Injury, Int. J. Care Injured 46 (2015) 1726–1733
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Spinal stab injury with retained knife blades: 51 Consecutive patients managed at a regional referral unit Basil Enicker a,*, Sonwabile Gonya a, Timothy C. Hardcastle b,c a
Department of Neurosurgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Inkosi Albert Luthuli Central Hospital, KwaZulu-Natal, South Africa b Trauma Unit and Trauma Intensive Care, Inkosi Albert Luthuli Central Hospital, South Africa c Department of Surgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, South Africa
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 9 May 2015
Background: Spinal stab wounds presenting with retained knife blades (RKB) are uncommon, often resulting in spinal cord injury (SCI) with catastrophic neurological consequences. The purpose of this study is to report a single unit’s experience in management of this pattern of injury at this regional referral centre. Methods: Retrospective review of medical records identified 51 consecutive patients with spinal stabs presenting with a RKB at the Neurosurgery Department at Inkosi Albert Luthuli Central Hospital between January 2003 and February 2015. The data was analyzed for patient characteristics, level of the RKB, neurological status using the ASIA impairment scale, associated injuries, radiological investigations, management, hospital length of stay, complications and mortality. Results: The mean age was 28 10.9 years (range 14–69), with 45 (88%) males (M: F = 7.5:1). The median Injury Severity Score was 16 (range 4–26). RKB were located in the cervical [9,18%], thoracic [38,74%], lumbar [2,4%] and sacral [2,4%] spine. Twelve patients (24%) sustained complete SCI (ASIA A), while 21 (41%) had incomplete (ASIA B, C, D), of which 17 had features of Brown–Sequard syndrome. Eighteen (35%) patients were neurologically intact (ASIA E). There were 8 (16%) associated pneumothoraces and one vertebral artery injury. Length of hospital stay was 10 7.1 days (range 1–27). One patient (2%) died during this period. Conclusions: Stab injuries to the spine presenting with RKB are still prevalent in South Africa. Resources should be allocated to prevention strategies that decrease the incidence of inter-personal violence. All RKBs should be removed in the operating theatre by experienced surgeons to minimise complications. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Brown–Sequard syndrome Inter-personal violence Laminectomy Stab injuries Retained knife blades Spinal cord injury Vertebral–venous fistula
Introduction The vertebral column plays an important role in protecting the spinal cord from external injuries [1]. However, despite this protection, the spinal cord is still vulnerable to injuries from sharp objects, commonly knives, which can enter the spinal canal either through the interlaminar space or directly through the vertebrae [2]. Stabs to the spine are uncommon in developed countries, but continue to be a source of trauma burden in the developing world [3], particularly in the Province of KwaZulu-Natal (KZN), South Africa. Even more uncommon is when patients present with a retained knife blade (RKB) following these assaults (Fig. 1). The blade is frequently lodged in the vertebral body, lamina, and or pedicle [4].
* Corresponding author. Tel.: +27 798926711; fax: +27 312401132. E-mail address: [email protected] (B. Enicker). http://dx.doi.org/10.1016/j.injury.2015.05.037 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
On review of the literature, RKBs in the spine have primarily been the subject of case reports [5–11], with no large series reporting on this entity. Small series examining retained foreign bodies anywhere in the body have included small numbers of such cases [12]. Penetrating injuries commonly occur as a result of interpersonal violence which is a major contributor to the incidence of trauma in KZN [13], with the World Health Organization (WHO) identifying inter-personal violence as one the leading causes of morbidity and mortality in young adults, and males in particular [14]. These injuries present in a dramatic fashion, as the impaled knife is visible to spectators and often results in acute spinal cord injury (SCI), which has a catastrophic emotional impact, with severe social and health care costs, since the majority of these victims are at the prime of their lives [15] and may be the sole breadwinner. The purpose of this study was to evaluate this unit’s experience in managing stabs to the spine, presenting with RKB in a series of 51 consecutive patients admitted and treated at the
B. Enicker et al. / Injury, Int. J. Care Injured 46 (2015) 1726–1733
Fig. 1. A male patient who sustained a stab to the spine and presented with a retained knife blade (RKB).
