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.
This 2-year-old boy, a rural inhabitant, was delivered to the Neurosurgical Department of the Children's Municipal Hospital of Omsk, with a suspected penetrating wound of the spinal cord, complicated by meningitis. During admission, the child's condition was serious, with stunned consciousness, a monotonous, long drawn-out moan, pyretic fever, nuchal rigidity, and meningeal symptoms all observed. Tendon reflexes S = D, and sensitivity disorders were not found. There was a wound after surgery which was about 6 cm long with skin maceration around it and a transparent discharge between stitches in the lumbar region [].\nIt was determined in the case history that 12 days ago, the boy had been accidentally injured by a sharp agricultural tool in the lumbar region on the right side at the L5-S1 level. The wound was stitched up in a rural hospital. On the 2nd day after the operation, a transparent, clear discharge had appeared. The quantity of the discharge had not been determined, but the bandage had been soaking, and it was necessary to change it several times per day. There were no pathologic changes in clinical analyses.\nInjury of the right ureter was suspected. The ultrasonic research and excretory urography were performed. Reliable data in favor of the ureter injury were not obtained.\nBy that time, the child's temperature had become elevated, and the leukocyte count in blood had increased.\nThe lumbotomia with the ureter revision was performed on the right side due to the suspected retroperitoneal infected uro-hematoma. No ureter injuries were found during the revision. The continuation of the discharge from the initial wound in the lumbar region, pyretic fever, and meningeal signs was observed in the early postoperative period.\nOn the 11th day, a new lumbar puncture was performed: Cerebrospinal fluid was cloudy, under a low pressure, cell count – 1094 in three fields of vision, with 50% neutrophils. During admission to the Neurosurgical Department, magnetic resonance imaging had been performed, and signs of penetrating injury of the spinal cord were found [].\nThere were no data confirming the presence of foreign bodies in the spinal canal. Penetrating spinal cord injury to the lumbosacral region, stab wound of the spinal cord in the left with dura mater damage at L5 level, liquorrhea, pneumocephalus. Purulent meningitis. Status after left-sided lumbotomy.\nThe decision was taken to perform the two-stage surgical treatment. The first stage was revision of the wound, and second was plastic surgery, and application of external lumbar drainage, with the delivery of antibacterial therapy.\nIf the liquorrhea had remained at the second stage, it would have been decided to perform the lumbotomia, laminotomia, and plastic surgery of the pachymeninx defect. The wound canal was directed to the lateral (right lateral) surface of the spine during the revision. An injured place and liquorrhea source in the wound were not found. The secondary surgical treatment of the wound was performed with local flap grafting. The external lumbar drainage was installed. Cell count was about 1820 in three fields of vision, mainly segmented, with 3149 g/L protein in cerebrospinal fluid. During the bacteriologic examination of the cerebrospinal fluid, Staphylococcus aureus was found.\nDuring the postoperative period infusions, antibacterial therapy (meropenem 500 mg three times per day intravenously) was performed in the intensive care unit.\nOn the 2nd day, 450 ml of cloudy cerebrospinal fluid was obtained through drainage. On the 9th day, the quantity of cerebrospinal fluid had decreased to 50 ml, body temperature had returned to normal, meningeal symptoms had regressed, and leukocytosis in the blood and in the cerebrospinal fluid had decreased. The external lumbar drainage was removed on the 12th day. By the time of drainage removal, the cell count in the cerebrospinal fluid was equal to 14 in three fields of vision (14% neutrophils and 86% lymphocytes). The liquorrhea from the wound did not resume. On the 22nd day, magnetic resonance imaging was performed, which detected cicatricial adhesion changes in soft tissues of the lumbar region at L5 level []. The child was discharged from the hospital on the 31st day in satisfactory condition.