- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, USA
Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, USA
DOI:10.4103/2152-7806.193729Copyright: © 2016 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Nasser R, Nakhla J, Sharif S, Kinon M, Yassari R. Penetrating thoracic spinal cord injury with ice pick extending into the aorta. A technical note and review of the literature. Surg Neurol Int 09-Nov-2016;7:
How to cite this URL: Nasser R, Nakhla J, Sharif S, Kinon M, Yassari R. Penetrating thoracic spinal cord injury with ice pick extending into the aorta. A technical note and review of the literature. Surg Neurol Int 09-Nov-2016;7:. Available from: http://surgicalneurologyint.com/surgicalint_articles/penetrating-thoracic-spinal-cord-injury-ice-pick-extending-aorta-technical-note-review-literature/
Background:Penetrating spinal cord injuries pose a great challenge to both patients and the treating physicians. Although the overall incidence of penetrating spinal cord injury is the highest in the military, the ubiquity of guns in our society continues to make penetrating spinal cord injury prevalent in the civilian population. These types of injuries are particularly complicated because, beyond the trauma to the neural elements and supporting structures, other organs can be affected and a team approach is required for successful treatment.
Case Description:In this report, the authors present a unique case of an ice pick penetrating posteriorly through the spinal canal into the aorta. The described surgical management involved careful consideration and planning to prevent worsening vascular and neurological compromise. Among the challenges faced are neurological compromise, vascular injury, spinal instability, and cerebrospinal fluid leak.
Conclusion:To the author’s knowledge, this challenging case represents the first description of a successful removal of a penetrating thoracic spinal foreign body that terminated within the lumen of the thoracic aorta.
Keywords: Aorta, penetrating trauma, thoracic spine, vascular injury
Penetrating spinal cord injuries pose a great challenge to both patients and the treating physicians. Although the overall incidence of penetrating spinal cord injury is the highest in the military, the ubiquity of guns in our society continues to make penetrating spinal cord injury prevalent in the civilian population. These types of injuries are particularly complicated because, beyond the trauma to the neural elements and supporting structures, other organs can be affected and a team approach is required for successful treatment. Among the challenges faced are neurological compromise, vascular injury, spinal instability and cerebrospinal fluid (CSF) leak; the latter has been shown to be as high as 36% in patients status after removal of the penetrating foreign bodies.[
A 34-year-old male presented as a trauma after he was assaulted with an ice pick. On presentation, he was an American Spinal Injury Association (ASIA) score C; the motor exam of the lower extremities demonstrated full strength in the right leg and weakness in the left leg; based on the MRC scale, the patient was 2/5 in the proximal and 3/5 in the distal muscle groups. His bowel and bladder function and sensation to light touch and pinprick remained intact. There was a small skin puncture site slightly asymmetric to the right in the lower thoracic spine that was identified as the entry point. A computed tomography (CT) scan demonstrated an 8 cm hyperdense foreign body, consistent with an ice pick fragment, entering the right T10 lamina with an upward and medial trajectory [
Given the patient’s neurologic status and concern for worsening vascular injury, a decision was made to take the patient to the operating room to repair the breach in the aorta and remove the retained ice pick. A multidisciplinary team consisting of neurosurgery, vascular surgery, and cardiothoracic surgery was formed, and the treatment plan consisted of endovascular repair of the aortic injury and removal of the ice pick from the aorta. The patient was positioned in a “lazy” left lateral decubitus position to allow access to the groins and the back. Although the foreign body was eccentric to the right, placing the position on the left would allow the cardiothoracic surgeons access to the aorta, in the event an endovascular solution was unsuccessful. Vascular surgery first gained bilateral access to the common femoral arteries under ultrasound guidance. A thoracic pigtail catheter was placed from the right side to image the descending thoracic aorta. A 12-French sheath was placed in the left common femoral artery in preparation for occlusion of the thoracic aorta with a Coda balloon if the patient became hemodynamically unstable. The aorta was measured and sized using the previous CT of the chest and a Cook TX2 28 × 80 mm graft was deemed appropriate for the repair of the aorta. First, an aortogram was performed via the pigtail catheter that showed no active extravasation of contrast from the entry site. The endograft was then advanced from the left side and positioned at T9. Once the endograft was in place, neurosurgery began exposing the foreign body. A paramedian incision that incorporated the entry site was made and the tract of the foreign body was followed to the spinous process of T10. A subperiosteal dissection was done and the foreign body was localized at its entry point in to the lamina medial to the spinous process. A circumferential exposure required drilling of the surrounding bone structures to optimize access to the foreign body. The distal end of the ice pick was then removed with a large thoracic sternal needle driver [
After securing the aortic injury, we examined the entry point of the ice pick. CSF was leaking posteriorly through the lamina with Valsalva maneuvers. A fat graft and fibrin sealant were placed over the defect. Special care was taken to minimize the dead space during the closure of the muscle and fascial layers. A lumbar drain was placed at the L4/L5 interspace with caution not to engage the level of the spinal cord injury with the catheter. A chest tube was placed by CT surgery to address the hemothorax; however, the chest tube was purposefully left closed for a few hours before the drainage was started to avoid creating an anterior CSF fistula. The patient was extubated on postoperative day 1, with improvement of his neurological examination (4/5 in all muscle groups of the left lower extremity). The lumbar drain was clamped 48 hours postoperatively and was removed after verifying that there was no leak from the incision site posteriorly. The patient had an uncomplicated hospital stay and was discharged on postoperative day 6 with a normal motor exam except for the left extensor hallucis longus and dorsiflexion at 5-/5.
The overall mortality of penetrating spinal cord injury in the military has been on the decline; during World War I, the mortality rate was 71.8% whereas by the end of the Vietnam War the rate had decreased to 2.3%.[
In our case, the foreign body was an ice pick which was 3.8 cm deep from the skin, adjacent to the T10 spinous process. Although the patient had an incomplete spinal cord injury, a laminectomy was not performed. The authors believed that the foreign body could be accessed and retrieved without removing the lamina. Furthermore, care was taken to minimize the tissue dissection to minimize the dead space for potential CSF collections. The need to surgically explore the trauma site of a penetrating injury remains controversial. While the basis to intervene largely depends on the patient’s hemodynamic status and neurological function, there are other factors that may compel surgeons to surgically explore. Gulamhuseinwala et al. described such factors as CSF leak and extrinsic cord compression to help guide management.[
Imaging studies are necessary to appropriately assess and manage instances of penetrating spinal cord injury. Careful consideration must be made using X-ray/CT or CT myelogram. Any unidentified ferromagnetic fragments may pose additional risk to the patient, and the risk of an MRI needs to be assessed.[
In penetrating spinal injuries with associated CSF leaks, it is advisable to promptly start broad spectrum antibiotics to prevent meningitis.[
The use of steroids (methylprednisolone) in patients with penetrating spinal cord injury have been shown to have an adverse outcome in the National Acute Spinal Cord Injury II trial,[
An injury to the thoracic aorta by any etiology can be fatal due to the immediate massive hemorrhage in the mediastinal and intrathoracic cavity.[
The mortality and morbidity from penetrating spinal cord injury remains a challenging and difficult to treat condition in trauma patients. This case illustrates how advancement in endovascular treatment minimizes the surgical trauma to the patient and allows for a safe and successful removal of an otherwise potentially fatal problem. The optimal treatment strategy is often assessed on a case-by-case basis and most often requires a multidisciplinary team approach.
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