Neurosurgery Department located at Inkosi Albert Luthuli Central Hospital (IALCH), KZN, South Africa (SA). Methods and materials This retrospective study reviewed the medical charts of patients with stabs to the spine admitted from January 2003, until February 2015, at the Neurosurgery Department (ND), IALCH, Durban, SA. The ND has maintained a comprehensive database of all admissions since it was commissioned at IALCH in December 2002. Prior to this the ND was based at Wentworth Hospital located in the same province [16]. The medical charts are kept in a password-protected computer programme (Soarian1, Siemens, Germany) where the data was obtained and exported into an Excel1, spreadsheet (Microsoft Inc., WA, USA). Variables examined included patient characteristics, spinal level of the RKB, presence of SCI and whether this was complete or incomplete, associated injuries, radiological investigations performed, management, length of hospital stay, complications and mortality. Ethical approval was granted by the Biomedical Research Ethics Committee of the University of KwaZulu-Natal (Ref. BE 507/14). Inclusion criteria were: all patients with RKB on presentation, while those where the blade was removed at the scene were excluded. The KZN province has a dedicated Spine Unit (SU) which is under the care of orthopaedic surgeons and is based in an off-site hospital. The SU also manages spinal trauma; however patients from this unit were not included in this study, since that unit mainly manages blunt spinal trauma. The management of these injuries involves stabilizing patients in accordance with the Advanced Trauma Life Support (ATLS1) principles, and excluding all life threatening injuries. Tetanus toxoid is administered to all patients in the emergency department, unless already provided at the referring facility. Signs of acute SCI are assessed and documented as either complete or incomplete using the American Spinal Injury Association (ASIA) impairment scale. Complete SCI is defined as no motor and sensory function more than three segments below the level of injury in the cord, while incomplete SCI is defined as residual motor and sensory
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function more than three segments below the level of injury, including sacral sparing [17]. The local policy is to perform a computerised tomography (CT) scan of the spine with axial, coronal and sagittal views on all patients to assess the trajectory of the knife and its relation to important organs and major vessels, an example which is shown in Fig. 2. X-ray or CT scan of the chest is performed if associated lung injury is suspected, while a contrast swallow is obtained to exclude oesophageal injury when suspected. Angiography is performed if the trajectory of the blade traverses an area of major blood vessels. Magnetic resonance imaging (MRI) of the spine is not routinely performed, especially if the blade is still in situ, but is performed only if there is progressive neurological deterioration or spinal abscess or empyema post removal of the blade. All RKBs are removed in the operating theatre (OT) under general anaesthesia (GA), and a first generation cephalosporin antibiotic, namely cefazolin is administered at induction for prophylaxis. The procedure is performed in the prone position, the wound is extended and the tract explored the objective being to remove the blade under direct vision in-line with its original trajectory and to remove foreign debris that might have contaminated the wound. A laminectomy is performed, when indicated, to facilitate removal of blades that are resistant to simple withdrawal, taking care not to rock the blade, as this worsens tissue damage and SCI. Loose bony fragments in the canal are removed and the dura mater is explored for penetration and repaired in a watertight tight fashion under direct vision, if breached. A lumbar drain may be inserted in the same setting after dural repair; however this is at the discretion of the primary surgeon. After debridement the wound is closed in layers and cefazolin administered for a period of 48 h if the dura is breached. Antibiotics of choice in patients with septic wound complications with associated meningitis are combinations of cloxacillin and ceftriaxone, which is used until microscopy, culture and sensitivity results are obtained from the laboratory and then directed therapy is instituted. Local wound care, deep vein thrombosis prophylaxis, pressure point care to prevent bedsores and bladder care to prevent urinary tract infection forms part of the standard postoperative management protocol in patients with SCI. Physiotherapy, occupational therapy and psychology consultations are sought post-operatively in patients with SCI as part of the multidisciplinary rehabilitation approach. Once patients are deemed stable they are discharged back to their local hospital for continuation of care. Results The ND at IALCH between January 2003 and February 2015 admitted a total of 338 patients with traumatic spinal injuries of whom 104 (31%) were as a result of stabs to the spine. Of those with stab wounds 51 (49%) presented with RKB (Table 1). Their mean age was 28 10.9 (range 14–69 years). There were 45 (88%) males and 6 (12%) females giving a male to female ratio of 7.5:1. The median Injury Severity Score (ISS) was 16 (range 4–26), interquartile range (IQR) 5–25. The median New Injury Severity Score (NISS) was 16 (range 4–34), IQR 5–25. In two females the injuries were following intimate partner violence (IPV). The spinal levels of RKB were cervical [9, 18%], thoracic [38,74%], lumbar [2, 4%] and sacrum [2,4%], examples of imaging is demonstrated in Fig. 3. The neurological impairment on admission was documented using the ASIA impairment scale, the results of which are shown in Table 2. Twelve (24%) patients had complete SCI, while in 21 (41%) it was incomplete. Of the patients with incomplete SCI 17 (81%) had features of Brown–Sequard syndrome. Eighteen (35%) patients were neurologically intact at presentation and these were the
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Fig. 2. Sagittal (A), coronal (B) and axial (C) CT scan views of the spine showing RKB in lower thoracic spine transecting the facet, extending through vertebral body abuting the posterior mediastinum. The blade has gone through the spinal canal and only a few millimetres separate the blade and the descending aorta (arrow).
