- Email: [email protected]
Medullar Injury Caused by Sewing Needle Puncture
The Journal of Emergency Medicine, Vol. 40, No. 1, pp. 65– 67, 2011 Copyright © 2011 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$–see front matter
doi:10.1016/j.jemermed.2008.01.002
Visual Diagnosis in Emergency Medicine
MEDULLAR INJURY CAUSED BY SEWING NEEDLE PUNCTURE Kohei Takahashi, MD, Naoto Morimura, MD, PHD, Tetsuya Sakamoto, Hiroshi Nagashima, MD, PHD, and Masafumi Hirata, MD, PHD
MD, PHD,
Trauma and Critical Care Center, Teikyo University School of Medicine, Tokyo, Japan Reprint Address: Kohei Takahashi, MD, Trauma and Critical Care Center, Teikyo University School of Medicine, 2-1-11 Kaga Itabashiku, Tokyo 173-8606, Japan
INTRODUCTION A number of injuries to the central nervous system caused by needles have been described, but injuries to the brain stem after needle penetration are very uncommon (1–7). Therefore, we report the case of a patient who had a lesion in the medulla oblongata caused by a sewing needle that had migrated through the foramen magnum; she had a good outcome after surgical extraction.
CASE REPORT A 23-year-old woman presented to the Emergency Department for treatment of a self-puncture wound to the posterior cervical area caused by a sewing needle (suicide attempt). The patient had a medical history of schizophrenia. On admission, the patient’s Glasgow Coma Scale score was 15. The blood pressure was 90/50 mm Hg, heart rate 74 beats/min, and respiratory rate 28 breaths/min. Physical findings included facial erythema, general hyperhydrosis, nausea, and vomiting. Neurological examination revealed motor disturbances (manual muscle test [MMT] 3/5) and paresthesia of the bilateral upper extremities, but no sensory disturbances were observed. There were no major findings in the cranial nerves or brain stem reflex. The needle was not visualized externally and was not palpable.
RECEIVED: 1 April 2007; FINAL ACCEPTED: 7 January 2008
SUBMISSION RECEIVED:
Figure 1. Plain X-ray study of the lateral neck. The needle is 5.4 cm in length (arrow). The tip of the needle was located between the occipital bone and atlas.
Lateral neck X-ray study revealed the 5.4-cm needle with its tip located between the occipital bone and atlas (C1; Figure 1). Computed tomography demonstrated that the needle had penetrated the left medulla oblongata via the great foramen (Figure 2).
26 December 2007; 65
66
K. Takahashi et al.
further changes on MRI scans performed on Day 19 after surgery. The patient was discharged on Day 22.
DISCUSSION
Figure 2. Head computed tomography scan of bone image. The arrows point to the needle. The tip of the needle reached the medulla via the great foramen.
The day after admission, a suboccipital craniotomy was performed, without electrocauterization. An X-ray study confirmed that the needle was inserted in muscle. After the needle had been exposed for approximately 3 cm, a string was threaded through the hole in the needle and it was carefully drawn out. There was no bleeding, but minor leakage of cerebrospinal fluid was observed. Exploration was continued cranially and a contusion of the left medulla under the cerebellar tonsil was observed. Post-surgical neurological examinations showed gradual improvement in motor disturbance and paresthesia of the bilateral upper extremities such that, after 5 days, only a slight motor disturbance (MMT 4⫹/5) in left grip strength and paresthesia in the dorsum of the left hand remained. The function of the cranial nerves was normal. The patient was treated with antibiotics and no infectious complications were encountered. Magnetic resonance imaging (MRI) on the 4th day after surgery showed a hypointense trabecular lesion on T1-weighted and fluidattenuated inversion recovery images, and hyperintensity on T2-weighted (Figure 3). These changes were considered to be scarring caused by the needle. There were no
Most penetrating needle injuries result in damage to the brain. Penetrating needle injury of the central nervous system has been reported after migration of acupuncture needles into the spinal nerve, as well as in cases of child abuse (2,8). In children, the most common route of needle penetration is through the anterior fontanel or orbit (3,4). Injuries to the medulla after needle penetration are rare; there have been only two such case reports published previously (6,7). Generally, neurological disturbances after direct needle trauma of the medulla oblongata are mild. In one case, no clinical disturbances were observed; in another, there was progressive motor and sensory disturbance of the right upper extremity. Neither of the patients in those two cases died (Table 1). In the present case, paresis and paresthesia in the bilateral upper extremities were observed at admission. These neurological disturbances are most likely related to the site of injury, which was near the pyramidal decussation and the decussation of the medial lemniscus. With time, gradual improvements were observed in the neurological disturbances owing to decreased cerebral edema around the injury site. Facial erythema and general hyperhydrosis were related to the patient’s mental state, because these symptoms were observed only at admission. Needle penetration has the potential to cause severe vascular injury, depending on the route of penetration. Although not a direct injury to the medulla oblongata, there is one report of death due to massive cerebral edema during a C7 nerve root block caused by dissection of the left vertebral artery by a 25G spinal needle and subsequent thrombosis (9).
