DMFR
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Bumbasirevic, M
Right arrow Articles by Djuric, M
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Bumbasirevic, M
Right arrow Articles by Djuric, M
Dentomaxillofacial Radiology (2006) 35, 38-42
© 2006 British Institute of Radiology
doi: 10.1259/dmfr/29317043

CASE REPORT

Gunshot injury to the face with a missile lodged in the upper cervical spine without neurological deficit

M Bumbasirevic1, A Lesic1, V Bumbasirevic2, Z Rakocevic3 and M Djuric*,4

1 Institute for Orthopaedic Surgery and Traumatology, University Clinical Centre, Visegradska 26, 11000 Belgrade, Serbia; 2 Institute for Anesthesiology and Intensive Care, University Clinical Centre, Belgrade, Visegradska 26, 11000 Belgrade, Serbia; 3 Department of Radiology, Dental School, University of Belgrade, Rankeova 6, 11000 Belgrade, Serbia; 4 Department of Anatomy, Medical Faculty, University of Belgrade, Dr Subotica 4/2, 11000 Belgrade, Serbia

*Correspondence to: Prof. Marija Djuric, Department of Anatomy, Medical Faculty, University of Belgrade, Dr Subotica 4/2, 11000 Belgrade, Serbia; E-mail: marijads{at}eunet.yu

Received 3 January 2005; revised 2 May 2005; accepted 14 June 2005


   Abstract
Top
 Abstract
Introduction
 Report of a case
 Discussion
 References
 
An unusual case of facial gunshot injury with the missile lodged in the cervical spinal canal, but without any neurological impairment is reported. The extent of tissue damage and missile track termination in a male patient who sustained gunshot trauma to the face was assessed by plain radiography and by CT scans. The patient was treated conservatively and observed for clinical manifestations of neurological deficit for 3 weeks. CT of the head and neck performed 13 years after injury with the three-dimensional (3D) reconstruction of skeletal elements revealed healed fractures of the right nasal bone, the labyrinth of the right ethmoid bone, and position of the missile on the medial aspect of the right lateral mass of the atlas. There was no migration of the missile during this period. This case report of gunshot wound to the face associated with injury of the cervical spine indicated possibility of survival and atypical absence of clinical manifestation that may occur even when a bullet remains in the spinal canal.

Keywords: gunshot; face; spine injury; treatment


   Introduction
Top
 Abstract
 Introduction
Report of a case
 Discussion
 References
 
Although the incidence of gunshot wounds to the face1–3 as well as penetrating spinal injuries4–7 has increased during past decades, craniofacial injuries caused by missiles are not generally as common as they are in other areas.8–10 The association of gunshot traumas to the face with cervical spine injuries is infrequent: the reported incidence varies up to 8.1% of facial gunshot wounds.1,11,12 According to the study of Kihtir et al,13 gunshots to the mid-face and orbit carry the highest risk for concomitant cervical spine injury (up to 20%).

There is consensus about the four main steps in the management of patients with gunshot wounds to the face: securing on airway, controlling haemorrhage, identifying other injuries, and repair of the traumatic facial deformities.1,12,14 However, literature reports are controversial in terms of time and methods of subsequent surgical facial reconstruction.14,15


   Report of a case
Top
 Abstract
 Introduction
 Report of a case
Discussion
 References
 
In October 1991, a 31-year-old male was admitted to the emergency department of Orthopaedic Clinic in Belgrade for management of a gunshot wound to his face. On arrival, the patient was conscious, walking, anxious, and complaining of facial pain and nasal bleeding. The patient stated that the firearm used was a handgun at close distance (1 m). Physical examination revealed an entry wound in the right region of the root of the nose but no exit wound (Figure 1Go). There were no signs of damage to orbital contents. The patient was in good general condition, with pulse of 75 beats per minute and blood pressure of 140 mmHg, without signs of respiratory distress, haemorrhage, significant haematoma, retropharyngeal oedema or neural impairment.


Figure 1
View larger version (93K):
[in this window]
[in a new window]
  		Figure 1 Photograph of the patient after surgical management of the wound

 
Radiography of the skull in posterior–anterior (PA) projection (Figure 2aGo) and lateral radiography of the cervical spine (Figure 2bGo) revealed location of the foreign body at the level of the anterior portion of atlas, behind the dens of the axis. There were no radiographic signs of damage to surrounding bone elements. CT scan was not available.


