Delayed presentation of spinal foreign body - Case report and review of literature.

BACKGROUND: Although spinal cord injuries are frequent causes of myelopathy in young patients, stab wounds of the spinal cord rarely occur and are typically maximal symptomatic immediately after the trauma. CASE DESCRIPTION: A 31-year-old male developed delayed onset of symptoms 4 years after a stab wound to the cervical spinal cord attributed to a plant needle (plant called Mandacaru). Following removal of the foreign body and decompression/excision of scarring at the C34 level, the patient's symptoms resolved.
CONCLUSION: Surgical excision should be encouraged to remove chronic penetrating foreign bodies to both decompress and untether the spinal cord.

INTRODUCTION

Spinal stab wounds account for 8–11% of all penetrating spinal injuries and almost all injuries are acute.[1234678] Rarely, patients may become symptomatic several months to even years following the original trauma. Here, we describe a patient who sustained a penetrating injury to the cervical spinal cord at the C3-C4 level attributed to a needle from a plant called Mandacaru. Postoperatively, following decompression and excision of the needle, the patient's myelopathic symptoms resolved.

CASE REPORT

A 31-year-old white male presented with a progressive spastic quadriparesis over 1-year duration. Four years previously, he had fallen from a horse into a tree called Mandacaru (Cereus jamaracu) in northeast Brazil. At the time of the injury, the patient had several skin wounds but no neurological symptoms or signs. Four years later, he presented with new onset of spastic tetraparesis characterized by motor 4/5 strength in the upper and lower limbs; he could only ambulate with assistance.

While plain radiographs of cervical spine revealed upper cervical kyphosis, computed tomography (CT) scan [Figure 1] demonstrated a foreign body resembling a needle that entered the spinal canal through the left C3-C4 foramen. Magnetic resonance imaging (MRI) [Figure 2] demonstrated extensive edema in the cervical spinal cord and enhancement with gadolinium of tissue surrounding the foreign body.

Figure 1

Computed tomography scan showing entrance of the thorn through left C3-C4 foramen

Figure 2

Magnetic resonance imaging showing gadolinium enhancement of the spinal cord

The needle was removed utilizing a left side approach to the left C3-C4 foramen. (Hodgson-like approach[4] posterior-lateral view).

A 5-cm thorn was removed [Figure 3]; of interest, there was no cerebrospinal fluid (CSF) leak. The postoperative course was uneventful and he continued to improve over the next 6 months.

Figure 3

The 5-cm thorn

DISCUSSION

There are seven reported[1235679] cases of delayed symptoms (8–30 years) involving stab wound injuries to the spinal cord [Table 1].

Table 1

Reported cases of delayed onset of symptoms after spinal cord stab wound

Mechanism of injury

The foreign body usually enters the spinal canal via the interlaminar space or through the intervertebral foramen. The delayed onset of neurological deficits are typically attributed to retained fragments within the spinal canal. These lesions may transfix the spinal cord causing slow progressive damage due to tethering[9] (e.g., as the cord is no longer free to move with normal body movements). Residual surrounding fibrosis may also maintain tethering after surgical extirpation.

CONCLUSION

Few patients exhibit delayed onset of symptoms following penetrating injuries to the spinal cord. If delayed neurological deterioration occurs, patients should be reassessed with X-ray, MRI, and CT to demonstrate the site, location, and type of penetrating lesion and whether it has been adequately excised, or whether there is a residual foreign body. Repeated surgical intervention, offering decompression and untethering, may or may not result in neurological recovery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.