Eleven-year-old boy presented to a hospital after he had been shot with an arrow by his younger brother while they were playing with a bow. The arrow stuck in a posterior surface of his neck (nuchal region) about the level of C5 vertebra and the arrow shaft was immediately removed by a brother. The parents brought their son to a local hospital where initial neck X-ray examination was performed. The only injury exposed to a physician’s view was a small, 1 cm long skin cut with no pathological secretion. The X-ray revealed a 35 mm long, cone-shaped metal arrowhead residing between C4 and C5 vertebra and protruding into the vertebral canal (Fig. ). Nevertheless, the boy did not present any neurological deficit nor paraesthesia. He was equipped with a professional neck support, placed on a rescue board, and transmitted to Department of Pediatric Neurosurgery. On admission, he underwent head and neck CT examination, that showed the arrowhead stuck between arches of C4 and C5 vertebrae, protruding inside the vertebral canal and passing through the cervical spinal cord penetrating to 2/3 of its P-A dimension (Fig. ). CT scans did not reveal any bone injury, intraspinal bleeding, nor edema. During neurological examination, the boy still did not demonstrate any neurological nor meningeal symptoms, numbness, neither sensation disorders. An initial treatment with methyl-prednisolone infusion according to National Acute Spinal Cord Injury Studies (NASCIS) protocol was implemented, and the patient was transported to an operating theater with a total of rescue supports. The boy was placed horizontally in prone position, with the nuchal region exposed. From the straight vertical skin incision, the C4-C5 area was achieved and the upper back muscles were carefully dissected and put aside. The exposed metal arrowhead was gently removed and no negative general patient reaction was observed. The arrowhead was cone-shaped and hollow, had 35 mm of length and 6 mm of diameter at its base (Fig. ). Subsequently, a bilateral C4–C5 hemilaminectomy was performed in order to verify the injury of spinal cord and dura. In the traumatized area, no fresh bleeding was observed but the leakage of transparent cerebrospinal fluid. The dura was closed with continuous suture, and precise hemostasis of the operative field was performed. Finally, all layers were closed down. The patient was equipped with a neck support and spent next 2 weeks at the Department of Pediatric Neurosurgery. The treatment included continuous intravenous antibioticotherapy (ceftriaxone, amicacinum, and metronidazole) and lying in bed during first week of hospital stay followed by a gradual rehabilitation in the second. Postoperative neurological statement did not deteriorate; the boy did not suffer from paraesthesia nor other deficits. Postoperative wound healed properly. Control neck MRI, performed soon after, revealed no fresh bleeding nor edema in operated region. After 2 weeks, the treatment was terminated and the boy was discharged from the hospital in a state of complete health. Follow-up MRI examination after 6 months from surgery revealed no pathological collection nor postoperative spinal stenosis in operated region. The presence of focal (Ø up to 10 mm) hyperintensive region in the spinal cord did not influence his neurological statement (Fig. ).
A 31-year-old white male presented with a progressive spastic quadriparesis over 1-year duration. Four years previously, he had fallen from a horse into a tree called Mandacaru (Cereus jamaracu) in northeast Brazil. At the time of the injury, the patient had several skin wounds but no neurological symptoms or signs. Four years later, he presented with new onset of spastic tetraparesis characterized by motor 4/5 strength in the upper and lower limbs; he could only ambulate with assistance.\nWhile plain radiographs of cervical spine revealed upper cervical kyphosis, computed tomography (CT) scan [] demonstrated a foreign body resembling a needle that entered the spinal canal through the left C3-C4 foramen. Magnetic resonance imaging (MRI) [] demonstrated extensive edema in the cervical spinal cord and enhancement with gadolinium of tissue surrounding the foreign body.\nThe needle was removed utilizing a left side approach to the left C3-C4 foramen. (Hodgson-like approach[] posterior-lateral view).\nA 5-cm thorn was removed []; of interest, there was no cerebrospinal fluid (CSF) leak. The postoperative course was uneventful and he continued to improve over the next 6 months.