Penetrating Thoracic Spinal Injury with Impacted Glass Fragment

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1 case report Penetrating Thoracic Spinal /jp-journals Injury with Impacted Glass Fragment Penetrating Thoracic Spinal Injury with Impacted Glass Fragment 1 Vinu V Gopal, 2 K Mahadevan STRCT Introduction: Penetrating injuries to the spine with retained foreign body is rare. We present a rare case of nonmetallic penetrating injury of thoracic spine with a retained glass fragment which was successfully removed. Case report: 46 years old presented with penetrating injury to thoracic spine following road traffic accident. On wound exploration, a glass fragment was found impacted in depth. Neurological examination revealed left lower limb monoparesis with grade 3 power. Investigation: X-ray showed radiopacity at the level of D4 vertebral body. Computed tomography (CT) of spine showed foreign body at the D4 vertebral level piercing the lamina, penetrating the left pedicle reaching up to D4 vertebra pushing spinal cord to the opposite side. Treatment: Emergency D4 laminectomy followed by retrieval of foreign body was done. Results: Postoperatively, weakness improved to normal power. On 6 weeks postoperative follow-up, he is able to walk without difficulty. Conclusion: Management of penetrating nonmetallic spinal foreign body is a real challenge which requires careful clinical and radiological assessment. Early decompression with retrieval of foreign body leads to better outcome. Keywords: Penetrating, glass, thoracic, spinal. How to cite this article: Gopal VV, Mahadevan K. Penet rating Thoracic Spinal Injury with Impacted Glass Fragment. J Spinal Surg 2014;1(4): Source of support: Nil Conflict of interest: None INTRODUCTION Penetrating injuries to the spine are relatively infrequent compared to other sites and is a real challenge to the treating surgeons. 1 Penetrating injuries with retained foreign body is still rare except following gunshot injuries. 2 In our case report, we present a rare case of penetrating injury of thoracic spine with impacted glass piece which was successfully removed. CSE REPORT The patient was a 46 years old gentleman, who was a lorry driver by profession, presented in the surgery casualty of our institution with weakness of left lower limb following a road traffic accident. On detailed history taking, we understood that, in the accident, he crashed into the front glass and was thrown out of the vehicle. In the fall, he sustained a penetrating injury on the back of chest with a broken glass piece. He had a penetrating entry wound of size 4 cm in length and 3 cm in breadth (depth of the wound could not be assessed) which was approximately 2 cm lateral to the midline toward left side (Fig. 1). There was profuse bleeding from the wound and hence explored in the casualty by general surgeons, and the bleeding was controlled. Few glass pieces which were found in the muscle plane were removed. One glass piece which was found impacted in depth was left in situ and the patient was shifted to trauma ICU. Since the patient had left lower limb weakness, neurosurgery consultation was sought. Detailed neurological examination revealed grade 3 power of left lower limb with no sensory impairment. Deep tendon reflex were all sluggish with extensor plantar on the left side. Right lower limb power was normal. Rectal tone was reduced. He had urinary retention and hence was catheterized. INVESTIGTIONS X ray thoracolumbar spine anteroposterior (P) and lateral views showed a radiopaque shadow at the level of D4 lamina and vertebral body (Figs 2 and ). Computed tomography (CT) of spine with threedimensional (3D) recons truction (Figs 3 to C) was taken which showed radiopaque foreign body cm 1 ssistant Professor, 2 Professor 1,2 Department of Neurosurgery, Government Medical College Kottayam, Kerala, India Corresponding uthor: Vinu V Gopal, ssistant Professor Department of Neurosurgery, Government Medical College Kottayam, Kerala, India, Phone: vinoogopa@gmail.com Fig. 1: Entry wound shown in black thick arrow The Journal of Spinal Surgery, October-December 2014;1(4):

Vinu V Gopal, K Mahadevan Since, it was sure that the intraspinal foreign body was a glass fragment, a magnetic resonance imaging (MRI) was done to precisely locate the foreign body as well as to

Cord was pushed to opposite side with possible dural tear. MNGEMENT He was started on prophylactic antibiotics preoperatively.

body consistent with glass at the D4 vertebral level piercing the lamina extending into spinal canal. Foreign body was found penetrating the pedicle reaching up to D4 body on the left side.

Glass fragment was found impacted after separating paraspinal muscles (Figs 5 and ). Three glass pieces in the intermuscular plane came out removed while separating paraspinal muscles. (Figs 5 and ). Glass piece was seen penetrating D4 lamina.

