A 58-year-old male presented to the emergency department neurologically intact, but with a common kitchen knife penetrating the spinal cord at the T11 level. His only complaint was a patchy, vague, and subjective nondermatomal sensory loss in the lower extremities. A computed tomography (CT) image showed that the knife had pierced the right-sided interlaminar space at the T11-T12 level where it fully entered the spinal canal []. All plates were removed from an open Jackson table to allow the patient to be intubated in the supine position. After intubation, the patient was moved back to a stretcher in the lateral position, and a similar turn was utilized to re-position him in the prone position []. Baseline intraoperative neuromonitoring, including motor and somatosensory evoked potentials (MEPs and SSEPs, respectively), was utilized throughout positioning and surgery, and at no point were any significant intraoperative changes were observed.\nSubsequent to sterile preparation and draping of the patient, the skin was opened perpendicular to the axis of blade, with care being taken to avoid any undue manipulation. In addition, no electrocautery was utilized during dissection and removal of the knife to avoid potential damage to the spinal cord. The serrated knife was firmly embedded in the T11-T12 laminar bone. An ultrasonic bone cutter was used to create a bone island around the knife, allowing the knife and the surrounding T11-T12 laminae to be removed without traumatic rotational force to the spinal cord. Under microscope visualization, the dural laceration from the knife was extended in order to look for intradural compressive hematoma or vascular injury. Although neither was present, there was a clear laceration of the spinal cord itself. Following copious irrigation, watertight dural closure was performed using running 4-0 Nurolon sutures. In order to minimize infection risk given the foreign body penetration, no adjuvant sealant was used, especially because solid dural closure had been achieved. The patient was placed on antibiotics and received a tetanus shot. Postoperatively, the patient's motor status remained normal, whereas his mild diffuse sensory loss was unchanged. Three months later, the patient continued to have residual sensory deficit, but was fully ambulatory and returned to work.
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. ).