Gunshot Wounds to the Neck.

ABSTRACT: Gunshot wounds to the neck are diagnostically and therapeutically challenging cases. We report such a case with vascular and neurologic injuries and describe the therapeutic options. Initial treatment is aimed at hemodynamic stabilization. Zone II neck injuries are managed selectively, and physical examination alone may dictate emergency surgical exploration. Spinal cord injury must be suspected and assessed clinically, as well as by computed tomography and angiography. Deteriorating or stable neurologic status and cord compression by bullet or bone fragments require surgical decompression. Improving neurologic status may be managed conservatively. In gunshot wounds to the neck, treatment should be individualized and multidisciplinary.

THE INCIDENCE of penetrating spinal cord injuries due to gunshot wounds has risen steadily over the past decades. These injuries occur mostly in large metropolitan areas with high crime rates. Involvement of the cervical region is particularly challenging for the surgeon because of its unique anatomy and the potential for severe sequelae. We report the case of a young patient with a gunshot wound to the posterior cervical region. Apparent vascular and neurologic injuries were managed by neck exploration and clinical observation for spinal cord injury. We review our rationale for this diagnostic and therapeutic approach.

CASE REPORT

A 25-year-old African American man arrived at the emergency room approximately 30 minutes after sustaining a single gunshot wound to the left posterior cervical region. His chief complaints were neck pain and the inability to move any extremity. Systolic blood pressure before his arrival was reported to be 90 mm Hg (palpatory). Neurologic examination showed intact cranial nerve (II through XII) functions, with flaccid paralysis of all four extremities except for bilateral forearm flexion, which was possible against gravity. Sensory examination was intact for pin prick and light touch throughout. Deep tendon reflexes were absent bilaterally. Rectal sphincter tone was decreased, with preserved bulbocavernosus reflex. The bullet entrance wound was in the left posterior cervical region, above and medial to the left scapula. The exit wound was midline in the anterior aspect of the neck. A bullet fragment was palpable in the left anterior aspect of the neck, lateral to the cricoid cartilage. A large left anterior n eck hematoma was present. Both carotid pulses were palpable, and there were no carotid bruits.

Initial radiographic studies showed multiple bullet fragments dispersed in the left side of the neck and multiple fractures of the cervical spine at the levels of C6, C7, and T1 (Fig 1).

Findings on the initial workup were consistent with a zone 11 neck injury, resulting in hypotension and neck hematoma as well as cervical spine injury with an incomplete motor deficit at the C5 level. Since the patient had an absolute indication for neck exploration, he was taken immediately to the operating room. Surgical exploration of the left anterior cervical region revealed an extensive hematoma and a lacerated left external jugular vein, which was ligated. The hyoid bone was fractured and repaired.

Postoperatively, the patient was taken immediately to the radiology suite for computed tomography (CT) of the cervical spine and cervical and cerebral angiography. Cervical spine CT without contrast medium revealed multiple bullet fragments extending from C6 to TI; comminuted fractures of the left transverse processes of C6, C7, and T1; and a 3-mm bullet fragment inside the spinal canal, against the left inner laminar surface at the level of C6 (Fig 2).

Cervical and cerebral angiography showed the left vertebral artery thrombosed at 2 cm from its origin (Fig 3) and mild diffuse spasm of the right vertebral artery, with reflux into the left vertebral artery up to the C5 level, covering the posterior inferior cerebellar artery territory. The posterior circulation run-off and the carotid system were normal.

Postoperatively, on serial neurologic examinations the patient showed significant improvement. At the time of this writing, he is able to walk without assistance and move all extremities against significant resistance.

DISCUSSION

Our case illustrates that a single bullet may cause a variety of injuries: arterial (vertebral artery), venous (external jugular vein), bony (cervical vertebrae and the hyoid bone), and neurologic (spinal cord). Prioritization of diagnostic and therapeutic options in these cases is critical. This requires emergency decision making and coordination among specialists, particularly surgeons, neurosurgeons, and radiologists.

Initial measures should aim at stabilization of vital signs. Physical examination alone offers a safe and accurate evaluation of the vascular injuries in penetrating injuries of the cervical region. [1] A hypotensive episode despite fluid resuscitation in a patient with zone II neck injury warrants immediate surgical exploration, since the probability of injury of the great vessels in the neck is high. [2] Every effort must be made to preserve the patency of the carotid artery and internal jugular vein, whereas smaller vessels such as the external jugular vein can be safely ligated. Thorough intraoperative exploration for a possible tracheal or esophageal injury is also mandatory.

The next step is the evaluation of the spinal cord injury. Mechanisms of injury may include direct spinal cord transsection, contusion caused by the shockwave created by the bullet, and spinal cord ischemia due to arterial injury.

Medical treatment should be instituted in all patients and consists of judicious intravenous fluid resuscitation, broad spectrum antibiotics, and tetanus prophylaxis. There is ongoing debate regarding the use of steroids in penetrating injuries of the spinal cord. Heary et al [3] noted that steroid use does not result in any significant functional improvement, but it does increase the rate of infectious and metabolic complications.

Computed tomography is a good tool to evaluate the location of bullet and bone fragments with respect to the spinal cord. Patients without frank cord compression should be treated medically, since surgical trauma might further injure the already contused nervous tissue. Computed tomography may identify the rare cases in which the vertebral fractures caused by the bullet are so extensive that the spine becomes unstable and requires surgical fusion, regardless of the neurologic deficit. Patients with gunshot wounds to the neck should also have angiography to assess the patency of the vertebral arteries and the presence of possible arteriovenous fistulas.

Serial neurologic examinations are the most important factor dictating therapy. [4] An incomplete neurologic lesion, especially with progressive deterioration, may be caused by direct compression of the neural elements and might benefit from surgical decompression. In our opinion, an improving neurologic examination is a relative contraindication for surgery as well as a complete neurologic lesion, in which the risks of wound infection, cerebrospinal fistulas, and spinal instability outweigh the minimal chances of neurologic recover. The decision to do surgical decompression should be made on an individual basis, taking into consideration the patient's potential for recovery and possible complications. [4]

CONCLUSION

Evaluation and treatment of penetrating neck injuries require a multidisciplinary approach, coordinated by the trauma surgeon. Selective management should be individualized according to clinical and radiologic findings.

From the Trauma Program, Charity Hospital New Orleans, New Orleans, La.

Reprint requests to Kennan J. Buechter, MD, Louisiana State University Health Science Center, Department of Surgery, 1542 Tulane Ave, New Orleans, LA 70112.

References

(1.) Atteberry LR, Dennis JW, Menawat SS, et al: Physical examination is safe and accurate for evaluation of vascular injuries in penetrating zone II neck trauma J Am Coll Surg 1994; 179:657-662

(2.) Klyachkin ML, Rohmiller M, Charash WE, et al: Penetrating injuries of the neck: selective management evolving. Am Surg 1997; 63:189-194

(3.) Heary RF, Vaccaro AR, Mesa JJ, et al: Steroids and gunshot wounds to the spine. Neurosurgery 1997; 41:576-583

(4.) Jallo GI: Neurosurgical management of penetrating spinal injury. Surg Neurol 1997; 47:328-330