage and the lining mucosa (Figure ). The pellet was removed. After complete repair of the cartilage and placing a drain, the subcutaneous tissue and skin were repaired.\nOur patient was discharged after drain removal with good general health. On a two-year follow-up he did not report any problem or complication and his physical examination remained normal.
A previously healthy 19-year-old male was shot on his left neck incidentally by his friend during recreational air rifle game from the range of approximately 2 m. He was taken to the nearest local hospital immediately to get his wounded neck treated by a surgeon and was admitted in the hospital ward for 3 days. Subsequently, the patient was referred to our hospital for his left hemiparesis complaint, which he recalled that happened shortly after the incident. The patient's previous drug history, familial history and psychosocial history were unremarkable. On physical examination at our hospital, the patient was fully alert and hemodinamically stable. General examination of the neck discovered sutured post-operative wound sized 5 cm as well as the entry point of the pellet sized 0.5 cm on the anterolateral of the neck at the level of thyroid cartilage (). Neurological examination revealed total loss of motoric function on his left side of the body together with sensoric function on the contralateral side from the level of C5 and below, with an intact bulbocavernosus reflex and perianal sensation. There was also facial lateralization characterized by ptosis and eyebrow as well as lip drooping on the left side.\nInitial imaging study of cervical plain radiograph revealed scattered pellet fragments at the level of C5-6 (). Therefore, we conducted CT scan for further ancillary study and revealed that foreign bodies with metallic density found at the left side of C5-6 level and suspicion of right laminar fracture of C5. In addition, the metallic foreign bodies were discovered both within the spinal canal of C5 and in close proximity to the vertebral artery foramen (). Thus, the surgery comprising of pellet fragments removal, decompression and posterior stabilization of the cervical spine was planned immediately.\nThe surgery, conducted by first author who is an orthopaedic spine surgeon, was brought by using posterior midline approach of the cervical region to expose the posterior column of the vertebrae. Lateral mass screws and rods were installed at the level of C4-7 followed by decompression, only to reveal that a pellet fragment was embedded at the posterior epidural space at the level of C5 with dural laceration (). Afterwards, the fragment sized 0.5 cm was delivered and the exploration by using the image intensifier (C-arm) was proceeded in order to search the other fragments. The other fragments were discovered at the vertebral artery foramen with concomitant vertebral artery transection. Then, the transected artery was packed with bone wax. During this further exploration, we succeeded to deliver 2 other fragments sized 0.5 and 0.4 cm (). Post-operatively, plain cervical radiograph () and CT angiography were commenced. The latter revealed that the left vertebral artery was completely transected at the level of C4 (). Consequently, incomplete spinal cord injury (SCI) because of the left VAI due to penetrating injury caused by air rifle pellet was marked as the working diagnosis.