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.
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.