Figure 2
View larger version (106K):
[in this window]
[in a new window]
  		Figure 2 (a) Radiograph of the skull in posteroanterior projection showing the missile at the level of the nasal cavity; (b) radiograph of the cervical spine in lateral projection showing the missile at the level of the anterior portion of atlas, behind the odontoid process of the axis

 
The injury was managed with conservative debridement; the nasal bone was immobilized by packing. After serial wound dressing changes, 3 weeks of permanent monitoring and antibiotic therapy, the patient was discharged from the hospital, since there were no signs of infection or neurological deficit.

In February 2004, 13 years after injury, the patient came from abroad to the hospital to have the first routine control (Figure 3Go). Neurological examination demonstrated no signs of disorders. Additional CT of the head and neck with the three-dimensional (3D) reconstruction of the facial skeleton, cranial base and cervical spine enabled the precise localization of the missile and evaluated the bone destruction. Cross sections in the orbitomeatal plane (Figure 4Go) indicated position of the missile on the medial aspect of the right lateral mass of the atlas. 3D reconstruction of the facial skeleton (Figure 5Go) revealed healed fractures of the right nasal bone, while cross section (Figure 6Go) indicated healed fracture of the labyrinth of the right ethmoid bone. There was no migration of the projectile compared with the time of injury.


Figure 3
View larger version (120K):
[in this window]
[in a new window]
  		Figure 3 Photograph of the patient 13 years after injury

 

Figure 4
View larger version (114K):
[in this window]
[in a new window]
  		Figure 4 CT section indicating position of the missile on the medial aspect of the right lateral mass of the atlas

 

Figure 5
View larger version (117K):
[in this window]
[in a new window]
  		Figure 5 3D reconstruction of the facial skeleton showing healed fracture of the right nasal bone

 

Figure 6
View larger version (123K):
[in this window]
[in a new window]
  		Figure 6 CT section at the level of nasal cavity showing disturbed architecture of the ethmoidal labyrinth on the right side

 

   Discussion
Top
 Abstract
 Introduction
 Report of a case
 Discussion
References
 
Penetrating cervical spine traumas usually lead to spinal cord injury by direct spinal cord transection, contusion, or ischaemia due to arterial injury.4 The main reason for not performing surgical bullet removal in the reported case was the absence of neurological deficit. The firearm damage of the upper cervical spine without neurological deficit occurs very infrequently.7,16 Saxon and coworkers17 illustrated possible delay in onset of clinical manifestation of cord injuries (Brown-Sequard syndrome) following a gunshot wound to the face. Delayed complications due to migration of impacted bullet18–21 are also described, although it was not always associated with neurological deficit.

The extent of tissue damage in gunshot wounds depends on the distance at which the gun is fired, missile track, and bullet structure, size and velocity.22–25 In the reported case, small-calibre missile of comparatively low velocity (<350 m s–1) caused injury by direct tissue crushing and laceration producing the cavity that is not as large as can be seen in high speed bullets, such as in rifle injuries.26 The fortunate combination of missile track and anatomical details led to avoiding damage of any of the vital structures. The missile, directed from above passed through the right nasal bone, ethmoidal labyrinth, pharynx, between anterior arch of atlas and foramen magnum, and stopped in the right lateral mass of atlas (Figure 7Go). The missile damaged anterior arch of atlas just right of the anterior median tubercle (Figure 8Go), penetrating the anterior atlanto-occipital membrane, and possibly the right alar ligament and the membrana tectoria, avoiding the apical ligament of dens and transverse ligament of atlas. By this way, all the main blood vessels and nerves were distant enough from the missile trajectory.


