Cerebrospinal fluid fistula due to penetrating trauma

The role of tertiary neurosurgical intervention in non-missile penetrating injuries of the spine

PURPOSE

The objective of the study was to determine whether all patients with spinal non-missile penetrating injuries (NMPIs) need to be managed at a tertiary neurosurgical centre.

METHODS

A retrospective analysis of clinical, demographic, and imaging records was performed on all NMPI patients referred to the Department of Neurosurgery at Tygerberg Academic Hospital in Cape Town, South Africa, between 1 January 2016 and 31 December 2019.

RESULTS

Ninety-six patients were identified (94 males and 2 females) with 35 cervical, 60 thoracic, and 1 lumbar spinal stab. Eighty-six had an incomplete spinal cord injury. Six patients presented with cerebrospinal fluid (CSF) leak, all of which resolved spontaneously. MRI was performed in nine patients. Six patients had retained blades, of which 5 were removed in the emergency room (ER). Surgery was performed in two patients (cervical intramedullary abscess and a retained blade). Two patients developed meningitis, and one an intramedullary abscess. Twenty-two patients had associated injuries (pneumothorax, bowel injury). The average length of stay was 17 days, with 81% being unchanged neurologically. The average time from discharge to leaving the hospital was 11 days.

CONCLUSION

Early management of NMPI should include prophylactic antibiotics and wound debridement and X-ray imaging to exclude retained blades. Bowel and lung injury must be managed accordingly. Tertiary neurosurgical referral is not routinely necessary and is only warranted for deteriorating neurology, retained blades not removable in the ER, and respiratory failure secondary to spinal cord injury. Complications include meningitis and persistent CSF leak, which should be referred timeously.

Spinal stab injury with retained knife blades: 51 Consecutive patients managed at a regional referral unit

BACKGROUND

Spinal stab wounds presenting with retained knife blades (RKB) are uncommon, often resulting in spinal cord injury (SCI) with catastrophic neurological consequences. The purpose of this study is to report a single unit's experience in management of this pattern of injury at this regional referral centre.

METHODS

Retrospective review of medical records identified 51 consecutive patients with spinal stabs presenting with a RKB at the Neurosurgery Department at Inkosi Albert Luthuli Central Hospital between January 2003 and February 2015. The data was analyzed for patient characteristics, level of the RKB, neurological status using the ASIA impairment scale, associated injuries, radiological investigations, management, hospital length of stay, complications and mortality.

RESULTS

The mean age was 28±10.9 years (range 14-69), with 45 (88%) males (M: F=7.5:1). The median Injury Severity Score was 16 (range 4-26). RKB were located in the cervical [9,18%], thoracic [38,74%], lumbar [2,4%] and sacral [2,4%] spine. Twelve patients (24%) sustained complete SCI (ASIA A), while 21 (41%) had incomplete (ASIA B, C, D), of which 17 had features of Brown-Sequard syndrome. Eighteen (35%) patients were neurologically intact (ASIA E). There were 8 (16%) associated pneumothoraces and one vertebral artery injury. Length of hospital stay was 10±7.1 days (range 1-27). One patient (2%) died during this period.

CONCLUSIONS

Stab injuries to the spine presenting with RKB are still prevalent in South Africa. Resources should be allocated to prevention strategies that decrease the incidence of inter-personal violence. All RKBs should be removed in the operating theatre by experienced surgeons to minimise complications.