2 Vinu V Gopal, K Mahadevan Since, it was sure that the intraspinal foreign body was a glass fragment, a magnetic resonance imaging (MRI) was done to precisely locate the foreign body as well as to assess the condition of thoracic spinal cord. Magnetic resonance imaging (Figs 4 and ) revealed hypointense foreign body confirming the CT findings. Cord was pushed to opposite side with possible dural tear. MNGEMENT He was started on prophylactic antibiotics preoperatively. Figs 2 and : Preoperative x-ray showing radiopaque foreign body at D4 vertebral body level: () P view thick white arrow showing radiopaque foreign body and () lateral view white arrow showing foreign body consistent with glass at the D4 vertebral level piercing the lamina extending into spinal canal. Foreign body was found penetrating the pedicle reaching up to D4 body on the left side. Spinal cord was pushed to the opposite side. OPERTIVE FINDINGS Emergency exploration with a midline incision away from the entry wound was done. Glass fragment was found impacted after separating paraspinal muscles (Figs 5 and ). Three glass pieces in the intermuscular plane came out removed while separating paraspinal muscles. (Figs 5 and ). Glass piece was seen penetrating D4 lamina. Small apical part of impacted glass which was lying loose were removed. D4 laminectomy (Fig. 6) C Figs 3 to C: Computerized tomography of spine: () xial view black arrow head showing foreign body piercing left D4 lamina entering spinal canal and impacting in D4 vertebral body through pedicle, () sagittal view black arrow head showing foreign body and (C) reconstructed CT foreign body shown in black arrow 170

Penetrating Thoracic Spinal Injury with Impacted Glass Fragment Figs 4 and : Magnetic resonance imaging of spine: () Sagittal T2-weighted image hypointense foreign body at D4 vertebral level shown in

() Exposure of glass fragment just before laminectomy and () glass fragment was seen going inside spinal canal Figs 6 and : () fter laminectomy and medial facetectomy, glass fragment was seen going

impacted glass fragment. High speed drilling was continued laterally into the facet and medial facetectomy was done (Fig. 6). Pedicle was also drilled laterally to loosen the glass fragment.

6) and removed, and retrieved glass fragments are shown in Figures 8 and.

3 Penetrating Thoracic Spinal Injury with Impacted Glass Fragment Figs 4 and : Magnetic resonance imaging of spine: () Sagittal T2-weighted image hypointense foreign body at D4 vertebral level shown in white arrow and () axial T2-weighted image hypointense foreign body abutting spinal cord and entering vertebral body violating medial pedicle shown in white arrow Figs 5 and : Intraoperative picture: () Exposure of glass fragment just before laminectomy and () glass fragment was seen going inside spinal canal Figs 6 and : () fter laminectomy and medial facetectomy, glass fragment was seen going in between nerve roots into vertebral body after violating medial pedicle wall and () glass fragment being removed in line of trajectory by careful disimpaction was done without disturbing the impacted glass fragment. High speed drilling was continued laterally into the facet and medial facetectomy was done (Fig. 6). Pedicle was also drilled laterally to loosen the glass fragment. Glass fragment was going in between nerve roots intending the cord medially and was found impacted on the vertebral body. Glass fragment was disimpacted carefully (Fig. 6) and removed, and retrieved glass fragments are shown in Figures 8 and. There was a small dural tear with cerebrospinal fluid (CSF) leak which was repaired with fat graft after attaining hemostasis (Figs 7 and ). Spinal canal was irrigated with antibiotic solution. Wound was closed in layers with drain. Intraoperatively, methylprednisolone was given. POSTOPERTIVE COURSE Postoperatively, left lower limb weakness improved to normal grade 5 power. There was no evidence of csf leak or features of meningitis. Drain was removed on 3rd day. Suture removal was done on day 10 and was discharged the same day. Postoperative x-ray (Figs 9 and ) was taken which showed complete removal of foreign body. On 6 weeks postoperative follow-up, he was able to do his profession without difficulty. DISCUSSION Nonmissile nonmetallic penetrating injuries are relatively infrequent, and only few case reports are available in literature. 1,3-5 Nonmetallic penetrating injuries are usually accidental in nature in contrast to metallic injuries. 1,6 Case reports with penetrating injuries with nonmetallic objects, like glass, pencil, sugarcane, broomstick, are reported. 3 Usually, they present late due to compression by foreign body granuloma or abcess formation. 6 Our case is unique in that patient presented with neurological deficit following a penetrating injury with The Journal of Spinal Surgery, October-December 2014;1(4):

Vinu V Gopal, K Mahadevan Figs 7 and : () ed after removal of glass fragment and () CSF leak repaired with fat graft Figs 8 and : Retrieved glass fragments: ig fragments in figure are impacted

removed resulting in complete recovery of the weakness. Thoracic spine is a common area of penetrating injury.