patients in whom the blade did not go across the spinal canal (Fig. 4). CT scans of the spine were performed in all patients and MRI spine was performed in only two patients (Fig. 5), one had spinal sepsis while the other had progressive neurological deficit post removal of the knife. Eight (16%) patients had associated pneumothoraces (Fig. 6) of which seven were treated with insertion of intercostal drain. One (2%) patient sustained injury to the left vertebral artery (VA) confirmed via catheter directed angiogram revealing a vertebral–venous fistula (VVF) occurring
Table 1 A summary of patient characteristics.
Stabs with RKB Gender Male Female Injury severity ISS median (IQR) NISS median (IQR) Spinal level of RKB Cervical Thoracic Lumbar Sacrum Lumbar drain insertion Patients with associated injuries Mortality
Number
%
51/108
49
45 6 16 (5–25) 16 (5–25)
88 12 Range 4–26 4–34
9 38 2 2 12 9 1
18 74 4 4 24 18 2
IQR = interquartile range; ISS = injury severity score; NISS = new injury severity score; RKB = retained knife blades.
between the left VA and the epidural vertebral venous plexus (Fig. 7). The VVF was treated by endovascular occlusion by placement of detachable coils after the blade had been removed. A post-coiling angiogram showed successful occlusion of the VVF and the patient tolerated unilateral VA occlusion (Fig. 8). None of the patients had associated oesophageal and abdominal injuries in this cohort. Two (4%) patients had septic wounds at presentation and the organism cultured in both was Staphylococcus aureus. Forty-seven (92%) patients required a laminectomy to facilitate removal of the blade while in four (8%) patients it could be safely withdrawn without this procedure. Intra-operatively the dura mater was found to be breached in 40 (78%) patients and was primarily repaired under direct vision. A lumbar drain was inserted in 12 (24%) patients at the same setting. Four (8%) patients developed postoperative wound sepsis, which was associated with meningitis in three patients and cerebrospinal fluid (CSF) leakage in two. The organisms cultured were Staphylococcus aureus in three patients, of which one was methicillin resistant and a Streptococcus group in the other patient. These patients were taken back to theatre for wound debridement, repair of CSF leaks (with lumbar drain insertion) and were put on directed antibiotic therapy post-operatively. The average hospital stay was 10 7.1 days (range 1–27 days) and there were no readmissions. Assessment of the ASIA impairment scale at discharge revealed no neurological changes in category A and B patients. Only three patients improved from category C to D, these were patients who presented with features of Brown–Sequard syndrome who had partial recovery (18%), while four patients with similar type syndrome in category D had complete recovery (23%) and improved to category E. One patient deteriorated from category D to C
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Fig. 3. CT scans showing RKBs in the cervical (A), thoracic (B), lumbar (C) and sacral (D) spine in patients treated during the study period.
and MRI spine showed a tract haematoma with associated spinal cord oedema. Of the patients treated, one (2%) died during the admission period and this was a patient who had ASIA impairment scale C, following a stab to the thoracic spine, developed septic wound complication with associated CSF leak and meningitis post removal of the blade. The patient required subsequent admission to intensive care for pneumonia which did not respond to ventilation and medical therapy. The rest of the patients were discharged back to their base hospital for continued care.
commonly affects young males at the peak of their lives, with reports suggesting that Sub-Saharan Africa has the highest incidence of violence-related SCI in the world [20,21]. Two females in the current study were victims of IPV which accounts for 62% of
Discussion The annual incidence of SCIs is reported to vary from 11 to 50 cases per million population [18], with penetrating injury to the spine making up approximately 25% of all causes of SCIs [19]. The current study confirms the widely held view that spinal trauma
Table 2 ASIA impairment scale of the 51 patients presenting with RKBs. ASIA scale
Admission
Discharge
A B C D E
12 2 9 10 18
12 2 7 8 22
ASIA = American Spinal Injury Association.
