A 20-year old male presented to the Emergency Department having been accidentally shot in the neck, by a friend using a 0.22 calibre air rifle, at a distance of approximately three metres. He complained of neck stiffness and pain on swallowing. Examination revealed an entry wound 1 cm below the level of the thyroid notch to the left of the midline, figure . A tense, non-pulsatile haematoma was evident deep to the entry wound. No bleeding or surgical emphysema were present. His voice was hoarse, although flexible endoscopic examination showed no pharyngeal or laryngeal abnormality. Cervical spine radiographs demonstrated an airgun pellet antero-lateral to the transverse process of C6, with a surrounding 6 cm diameter radiopacity consistent with haematoma and no deviation of the trachea, figure .\nPrimary resuscitation was uneventful, and the patient was taken to theatre within four hours for exploration of the wound and evacuation of the haematoma. Upon evacuation of the haematoma extensive haemorrhage developed from a defect in the anterior wall of the external carotid artery, which required rapid access and surgical repair. The airgun pellet was localised using image intensification and successfully retrieved from the paraspinous muscles, figure .\nThe pellet tract traversed the left lobe of the thyroid gland and the carotid sheath, impacting on the antero-medial aspect of the external carotid artery, just above the bifurcation, figure . It further traversed the paraspinous muscles and embedded immediately anterior to the transverse process of the sixth cervical vertebrae, at a depth of 8 cm from the skin entry wound.\nInitial recovery was uneventful, however at follow-up it was clear that the patient had Horner's syndrome from injury to the left cervical sympathetic chain and carotid arteries.
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.