Figure 3. Brain magnetic resonance imaging scan on the 4th day. The arrows point to the lesion from the needle injury. This trabecular lesion demonstrated hypointensity at T1 (A) and fluid-attenuated inversion recovery image (C), and hyperintensity at T2 (B).
Developed left facial paresthesia Improved
Improved
Observation (non-operation) Operation
Operation
None
23-year-old woman
60 year-old woman
Hama et al. (6) Abumi et al. (7) Present case
70-year-old man
The cervical cord between the C1 and the medulla The right anterolateral medulla oblongata at the level of the foramen magnum The left medulla oblongata via the great foramen
Progressive motor and sensory disturbance of the right upper extremity Paresis and hyperesthesia in bilateral upper extremities
Prognosis Symptom Injury Site Case Authors
Table 1. The Present Case Compared with Past Cases
67
Treatment
Medullar Injury by Needle Puncture
In one case of needle trauma to the medulla, a conservative approach was taken to avoid treatment-related morbidity and mortality (6). However, with this approach there is a risk of infection caused by the foreign body in the central nervous system. In addition, there is a risk of a severe inflammatory reaction in surrounding tissues due to the metal. For example, copper produces a severe inflammatory reaction in surrounding tissue, which is rarely seen in response to pure gold (7). In our case, it was not known what the needle was made of. Consequently, surgical removal of the needle was believed to be the most appropriate treatment. In previous cases, extirpation of the needle using a magnet has proved useful (5). In the present case, we did not use electrocauterization equipment to avoid further damage to the tissue and, thus, to optimize healing. In addition, considerable care had to be taken when pulling the needle out, because careless removal may have expanded the range of damage. We succeeded in removing the needle, carefully pulling it out using the string we threaded through the hole.
CONCLUSION We have reported a rare case of injury to the medulla caused by needle penetration. An improvement in the neurological findings was obtained after careful surgical removal of the needle and appropriate antibiotic treatment. The patient’s post-surgical course was unremarkable without any infectious complications.
REFERENCES 1. Sener RN. Intracranial sewing needles in a 20-year-old patient. J Neuroradiol 1997;24:212– 4. 2. Rahimizadeh A, Sabouri-Daylami M, Tabatabi M, Rabani M, Hadadian K. Intracranial sewing needles. Neurosurgery 1987;20: 666. 3. Abbassioun K, Ameli NO, Morshed AA. Intracranial sewing needles: review of 13 cases. J Neurol Neurosurg Psychiatry 1979;42: 1046 –9. 4. Di Roio C, Jourdan C, Mottolese C, Convert J, Artru F. Craniocerebral injury resulting from transorbital stick penetration in children. Childs Nerv Syst 2000;16:503– 6. 5. Ashkenazi E, Mualem N, Umansky F. Successful removal of an intracranial needle by an ophthalmologic magnet: case report. J Trauma 1990;30:114 –5. 6. Hama Y, Kaji T. A migrated acupuncture needle in the medulla oblongata. Arch Neurol 2004;61:1608. 7. Abumi K, Anbo H, Kaneda K. Migration of an acupuncture needle into the medulla oblongata. Eur Spine J 1996;5:137–9. 8. Murata K, Nishio A, Nishikawa M, et al. Subarachnoid hemorrhage and spinal root injury caused by acupuncture needle: case report. Neurol Med Chir (Tokyo) 1990;30:956 –9. 9. Rozin L, Rozin R, Koehler SA, et al. Death during transforaminal epidural steroid nerve root block (C7) due to perforation of the left vertebral artery. Am J Forensic Med Pathol 2003;24: 351–5.
