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Penetrating injury of the spinal cord
Injury
(1984)
16, 7-8
Printed in Great Britain
Penetrating Douglas
Gentleman
injury and Michael
institute of Neurological
of the spinal cord Harrington
Sciences, Glasgow
Summary
We describe 2 cases of penetrating injury of the thoracic spinal cord complicating stab wounds of the chest. Both patients exhibited the Brown-SCquard syndrome, with disturbances of sphincters as well as motor and sensory changes; both developed meningitis. The diagnosis and management of these patients are discussed. INTRODUCTION injury of the spinal cord as assault is well recognized in South Africa 1976; Peacock et al., 1977) but is extremely UK. From 1975 to 1979, 7712 cases of injuries of the neck, chest or abdomen were PENETRATING
a result of (Lipschitz, rare in the penetrating
recorded in Scotland, but only 4 of these (0.05 per cent) were associated with neurological complications, and none had meningitis (Scottish Hospital In-Patient Statistics, 1975-1979). We describe 2 cases in which spinal cord damage complicated stab wounds of the back of the chest. CASE REPORTS Case 1
A 22-year-old male painter was assailed with a sharpened screwdriver in August 1981. On admission to hospital 1 hour later he complained of weakness, heaviness and paraesthesiae in both lower limbs, with dysuria, hesitancy of micturition and loss of normal bowel sensation. He was a lean man with 12 stab wounds a few millimetres long on both sides of the back of his chest, 2 of which were just to the left of the midline at the levels of the fifth and tenth thoracic spinous processes. There was a severe flaccid paraparesis, with loss of vibration sense up to the knees and impaired joint position sense in the toes; these signs were all more marked on the left side. Perception of pinprick was dulled between T5 and T12 dermatomes on the right. Both knee jerks were diminished; the left ankle jerk was brisk and the plantar responses were extensor. The abdominal reflexes were absent. The bladder was distended to the umbilicus and the patient did not have the desire to void urine. A chest X-ray film showed a left pneumothorax, and this was drained. The stab wounds were cleaned and sutured, and antitetanus prophylaxis was provided. Plain X-ray films of the thoracic spine showed no abnormality. The diagnosis was that of a partial Brown-Sequard lesion from penetration of the thoracic cord on the left side. Management was conservative, with penicillin and sulphadimidine for prophylaxis against meningitis. During the third week after injury the patient developed pneumonia, which was treated with co-trimoxazole. However, on day 19 after admission he developed fever, meningism, headache, photophobia and general malaise. Examination of the cerebrospinal fluid showed a protein level of 144g/l (normal range 0.15-0.45 g/l), normal glucose level, 18 white blood cells/mm3, 250 red blood
cells/mm3, no organisms and a sterile culture. This was interpreted as the result of a partially treated bacterial meningitis. The 3 antibiotics were continued for 7 days and his symptoms disappeared. The disturbance of bowel and bladder function had resolved by 10 days after injury. Power and sensation in the lower limbs steadily improved, and the patient walked out of hospital 4 weeks after injury. Examination 3 months later revealed a mild weakness of all muscle groups in the left lower limb and patchy impairment of spinothalamic sensation in the lower thoracic dermatomes on the right. The patient had returned to work, Case 2 A 37-year-old housewife was involved in a drunken brawl with her husband in December 1982, and he stabbed her once in the back with a large kitchen knife. She immediately felt pain in the right thigh and was unable to move this limb. She also described numbness and heaviness of the left lower limb, altered sensation in the lower bowel and an abnormal feeling during micturition; indeed she had to initiate micturition by pressing on the lower abdomen. Examination showed a single, ragged stab wound of the back, 3cm to the right of the midline at the level of the sixth and seventh thoracic spinous processes. She had a flaccid paralysis of the whole right lower limb, with normal power on the left. Spinothalamic sensation was diminished on the left from S5 segment up to a level that varied between T5 and T9. There was hyperaesthesia on the right from T9 to Ll dermatomes. Joint position sense was impaired in the toes on the right; the right knee and ankle jerks were diminished, and the right plantar response was absent. The wound was cleaned and sutured, and anti-tetanus prophylaxis was given. X-ray films of the chest and thoracic spine were normal. This was diagnosed as a Brown-Siquard syndrome due to penetration of the right side of the thoracic spinal cord. Penicillin and sulphadimidine were started, but 8 days after injury the patient developed clinical signs of meningitis, though no cerebrospinal fluid could be obtained to confirm this. She responded within a few days to treatment with flucloxacillin, gentamicin and chloramphenicol. Her paralysis began to improve 5 days after injury and sphincter control was normal by 2 weeks. Recovery was uneventful thereafter. At 4 months she had a slight limp but was able to walk adequately. The spinothalamic sensory loss on the left was less marked and the right-sided hyperaesthesia had resolved. However, she stated that since the injury she had lost normal vaginal sensation during intercourse. DISCUSSION
Penetration of the spinal cord during assault is most commonly due to a knife or similar instrument, and usually produces the Brown-Stquard syndrome or some variant thereof (Peacock et al., 1977). The seemingly bizarre neurological picture may lead to confusion and
8
Injury: the British Journal of Accident
delay in reaching the diagnosis. Indeed, a diagnosis of hysteria was considered in both our patients on admission. Clearly, accurate diagnosis is an essential prelude to proper investigation and management. The lesion is thought to be intrinsic cord damage from direct penetration, though vascular compromise and contrecoup injury of the cord against its bony walls may also play a part (Lipschitz, 1976). Extrinsic compression is only rarely present and there is no place for myelography or spinal computerized axial tomography unless there are foreign bodies or bone fragments that require surgical removal (Baghai and Sheptak, 1982). Some knowledge of the weapon and plain radiography will be enough to decide this in most cases. Rarely, an extradural abscess or granuloma may form, reversing initial improvement, and surgical exploration may be indicated in these cases. Both our patients developed meningitis despite antibiotic prophylaxis. In retrospect, more appropriate antibiotics could have been used, in view of the wide range of potential causative organisms. In future we would use cephradine and chloramphenicol in the first instance. One-third of patients with penetrating injury of the cord suffer complete transection and remain paraplegic. The prognosis in the rest is good, and about half of these will return to their former occupations. However, complete recovery is uncommon, and a variety of motor, sensory and autonomic defects may persist (Lipschitz,
1976). The best management continues to be based on accurate clinical diagnosis, limited investigations and effective prophylaxis against meningitis, with surgical exploration playing only a very small role. Violence in British cities is increasing, and it is important that casualty officers and surgeons be aware of this uncommon complication of stab injuries.