2 Lumen of Figs 9 and : Postoperative X ray: () P view and () lateral views showing complete removal view the spinal canal is narrowest in thoracic spine.

7 Computed tomography (CT) is a good investigation modality for patients with nonmetallic foreign body as well in considering ability to detect retained foreign body, spinal/paraspinal hematoma and

4 Vinu V Gopal, K Mahadevan Figs 7 and : () ed after removal of glass fragment and () CSF leak repaired with fat graft Figs 8 and : Retrieved glass fragments: ig fragments in figure are impacted fragments, small fragments in figure are retrieved from intermuscular plane: () View from above and () view after placing flat on surface glass fragment in thoracic spine which was successfully removed resulting in complete recovery of the weakness. Thoracic spine is a common area of penetrating injury. Injury to this region differs from other regions as it is less mobile and is responsible for trunk stability. 2 Lumen of Figs 9 and : Postoperative X ray: () P view and () lateral views showing complete removal view the spinal canal is narrowest in thoracic spine. Nerve roots existing are responsible for intercostals muscle function. Thoracic region is a constant watershed area of the spine. Plain radiographs are the initial investigation in all cases. 7 Computed tomography (CT) is a good investigation modality for patients with nonmetallic foreign body as well in considering ability to detect retained foreign body, spinal/paraspinal hematoma and bone fragments. 1 lthough, MR is a powerful tool for identifying injury track, cord, root lesion and associated lesion like hematoma, role of MRI is controversial in metallic penetra ting injury as magnetic field is associated with movement of material and heat production causing neurological deficits. 3 Management of patients with penetrating spinal cord trauma depends on the mechanism and duration of injury. Surgical intervention is critical to neurological outcome regardless of initial neurological status. 5 Early surgical intervention decreases infection rate, csf leak and arachnoiditis. Early surgical retrieval of nonmetallic foreign body can prevent foreign body granuloma, abcess formation causing neurological deficit. 7 It can also prevent foreign body migration later. 7 The technical aspects of surgical intervention include identifying correct spinal level of foreign body, surgical decompression with removal of foreign body in the line of original trajectory to minimize additional damage. Dural repair without primary closure needs to be done to contain spinal cord edema. 5 Manipulation or closed removal may result in fresh neurological deficit, csf leak, and infection. CONCLUSION Penetrating nonmissile nonmetallic foreign body is a real challenge and its management requires careful clinical and radiological investigation and needs meticulous surgical planning. Early surgical decompression with 172

5 Penetrating Thoracic Spinal Injury with Impacted Glass Fragment disimpaction of foreign body in line with the original trajectory without disturbing vital structures lead to better outcome by preventing neurological deficit, abcess formation, foreign body granuloma and csf leak. REFERENCES 1. kcakaya MO, ras Y, Yorukoglu G, Ovalioglu C, Sencer. Cervical intradural glass fragment: a rare cause of neuropathic pain. Turkish neurosurgery 2012;22(5): Li X, Curry EJ, lais M, Ma R, Sungarian S. Intraspinal penetrating stab injury to the middle thoracic spinal cord with no neurologic deficit. Orthopedics 2012;35(5):e Thakur RC, Khosla VK, Kak VK. Non-missile penetrating injuries of the spine. cta neurochirurgica 1991;113(3-4): Opel DJ, Lundin D, Stevenson KL, Klein EJ. Glass foreign body in the spinal canal of a child: case report and review of the literature. Pediatric emergency care 2004;20(7): Kumar, Pandey PN, Ghani, Jaiswal G. Penetrating spinal injuries and their management. J craniovertebral junction and spine 2011;2(2): Pal D, Timothy J, Marks P. Penetrating spinal injury with wooden fragments causing cauda equina syndrome: case report and literature review. European spine journal: official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society 2006;15(Suppl 5): aghai P, Sheptak PE. Penetrating spinal injury by a glass frag ment: case report and review. Neurosurgery 1982;11(3): The Journal of Spinal Surgery, October-December 2014;1(4):

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