Fig. 4. RKB in the thoracic spine. The blade missed the spinal canal and the patient was neurologically intact at presentation.
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Fig. 5. Sagittal T1—weighted (A), T2—weighted (B) and axial T2—weighted (C) MR images performed post removal of a RKB at T10 level showing blooming artefact representing intraspinal haemorrhage with associated oedema (arrows) in a patient with progressive neurological deterioration post removal of the blade.
Fig. 6. Axial (A and B) and coronal (C) CT scan images showing RKB with left sided pneumothorax (arrows).
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Fig. 7. Axial CT scan image showing RKB in the cervical spine (A). Anterioposterior (AP) left vertebral artery (VA) angiogram performed in the same patient showed a VA injury resulting in a vertebral–venous fistula (VVF).
documented cases of violence against women in SA [22], which unfortunately also has rate of 8.8 per 100 000 women murdered by an intimate partner [23]. RKBs in the spine are uncommon, but potentially life threatening, requiring prompt evaluation and management, which is essential in preserving neurological function. Jacobsohn et al. found only one patient presenting with a RKB in their series of 22 patients with stab injuries to the spine [24]. Other instruments used to inflict these injuries in the SA experience are bicycle spokes, screwdrivers, forks, and scissors [25]. The knife is typically lodged in the vertebral body, lamina or pedicle making it difficult for the perpetrator to remove it; with forceful attempts resulting in breakage of the blade [26]. In the current study the commonest site of injury was the thoracic spine a finding reported by other authors [3,25,27].
The mechanism of acute SCI is related to focal injury or transection of the cord, injury to the artery of Adamkiewicz (which provides major blood supply to the cord), in-driven bone fragments causing cord compression and, lastly, secondary to associated spinal haematomas following injury to vessels [7]. The SCI is further worsened by a sustained period of hypotension which can occur when there is associated major systemic blood loss [28] or even after neurogenic shock. SCI can occur in delayed fashion as a result of associated postoperative spinal sepsis, delayed CSF leak, spinal cord oedema, metallic blade fragments causing fibrosis and post-traumatic syrinx; hence the recommendation that all RKB be removed to prevent these complications [29,30]. Stabs of the spine typically cause a Brown–Sequard syndrome, a finding confirmed in the current study, which is caused by hemisection of the cord [31],
Fig. 8. AP view of the right VA angiogram injection (A) performed post-coiling showing retrograde flow from right VA to the intracranial segment of the left VA indicating that the patient would tolerate occlusion of the left VA. An angiogram (B) showing the coils (arrow) placed in the cervical segment of the left VA to occlude the VVF.
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while rarely patients present with isolated nerve root injury and cauda equina syndrome [11]. The diagnosis of RKB is straightforward when the knife protrudes outside the skin, whereas it can easily be missed when hidden within soft tissues, therefore, a simple X-ray of the spine is recommended in patients who present with the blade allegedly already removed, to avoid this mishap. A CT scan of the spine, in our opinion, is mandatory in patients with retained RKB for reasons mentioned earlier, however the only drawbacks are the artefacts caused by the metallic blades, which can obscure proper visualisation. In patients with complete SCI abdominal examination may be unreliable due to loss of sensation and can result in missed abdominal injuries. In these instances ultrasound and/or CT abdomen are invaluable tools in ruling out injuries when suspected. The associated injuries are a major factor in the management of these patients as shown in the current study where chest injuries were diagnosed in patients with mainly stabs to the thoracic spine due to proximity of the lung. Stabs to the cervical spine are frequently associated with vertebral artery (VA) injuries with a reported incidence of 7.4% [32,33]. VA injury can result in cerebral posterior circulation ischaemia and should be treated as a matter of urgency [34]. Park et al. [35] reported on a patient with cerebellar infarction as a result of VA injury following stab injury to the cervical spine which was managed by surgical repair, while Xia et al. [36] reported on a stab in the cervical spine where VA injury was confirmed on angiography and treated by endovascular embolisation. The endovascular treatment option was also used in the current study with good results [37]. MRI scan of the spine is contra-indicated in patients presenting with RKB as the magnetic fields may cause movement of the blade, further worsening the SCI [4,27]. In this unit we share the view of other authors, namely that MRIs should be reserved for patients with progressive neurological deficits to exclude cord oedema, epidural or subdural haematomas and empyemas of the spine [24]. It is our recommendation that RKB be removed in OT under a controlled environment as removal can result in bleeding from the epidural venous plexus, worsen damage to the cord and surrounding structures, and result in a CSF leak which requires proper repair of the dura. Intubation of these patients can be a challenge as the RKB