Figure 7
View larger version (120K):
[in this window]
[in a new window]
  		Figure 7 Reconstruction of the missile trajectory in midsagittal plane and termination of the missile

 

Figure 8
View larger version (163K):
[in this window]
[in a new window]
  		Figure 8 3D reconstruction of the cranial base and cervical spine showing defect of the arch of atlas

 
There are a very small number of reported cases of transpharyngeal cervical spine injury, but most agree that progression of neurological deficit is an indication for urgent bullet removal.7,27,28 Retained bullets rarely cause problems of delayed infection and late neurological decline, and only if a neurological deficit develops, which is possible after many years, should surgical intervention be considered.6,29,30 Even in patients with static neural deficit surgical decompression and bullet removal are sometimes not useful because of the absence of significant effect on neurological outcome and possible post-operative complications.7,31–33 In a reported case of fractures of the C1 anterior ring and the odontoid process, both associated with multiple bullet fragments, the patient's motor and functional recovery supported the decision of not performing spinal surgery.34 The clinical benefits of bullet removal to avoid lead toxicity or neurotoxic effects of copper are still unclear.7,35–37

Our report illustrates that knowledge of the path of the missile and its termination, and close clinical observation of the patient are critical for assessment of management of patient with gunshot wounds to the face. No surgery was performed, and the patient remained stable for 13 years without any complication and migration of the missile, which was plunged into lateral mass of atlas.


