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 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.