prevents them from lying in a supine position. Unnecessary movements can push the blade deeper, worsening SCI hence special precautions should be taken with regards to proper positioning of patients. Some authors have proposed use of two trolleys at induction of anaesthesia with the area with the RKB positioned in-between the two trolleys or use of the lateral position both of which are adequate strategies in dealing with this dilemma [26]. After intubation the patient is rolled on—to a prone position to facilitate removal of the blade. We do not subscribe to administration of steroids as they have shown no benefit in patients with penetrating SCIs and increase the risk of post-operative infections [38,39]. Post-operative antibiotics should be routinely administered as prophylaxis for those patients with penetration of the dura with associated CSF leaks and as directed therapy for those with suspected wound sepsis. Rehabilitation is crucial post-operatively and involves physiotherapy and occupational therapy. Referral to a psychologist is a vital, but often overlooked, component in the treatment paradigm, as often patients with permanent disability require assistance in accepting and adjusting to their new circumstances. Patients with penetrating SCI following stabs have a better prognosis when compared to patients who sustain blunt or gunshot injuries to the spinal cord [39,40] especially if they have Brown–Sequard syndrome which has a recovery rate ranging from 70 to 90% [17]. The overall rate of improvement of patients with features of Brown–Sequard syndrome in the current study was 41%
at discharge, however there is limited long-term follow-up of patients in our unit. Recovery is poor in patients with complete SCI as shown in the current study and associated morbidity remains a major social problem, which is compounded by lack of adequate rehabilitation facilities in SA. The reported mortality rate of patients with penetrating SCIs is 4–7% [3,15,24,25,41]. However there should be a sustained effort to reduce the mortality rate. Conclusions Stab injuries to the spine presenting with RKBs are prevalent in SA, but were associated with low mortality in this series. These injuries can cause devastating neurological deficits and resources should be allocated to prevention strategies that decrease the incidence of inter-personal violence in SA. When confronted with these injuries it is crucial to prevent further SCI, which exert pressure on the already overburdened health care facilities, since these patients require long-term rehabilitation. Limited bed availability in the public health care sector in SA makes longterm admission and intense rehabilitation a difficult goal to attain, due to high turnover of bed occupancy. All RKBs should be removed in a controlled environment in theatre by experienced surgeons to minimise complications. Missed blades should not be underestimated, as these are associated with progressive neurological deterioration and sepsis. Patients with SCI require a multidisciplinary team management as this approach offers the best chance at recovery and re-integration into society. Limitations of the study The study was retrospective in nature and there was no followup of patients to assess their long-term ASIA impairment scales and morbidity in terms of incidence of pneumonia, urinary tract infections, deep vein thrombosis and pressure sores. In order to ascertain these, a prospective study is warranted. In contrast, while it is a single centre study, it emanates from the only public neurosurgical unit at the primary Level 1 Trauma Centre for the 11 million people of the KZN Province. Conflict of interest statement The authors had no conflict of interest when preparing this manuscript and the research was not externally funded. References [1] Kowalski RJ, Ferrara LA, Benzel EC. Biomechanics of the spine. Neurosurg Q 2005;15:52–9. [2] Ozsoy KM, Menekse G, Okten AI, Guzel A. Cerebrospinal fluid fistula due to penetrating trauma. IJNT 2013;10:52–4. [3] Waters RL, Sie I, Adkins RH, Yakura JS. Motor recovery following spinal cord injury caused by stab wounds: a multicenter study. Paraplegia 1995;33:98–101. [4] Gumus H, Tekbas G, Onder H, Ekici F, Gocmez C. Penetrating cervical spinal cord injury: CT and MRI findings. EJR Extra 2011;78:43–4. [5] Gulamhuseinwala N, Terris J. Evolving presentation of spinal canal penetrating injury. Injury 2004;35:948–9. [6] Schulz F, Colmant HJ, Trubner K. Penetrating spinal injury inflicted by a screwdriver: unusual morphological findings. JCFM 1995;2:153–5. [7] Dogan S, Kocaeli H, Taskapilioglu MO, Bekar A. Stab injury of the thoracic spinal cord: case report. Turk Neurosurg 2008;18:298–301. [8] Frangos SF, Ben-Arie E, Bernstein MP, Miglietta MA. Thoracic stab wound with impaled knife. J Trauma 2006;60:1379. [9] Held M, Laubscher M, Kruger N, Navsaria P, Dunn RN. An unusual case of a transbdominal, transdiscal stab wound to the spine. SAOJ 2012;4:61–4. [10] Kong V, Bruce J, Naidoo L, Oosthuizen G, Laing GL, Clarke D. Missed retained knife blade injury: a potentially lethal trap for the unwary. IJCRI 2013;4:507–10. [11] Bhatoe H. Stabbed in the back? IJNT 2007;4:9–10. [12] Sobnach S, Nicol A, Nathire H, Khan D, Navsaria P. Management of the retained knife blade. World J Surg 2010;34:1648–52. [13] Hardcastle TC, Samuels C, Muckart DJ. An assessment of the hospital disease burden and the facilities for the in-hospital care of trauma in KwaZulu-Natal, South Africa. World J Surg 2013;37:1550–61.
