Direct withdrawal of a knife lodged in the thoracic spinal canal in a patient with normal neurologic examination: is it safe?

Thoracic spine stab injury with a retained knife

A female was admitted to a Major Trauma Centre with an isolated thoracic spine stab injury involving a retained knife. The patient was haemodynamically stable with an unremarkable peripheral neurological examination. A CT scan with three-dimensional image reconstruction showed the knife blade lodged in the T11 vertebra with its tip close to the spinal cord, aorta and inferior vena cava. A multidisciplinary trauma team, including anaesthetists, vascular, neurosurgeons and general surgeons, agreed on the treatment strategy. The lodged knife was safely withdrawn in the operating theatre with the patient in a prone position under sedation and local anaesthesia. Following the procedure, neurological examination remained normal, and an MRI scan revealed no spinal cord injury. We discuss the management of penetrating spinal injuries, the importance of detailed preoperative imaging, timely multidisciplinary input and how to safely remove a knife when a prone position prevents standard airway management.

Airway management in prone position: a case of knife injury in the posterior spine

Airway management in prone position is a very challenging procedure, predicting a difficult airway situation. We present a case of an adult with knife injury in the posterior spine, needing surgical care. Because of possible dislodgment of the knife with life-threatening complications, supine and lateral decubitus positions were not considered for airway management. To get around this difficulty, we used a fiberoptic intubation through supraglottic device I-gel® in prone position, under general anesthesia, to secure the airway. This case shows the use of fiberoptic intubation through an I-gel® supraglottic device, in prone position, as a valid choice.

Through-and-through stab wound of the cervical spinal canal with retained weapon but no neurological repercussions: an exceptionally rare injury and the case for direct withdrawal. Illustrative case

BACKGROUND

Nonmissile penetrating spinal injuries are rare and potentially debilitating. Such injuries can sometimes be complicated by the retention of a foreign body, which is usually part of the assailant’s weapon, making their management even more problematic.

OBSERVATIONS

We present a unique case of stab wound to the neck with a retained ice pick, traversing the spinal canal from one intervertebral foramen to the other, yet with no ensuing neurological damage to the patient. After carefully analyzing the weapon’s trajectory on computed tomography and ruling out vertebral artery injury via catheter angiography, the ice pick was successfully withdrawn under general anesthesia and intraoperative neurophysiological monitoring, averting the need for a more invasive surgical procedure.

LESSONS

Stab wounds of the spinal canal with a retained foreign body can occasionally be managed by direct withdrawal. Whether this simple technique is a safe alternative to open surgical exploration should be determined on a case-by-case basis after careful review of spinal and vascular imaging. The absence of significant neurological or vascular injury is an absolute prerequisite for attempting direct withdrawal. Moreover, preparations should be made for possible conversion to open surgical exploration in the rare event of active hemorrhage, expanding hematoma, or acute neurological deterioration.

Non missile penetrating spinal injury

Non-missile penetrating spinal injury (NMPSI) is a rare form of traumatic spinal injury. Cases with neurological deficit on presentation are treated surgically. In the extremely rare circumstance of NMPSI presenting with no neurological deficit the management is contentious. We report a case of a 43-year-old male presenting with a penetrating stab injury through the thoracolumbar spinal canal. On presentation he had no neurological deficits and subsequently the knife was removed in theatre without deep surgical exploration. In this report we review the literature of non-missile penetrating spinal injuries as well as their management and conclude that exploratory surgery for NMPSI without neurological deficit may not be necessary as previously thought.

Direct withdrawal of a knife in the lumbar spinal canal in a patient without neurological deficit: case report and review of the literature

Introduction

Stab-wound injuries to the spinal cord are rare and currently, do not have a well-established management in the literature despite its strong association with neurological injury.

Case presentation

We report a case of a patient with a stab-wound injury with a knife in the lumbar region, who underwent direct removal in the operating room without surgical exploration. Upon admission, the patient had no neurological deficit. The X-rays and CT scan before removal showed the involvement of >50% of the intramedullary canal at L2. The removal was performed in the operating room with a surgical team available and ready in case there was neurological deterioration during the procedure.

Discussion

We concluded that any neurologic deficit in a patient with a stab-wound injury in the spine must mandate surgical exploration and in patients without neurological deficit, direct removal of the stabbing object is a safe and effective method without adding the risks of a surgical exploration.