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. ).
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.