Requests for reprints should be addressed to:
Surgery (1984) Vol. 1 ~/NO. 1
Acknowledgements
We wish to express our thanks to Mr Gordon Gillespie FRCS and Mr Robert Venner FRCS for permission to report these cases.
REFERENCES
Baghai P. and Sheptak P. E. (1982) Penetrating spinal injury by a glass fragment. Neurosurgery 11(3), 419. Lipschitz R. (1976) Stab wounds of the spinal cord. In: Vinken P. J. and Vruyn G. W. (eds) Handbook of Clinical Neurology. Amsterdam: North Holland Publishing Co., 197. Peacock W. J., Shrosbree R. D. and Key A. G. (1977) A review of 450 stab wounds of the spinal cord. S. Afr. Med. J. 51,961. Scottish Hospital In-Patient Statistics (1975-1979) Information Services Division of the Common Services Agency, Scottish Health Service. Paper accepted 10 October 1983.
Douglas Gentleman, Dept of Neurosurgery, Institute of Neurological Sciences, Southern General
Hospital, 1345 Goven Road, Glasgow G514JF.
(1984)
16, 7-8
Printed in Great Britain
Penetrating Douglas
Gentleman
injury and Michael
institute of Neurological
of the spinal cord Harrington
Sciences, Glasgow
Summary
We describe 2 cases of penetrating injury of the thoracic spinal cord complicating stab wounds of the chest. Both patients exhibited the Brown-SCquard syndrome, with disturbances of sphincters as well as motor and sensory changes; both developed meningitis. The diagnosis and management of these patients are discussed. INTRODUCTION injury of the spinal cord as assault is well recognized in South Africa 1976; Peacock et al., 1977) but is extremely UK. From 1975 to 1979, 7712 cases of injuries of the neck, chest or abdomen were PENETRATING
a result of (Lipschitz, rare in the penetrating
recorded in Scotland, but only 4 of these (0.05 per cent) were associated with neurological complications, and none had meningitis (Scottish Hospital In-Patient Statistics, 1975-1979). We describe 2 cases in which spinal cord damage complicated stab wounds of the back of the chest. CASE REPORTS Case 1
A 22-year-old male painter was assailed with a sharpened screwdriver in August 1981. On admission to hospital 1 hour later he complained of weakness, heaviness and paraesthesiae in both lower limbs, with dysuria, hesitancy of micturition and loss of normal bowel sensation. He was a lean man with 12 stab wounds a few millimetres long on both sides of the back of his chest, 2 of which were just to the left of the midline at the levels of the fifth and tenth thoracic spinous processes. There was a severe flaccid paraparesis, with loss of vibration sense up to the knees and impaired joint position sense in the toes; these signs were all more marked on the left side. Perception of pinprick was dulled between T5 and T12 dermatomes on the right. Both knee jerks were diminished; the left ankle jerk was brisk and the plantar responses were extensor. The abdominal reflexes were absent. The bladder was distended to the umbilicus and the patient did not have the desire to void urine. A chest X-ray film showed a left pneumothorax, and this was drained. The stab wounds were cleaned and sutured, and antitetanus prophylaxis was provided. Plain X-ray films of the thoracic spine showed no abnormality. The diagnosis was that of a partial Brown-Sequard lesion from penetration of the thoracic cord on the left side. Management was conservative, with penicillin and sulphadimidine for prophylaxis against meningitis. During the third week after injury the patient developed pneumonia, which was treated with co-trimoxazole. However, on day 19 after admission he developed fever, meningism, headache, photophobia and general malaise. Examination of the cerebrospinal fluid showed a protein level of 144g/l (normal range 0.15-0.45 g/l), normal glucose level, 18 white blood cells/mm3, 250 red blood
cells/mm3, no organisms and a sterile culture. This was interpreted as the result of a partially treated bacterial meningitis. The 3 antibiotics were continued for 7 days and his symptoms disappeared. The disturbance of bowel and bladder function had resolved by 10 days after injury. Power and sensation in the lower limbs steadily improved, and the patient walked out of hospital 4 weeks after injury. Examination 3 months later revealed a mild weakness of all muscle groups in the left lower limb and patchy impairment of spinothalamic sensation in the lower thoracic dermatomes on the right. The patient had returned to work, Case 2 A 37-year-old housewife was involved in a drunken brawl with her husband in December 1982, and he stabbed her once in the back with a large kitchen knife. She immediately felt pain in the right thigh and was unable to move this limb. She also described numbness and heaviness of the left lower limb, altered