doi:10.1016/j.jemermed.2008.01.002
Visual Diagnosis in Emergency Medicine
MEDULLAR INJURY CAUSED BY SEWING NEEDLE PUNCTURE Kohei Takahashi, MD, Naoto Morimura, MD, PHD, Tetsuya Sakamoto, Hiroshi Nagashima, MD, PHD, and Masafumi Hirata, MD, PHD
MD, PHD,
Trauma and Critical Care Center, Teikyo University School of Medicine, Tokyo, Japan Reprint Address: Kohei Takahashi, MD, Trauma and Critical Care Center, Teikyo University School of Medicine, 2-1-11 Kaga Itabashiku, Tokyo 173-8606, Japan
INTRODUCTION A number of injuries to the central nervous system caused by needles have been described, but injuries to the brain stem after needle penetration are very uncommon (1–7). Therefore, we report the case of a patient who had a lesion in the medulla oblongata caused by a sewing needle that had migrated through the foramen magnum; she had a good outcome after surgical extraction.
CASE REPORT A 23-year-old woman presented to the Emergency Department for treatment of a self-puncture wound to the posterior cervical area caused by a sewing needle (suicide attempt). The patient had a medical history of schizophrenia. On admission, the patient’s Glasgow Coma Scale score was 15. The blood pressure was 90/50 mm Hg, heart rate 74 beats/min, and respiratory rate 28 breaths/min. Physical findings included facial erythema, general hyperhydrosis, nausea, and vomiting. Neurological examination revealed motor disturbances (manual muscle test [MMT] 3/5) and paresthesia of the bilateral upper extremities, but no sensory disturbances were observed. There were no major findings in the cranial nerves or brain stem reflex. The needle was not visualized externally and was not palpable.
RECEIVED: 1 April 2007; FINAL ACCEPTED: 7 January 2008
SUBMISSION RECEIVED:
Figure 1. Plain X-ray study of the lateral neck. The needle is 5.4 cm in length (arrow). The tip of the needle was located between the occipital bone and atlas.
Lateral neck X-ray study revealed the 5.4-cm needle with its tip located between the occipital bone and atlas (C1; Figure 1). Computed tomography demonstrated that the needle had penetrated the left medulla oblongata via the great foramen (Figure 2).
26 December 2007; 65
66
K. Takahashi et al.
further changes on MRI scans performed on Day 19 after surgery. The patient was discharged on Day 22.
DISCUSSION
Figure 2. Head computed tomography scan of bone image. The arrows point to the needle. The tip of the needle reached the medulla via the great foramen.
The day after admission, a suboccipital craniotomy was performed, without electrocauterization. An X-ray study confirmed that the needle was inserted in muscle. After the needle had been exposed for approximately 3 cm, a string was threaded through the hole in the needle and it was carefully drawn out. There was no bleeding, but minor leakage of cerebrospinal fluid was observed. Exploration was continued cranially and a contusion of the left medulla under the cerebellar tonsil was observed. Post-surgical neurological examinations showed gradual improvement in motor disturbance and paresthesia of the bilateral upper extremities such that, after 5 days, only a slight motor disturbance (MMT 4⫹/5) in left grip strength and paresthesia in the dorsum of the left hand remained. The function of the cranial nerves was normal. The patient was treated with antibiotics and no infectious complications were encountered. Magnetic resonance imaging (MRI) on the 4th day after surgery showed a hypointense trabecular lesion on T1-weighted and fluidattenuated inversion recovery images, and hyperintensity on T2-weighted (Figure 3). These changes were considered to be scarring caused by the needle. There were no
Most penetrating needle injuries result in damage to the brain. Penetrating needle injury of the central nervous system has been reported after migration of acupuncture needles into the spinal nerve, as well as in cases of child abuse (2,8). In children, the most common route of needle penetration is through the anterior fontanel or orbit (3,4). Injuries to the medulla after needle penetration are rare; there have been only two such case reports published previously (6,7). Generally, neurological disturbances after direct needle trauma of the medulla oblongata are mild. In one case, no clinical disturbances were observed; in another, there was progressive motor and sensory disturbance of the right upper extremity. Neither of the patients in those two cases died (Table 1). In the present case, paresis and paresthesia in the bilateral upper extremities were observed at admission. These neurological disturbances are most likely related to the site of injury, which was near the pyramidal decussation and the decussation of the medial lemniscus. With time, gradual improvements were observed in the neurological disturbances owing to decreased cerebral edema around the injury site. Facial erythema and general hyperhydrosis were related to the patient’s mental state, because these symptoms were observed only at admission. Needle penetration has the potential to cause severe vascular injury, depending on the route of penetration. Although not a direct injury to the medulla oblongata, there is one report of death due to massive cerebral edema during a C7 nerve root block caused by dissection of the left vertebral artery by a 25G spinal needle and subsequent thrombosis (9).