   References
Top
 Abstract
 Introduction
 Report of a case
 Discussion
 References
 

  1. Demetriades D, Chahwan S, Gomez H, Falabella A, Velmahos G, Yamashita D. Initial evaluation and management of gunshot wounds to the face. J Trauma 1998; 45: 39–41.[Medline]
  2. Reiss M, Reiss G, Pilling E. Gunshot injuries in the head-neck area: basic principles, diagnosis and management. Schweiz Rundsch Med Prax 1998; 87: 832–838.[Medline]
  3. Puzovic D, Konstatinovic VS, Dimitrijevic M. Evaluation of maxillofacial weapon injuries: 15-year experience in Belgrade. J Craniofac Surg 2004; 15: 543–546.[CrossRef][Medline]
  4. Tender GC, Ratliff J, Awasthi D, Buechter K. Gunshot wounds to the neck. South Med J 2001; 94: 830–832.[Medline]
  5. Kitchel SH. Current treatment of gunshot wounds to the spine. Clin Orthop Relat Res 2003; 408: 115–119.
  6. Waters RL, Sie IH. Spinal cord injuries from gunshot wounds to the spine. Clin Orthop Relat Res 2003; 408: 120–125.
  7. Bono CM, Heary RF. Gunshot wounds to the spine. Spine 2004; 4: 230–240.[CrossRef]
  8. Ameen AA. The management of acute craniocerebral injuries caused by missiles: analysis of 110 consecutive penetrating wounds of the brain from Basrah. Injury 1984; 16: 88–90.[CrossRef][Medline]
  9. Cowey A, Mitchell P, Gregory J, Maclennan I, Pearson R. A review of 187 gunshot wound admissions to a teaching hospital over a 54-month period: training and service implications. Ann R Coll Surg Engl 2004; 86: 104–107.[CrossRef][Medline]
  10. Hecimovic I, Vrankovic D, Rubin O, Maksimovic Z, Rukovanjski M. Transoral missile removal from the anterior C1 region following transpharyngeal missile wound. Arch Orthop Trauma Surg 1999; 119: 340–343.
  11. Dolin J, Scalea T, Mannor L, Sclafani S, Trooskin S. The management of gunshot wounds to the face. J Trauma 1992; 33: 508–514.[Medline]
  12. Perry CW, Phillips BJ. Gunshot wounds sustained injuries to the face: a university experience. The Internet Journal of Surgery 2001; 2: 1–10.
  13. Kihtir T, Ivatury RR, Simon RJ, Nassoura R, Leban S. Early management of civilian gunshot wounds to the face. J Trauma 1993; 35: 575–596.
  14. Hollier L, Grantcharova EP, Kattash M. Facial gunshot wounds: a 4-year experience. J Oral Maxillofac Surg 2001; 59: 277–282.[CrossRef][Medline]
  15. Siberchicot F, Pinsolle J, Majoufre C, Ballanger A, Gomez D, Caix P. Gunshot injuries of the face. Analysis of 165 cases and reevaluation of the primary treatment. Ann Chir Plast Esthet 1998; 43: 132–140.[Medline]
  16. Mangiardi JR, Alleva M, Dynia R, Zubowski R. Transoral removal of missile fragments from the C1- C2 area: report of four cases. Neurosurgery 1988; 23: 254–257.[Medline]
  17. Saxon M, Snyder HA, Washington Jr JA. Atypical Brown-Sequard syndrome following gunshot wound to the face. J Oral Maxillofac Surg 1982; 40: 299–302.[Medline]
  18. Nicol JW, Yardley MP, Parker AJ. Pharyngolaryngeal migration: a delayed complication of an impacted bullet in the neck. J Laryngol Otol 1992; 106: 1091–1093.[Medline]
  19. Conway JE, Crofford TW, Terry AF, Protzman RR. Cauda equina syndrome occurring nine years after a gunshot injury to the spine. A case report. J Bone Joint Surg Am. 1993; 75: 760–763.[Free Full Text]
  20. Oktem I, Selcuklu A, Kurtsoy A, Kavuncu I, Pasaoglu A. Migration of bullet in the spinal canal: a case report. Surg Neurol 1995; 44: 548–550.[CrossRef][Medline]
  21. Jeffery J, Borgstein R. Case report of a retained bullet in the lumbar spinal canal with preservation of cauda equina function. Injury 1998; 29: 724–726.[CrossRef][Medline]
  22. Osborne TE, Bays RA. Pathophysiology and management of gunshot wounds to the face. In: Fonseca RJ, Walker RV (eds). Oral and maxillofacial trauma. WB Saunders, 1991: pp. 672–701.
  23. Yetiser S, Kahramanyol M. High-velocity gunshot wounds to the head and neck: a review of wound ballistics. Mil Med 1998; 163: 346–351.[Medline]
  24. Stewart MG. Penetrating face and neck trauma. In: Byron J, (editor). Bailey's head and neck surgery – otolaryngology. Lippincott Williams and Wilkins, 2001: pp. 813–821.
  25. Haug RH, Lexington KY. Ballistic injuries of the maxillofacial region. J Oral Maxillofac Surg 2002; 60:Suppl. 1.
  26. Clasper JC, Hodgetts TJ. High-velocity gunshot wound through bone with low energy transfer. Injury 1994; 25: 264–266.[CrossRef][Medline]
  27. Demetriades D, Theodorou D, Cornwell E, Asensio J, Belzberg H, Velmahos G, et al. Transcervical gunshot injuries: mandatory operation is not necessary. J Trauma 1996; 40: 758–760.[Medline]
  28. Paran H, Shwartz I, Freund U. The evolving management of penetrating neck injuries. IMAJ 2000; 2: 762–766.
  29. Yoshida GM, Garland D, Waters RL. Gunshot wounds to the spine. Orthop Clin North Am 1995; 26: 109–116.[Medline]
  30. Kuijlen JM, Herpers MJ, Beuls EA. Neurogenic claudication, a delayed complication of a retained bullet. Spine 1997; 22: 910–914.[CrossRef][Medline]
  31. Kupcha PC, Cotler JM. Gunshot wounds to the cervical spine. Spine 1990; 15: 1058–1063.[Medline]
  32. Roberts DP, Simpson RK. Penetrating injuries restricted to the cauda equina: a retrospective review. Neurosurgery 1992; 31: 265–269.[Medline]
  33. Kahraman S, Gonul E, Kayali H, Sirin S, Duz B, Beduk A, et al. Retrospective analysis of spinal missile injuries. Neurosurg Rev 2004; 27: 42–45.[CrossRef][Medline]
  34. Hatzakis Jr MJ, Bryce N, Marino R. Cruciate paralysis, hypothesis for injury and recovery. Spinal Cord 2000; 38: 120–125.[CrossRef][Medline]
  35. Grogan D, Bucholz R. Acute lead intoxication from a bullet in an intervertebral disc space. J Bone Joint Surg 1981; 63(A): 1180–1182.[Free Full Text]
  36. Tindel NL, Marcillo AE, Tay BK, Bunge RP, Eismont FJ. The effect of surgically implanted bullet fragments on the spinal cord in a rabbit model. J Bone Joint Surg Am 2001; 83(A): 884–890.[Abstract/Free Full Text]
  37. Scuderi GJ, Vaccaro AR, Fitzhenry LN, Greenberg S, Eismont F. Long-term clinical manifestations of retained bullet fragments within the intervertebral disk space. J Spinal Disord Tech 2004; 17: 108–111.[Medline]




This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Bumbasirevic, M
Right arrow Articles by Djuric, M
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Bumbasirevic, M
Right arrow Articles by Djuric, M

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
BJR DMFR IMAGING ALL BIR JOURNALS