sensation in the lower bowel and an abnormal feeling during micturition; indeed she had to initiate micturition by pressing on the lower abdomen. Examination showed a single, ragged stab wound of the back, 3cm to the right of the midline at the level of the sixth and seventh thoracic spinous processes. She had a flaccid paralysis of the whole right lower limb, with normal power on the left. Spinothalamic sensation was diminished on the left from S5 segment up to a level that varied between T5 and T9. There was hyperaesthesia on the right from T9 to Ll dermatomes. Joint position sense was impaired in the toes on the right; the right knee and ankle jerks were diminished, and the right plantar response was absent. The wound was cleaned and sutured, and anti-tetanus prophylaxis was given. X-ray films of the chest and thoracic spine were normal. This was diagnosed as a Brown-Siquard syndrome due to penetration of the right side of the thoracic spinal cord. Penicillin and sulphadimidine were started, but 8 days after injury the patient developed clinical signs of meningitis, though no cerebrospinal fluid could be obtained to confirm this. She responded within a few days to treatment with flucloxacillin, gentamicin and chloramphenicol. Her paralysis began to improve 5 days after injury and sphincter control was normal by 2 weeks. Recovery was uneventful thereafter. At 4 months she had a slight limp but was able to walk adequately. The spinothalamic sensory loss on the left was less marked and the right-sided hyperaesthesia had resolved. However, she stated that since the injury she had lost normal vaginal sensation during intercourse. DISCUSSION
Penetration of the spinal cord during assault is most commonly due to a knife or similar instrument, and usually produces the Brown-Stquard syndrome or some variant thereof (Peacock et al., 1977). The seemingly bizarre neurological picture may lead to confusion and
8
Injury: the British Journal of Accident
delay in reaching the diagnosis. Indeed, a diagnosis of hysteria was considered in both our patients on admission. Clearly, accurate diagnosis is an essential prelude to proper investigation and management. The lesion is thought to be intrinsic cord damage from direct penetration, though vascular compromise and contrecoup injury of the cord against its bony walls may also play a part (Lipschitz, 1976). Extrinsic compression is only rarely present and there is no place for myelography or spinal computerized axial tomography unless there are foreign bodies or bone fragments that require surgical removal (Baghai and Sheptak, 1982). Some knowledge of the weapon and plain radiography will be enough to decide this in most cases. Rarely, an extradural abscess or granuloma may form, reversing initial improvement, and surgical exploration may be indicated in these cases. Both our patients developed meningitis despite antibiotic prophylaxis. In retrospect, more appropriate antibiotics could have been used, in view of the wide range of potential causative organisms. In future we would use cephradine and chloramphenicol in the first instance. One-third of patients with penetrating injury of the cord suffer complete transection and remain paraplegic. The prognosis in the rest is good, and about half of these will return to their former occupations. However, complete recovery is uncommon, and a variety of motor, sensory and autonomic defects may persist (Lipschitz,
1976). The best management continues to be based on accurate clinical diagnosis, limited investigations and effective prophylaxis against meningitis, with surgical exploration playing only a very small role. Violence in British cities is increasing, and it is important that casualty officers and surgeons be aware of this uncommon complication of stab injuries.
Requests for reprints should be addressed to:
Surgery (1984) Vol. 1 ~/NO. 1
Acknowledgements
We wish to express our thanks to Mr Gordon Gillespie FRCS and Mr Robert Venner FRCS for permission to report these cases.
REFERENCES
Baghai P. and Sheptak P. E. (1982) Penetrating spinal injury by a glass fragment. Neurosurgery 11(3), 419. Lipschitz R. (1976) Stab wounds of the spinal cord. In: Vinken P. J. and Vruyn G. W. (eds) Handbook of Clinical Neurology. Amsterdam: North Holland Publishing Co., 197. Peacock W. J., Shrosbree R. D. and Key A. G. (1977) A review of 450 stab wounds of the spinal cord. S. Afr. Med. J. 51,961. Scottish Hospital In-Patient Statistics (1975-1979) Information Services Division of the Common Services Agency, Scottish Health Service. Paper accepted 10 October 1983.
Douglas Gentleman, Dept of Neurosurgery, Institute of Neurological Sciences, Southern General
Hospital, 1345 Goven Road, Glasgow G514JF.