Figure 3. Brain magnetic resonance imaging scan on the 4th day. The arrows point to the lesion from the needle injury. This trabecular lesion demonstrated hypointensity at T1 (A) and fluid-attenuated inversion recovery image (C), and hyperintensity at T2 (B).
Developed left facial paresthesia Improved
Improved
Observation (non-operation) Operation
Operation
None
23-year-old woman
60 year-old woman
Hama et al. (6) Abumi et al. (7) Present case
70-year-old man
The cervical cord between the C1 and the medulla The right anterolateral medulla oblongata at the level of the foramen magnum The left medulla oblongata via the great foramen
Progressive motor and sensory disturbance of the right upper extremity Paresis and hyperesthesia in bilateral upper extremities
Prognosis Symptom Injury Site Case Authors
Table 1. The Present Case Compared with Past Cases
67
Treatment
Medullar Injury by Needle Puncture
In one case of needle trauma to the medulla, a conservative approach was taken to avoid treatment-related morbidity and mortality (6). However, with this approach there is a risk of infection caused by the foreign body in the central nervous system. In addition, there is a risk of a severe inflammatory reaction in surrounding tissues due to the metal. For example, copper produces a severe inflammatory reaction in surrounding tissue, which is rarely seen in response to pure gold (7). In our case, it was not known what the needle was made of. Consequently, surgical removal of the needle was believed to be the most appropriate treatment. In previous cases, extirpation of the needle using a magnet has proved useful (5). In the present case, we did not use electrocauterization equipment to avoid further damage to the tissue and, thus, to optimize healing. In addition, considerable care had to be taken when pulling the needle out, because careless removal may have expanded the range of damage. We succeeded in removing the needle, carefully pulling it out using the string we threaded through the hole.
CONCLUSION We have reported a rare case of injury to the medulla caused by needle penetration. An improvement in the neurological findings was obtained after careful surgical removal of the needle and appropriate antibiotic treatment. The patient’s post-surgical course was unremarkable without any infectious complications.
REFERENCES 1. Sener RN. Intracranial sewing needles in a 20-year-old patient. J Neuroradiol 1997;24:212– 4. 2. Rahimizadeh A, Sabouri-Daylami M, Tabatabi M, Rabani M, Hadadian K. Intracranial sewing needles. Neurosurgery 1987;20: 666. 3. Abbassioun K, Ameli NO, Morshed AA. Intracranial sewing needles: review of 13 cases. J Neurol Neurosurg Psychiatry 1979;42: 1046 –9. 4. Di Roio C, Jourdan C, Mottolese C, Convert J, Artru F. Craniocerebral injury resulting from transorbital stick penetration in children. Childs Nerv Syst 2000;16:503– 6. 5. Ashkenazi E, Mualem N, Umansky F. Successful removal of an intracranial needle by an ophthalmologic magnet: case report. J Trauma 1990;30:114 –5. 6. Hama Y, Kaji T. A migrated acupuncture needle in the medulla oblongata. Arch Neurol 2004;61:1608. 7. Abumi K, Anbo H, Kaneda K. Migration of an acupuncture needle into the medulla oblongata. Eur Spine J 1996;5:137–9. 8. Murata K, Nishio A, Nishikawa M, et al. Subarachnoid hemorrhage and spinal root injury caused by acupuncture needle: case report. Neurol Med Chir (Tokyo) 1990;30:956 –9. 9. Rozin L, Rozin R, Koehler SA, et al. Death during transforaminal epidural steroid nerve root block (C7) due to perforation of the left vertebral artery. Am J Forensic Med Pathol 2003;24: 351–5.