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Spinal stab injury with retained knife blades: 51 Consecutive patients managed at a regional referral unit Basil Enicker a,*, Sonwabile Gonya a, Timothy C. Hardcastle b,c a
Department of Neurosurgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Inkosi Albert Luthuli Central Hospital, KwaZulu-Natal, South Africa b Trauma Unit and Trauma Intensive Care, Inkosi Albert Luthuli Central Hospital, South Africa c Department of Surgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, South Africa
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 9 May 2015
Background: Spinal stab wounds presenting with retained knife blades (RKB) are uncommon, often resulting in spinal cord injury (SCI) with catastrophic neurological consequences. The purpose of this study is to report a single unit’s experience in management of this pattern of injury at this regional referral centre. Methods: Retrospective review of medical records identified 51 consecutive patients with spinal stabs presenting with a RKB at the Neurosurgery Department at Inkosi Albert Luthuli Central Hospital between January 2003 and February 2015. The data was analyzed for patient characteristics, level of the RKB, neurological status using the ASIA impairment scale, associated injuries, radiological investigations, management, hospital length of stay, complications and mortality. Results: The mean age was 28 10.9 years (range 14–69), with 45 (88%) males (M: F = 7.5:1). The median Injury Severity Score was 16 (range 4–26). RKB were located in the cervical [9,18%], thoracic [38,74%], lumbar [2,4%] and sacral [2,4%] spine. Twelve patients (24%) sustained complete SCI (ASIA A), while 21 (41%) had incomplete (ASIA B, C, D), of which 17 had features of Brown–Sequard syndrome. Eighteen (35%) patients were neurologically intact (ASIA E). There were 8 (16%) associated pneumothoraces and one vertebral artery injury. Length of hospital stay was 10 7.1 days (range 1–27). One patient (2%) died during this period. Conclusions: Stab injuries to the spine presenting with RKB are still prevalent in South Africa. Resources should be allocated to prevention strategies that decrease the incidence of inter-personal violence. All RKBs should be removed in the operating theatre by experienced surgeons to minimise complications. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Brown–Sequard syndrome Inter-personal violence Laminectomy Stab injuries Retained knife blades Spinal cord injury Vertebral–venous fistula
Introduction The vertebral column plays an important role in protecting the spinal cord from external injuries [1]. However, despite this protection, the spinal cord is still vulnerable to injuries from sharp objects, commonly knives, which can enter the spinal canal either through the interlaminar space or directly through the vertebrae [2]. Stabs to the spine are uncommon in developed countries, but continue to be a source of trauma burden in the developing world [3], particularly in the Province of KwaZulu-Natal (KZN), South Africa. Even more uncommon is when patients present with a retained knife blade (RKB) following these assaults (Fig. 1). The blade is frequently lodged in the vertebral body, lamina, and or pedicle [4].
