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 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.