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.
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.