A 45-year-old male presented to the emergency department with alleged history of getting hit over the left side of neck by some air-borne object while standing on the roadside. This was followed up with severe, piercing pain in the neck region associated with bleeding from the wound site. He also gave history of transient loss of consciousness but had no neurological sequelae thereafter. There was no history of difficulty in breathing, change in voice, or swelling over the neck or face. On examination, his vitals were stable. There was no respiratory distress. There was a 2 cm × 1 cm linear lacerated wound on the left side of neck at the junction of upper 1/3rd and lower 2/3rd of the sternomastoid muscle on its anterior border. There was no active bleed or crepitus at the time of examination. No foreign body was visible or palpable in the neck. Indirect laryngoscopic examination was normal. An X-ray of the cervical region showed a radio-opaque foreign body in the left side of neck suggestive of a pellet (). A CT scan was ordered before taking up the patient for an exploration and removal of the foreign body. The scan confirmed the position of the pellet as being medial to the sternomastoid around the level of the glottis (Figures and ).\nThe neck was explored under general anaesthesia. On going medial to the sternomastoid, a thrill was palpable over the carotid sheath proximal to the foreign body. The pellet was identified within the carotid sheath partially piercing the internal jugular vein such that a part of it was outside the vessel and half of it was within the lumen. The pellet was carefully removed. The bleed was controlled with local pressure, and the vein was ligated and transfixed both proximal and distal to the site of injury.\nThe postoperative period was uneventful, and the patient is asymptomatic in his follow-up visits.
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. ).