* Corresponding author. Tel.: +27 798926711; fax: +27 312401132. E-mail address: [email protected] (B. Enicker). http://dx.doi.org/10.1016/j.injury.2015.05.037 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
On review of the literature, RKBs in the spine have primarily been the subject of case reports [5–11], with no large series reporting on this entity. Small series examining retained foreign bodies anywhere in the body have included small numbers of such cases [12]. Penetrating injuries commonly occur as a result of interpersonal violence which is a major contributor to the incidence of trauma in KZN [13], with the World Health Organization (WHO) identifying inter-personal violence as one the leading causes of morbidity and mortality in young adults, and males in particular [14]. These injuries present in a dramatic fashion, as the impaled knife is visible to spectators and often results in acute spinal cord injury (SCI), which has a catastrophic emotional impact, with severe social and health care costs, since the majority of these victims are at the prime of their lives [15] and may be the sole breadwinner. The purpose of this study was to evaluate this unit’s experience in managing stabs to the spine, presenting with RKB in a series of 51 consecutive patients admitted and treated at the
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Fig. 1. A male patient who sustained a stab to the spine and presented with a retained knife blade (RKB).
Neurosurgery Department located at Inkosi Albert Luthuli Central Hospital (IALCH), KZN, South Africa (SA). Methods and materials This retrospective study reviewed the medical charts of patients with stabs to the spine admitted from January 2003, until February 2015, at the Neurosurgery Department (ND), IALCH, Durban, SA. The ND has maintained a comprehensive database of all admissions since it was commissioned at IALCH in December 2002. Prior to this the ND was based at Wentworth Hospital located in the same province [16]. The medical charts are kept in a password-protected computer programme (Soarian1, Siemens, Germany) where the data was obtained and exported into an Excel1, spreadsheet (Microsoft Inc., WA, USA). Variables examined included patient characteristics, spinal level of the RKB, presence of SCI and whether this was complete or incomplete, associated injuries, radiological investigations performed, management, length of hospital stay, complications and mortality. Ethical approval was granted by the Biomedical Research Ethics Committee of the University of KwaZulu-Natal (Ref. BE 507/14). Inclusion criteria were: all patients with RKB on presentation, while those where the blade was removed at the scene were excluded. The KZN province has a dedicated Spine Unit (SU) which is under the care of orthopaedic surgeons and is based in an off-site hospital. The SU also manages spinal trauma; however patients from this unit were not included in this study, since that unit mainly manages blunt spinal trauma. The management of these injuries involves stabilizing patients in accordance with the Advanced Trauma Life Support (ATLS1) principles, and excluding all life threatening injuries. Tetanus toxoid is administered to all patients in the emergency department, unless already provided at the referring facility. Signs of acute SCI are assessed and documented as either complete or incomplete using the American Spinal Injury Association (ASIA) impairment scale. Complete SCI is defined as no motor and sensory function more than three segments below the level of injury in the cord, while incomplete SCI is defined as residual motor and sensory
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function more than three segments below the level of injury, including sacral sparing [17]. The local policy is to perform a computerised tomography (CT) scan of the spine with axial, coronal and sagittal views on all patients to assess the trajectory of the knife and its relation to important organs and major vessels, an example which is shown in Fig. 2. X-ray or CT scan of the chest is performed if associated lung injury is suspected, while a contrast swallow is obtained to exclude oesophageal injury when suspected. Angiography is performed if the trajectory of the blade traverses an area of major blood vessels. Magnetic resonance imaging (MRI) of the spine is not routinely performed, especially if the blade is still in situ, but is performed only if there is progressive neurological deterioration or spinal abscess or empyema post removal of the blade. All RKBs are removed in the operating theatre (OT) under general anaesthesia (GA), and a first generation cephalosporin antibiotic, namely cefazolin is administered at induction for prophylaxis. The procedure is performed in the prone position, the wound is extended and the tract explored the objective being to remove the blade under direct vision in-line with its original trajectory and to remove foreign debris that might have contaminated the wound. A laminectomy is performed, when indicated, to facilitate removal of blades that are resistant to simple withdrawal, taking care not to rock the blade, as this worsens tissue damage and SCI. Loose bony fragments in the canal are removed and the dura mater is explored for penetration and repaired in a watertight tight fashion under direct vision, if breached. A lumbar drain may be inserted in the same setting after dural repair; however this is at the discretion of the primary surgeon. After debridement the wound is closed in layers and cefazolin administered for a period of 48 h if the dura is breached. Antibiotics of choice in patients with septic wound complications with associated meningitis are combinations of cloxacillin and ceftriaxone, which is used until microscopy, culture and sensitivity results are obtained from the laboratory and then directed therapy is instituted. Local wound care, deep vein thrombosis prophylaxis, pressure point care to prevent bedsores and bladder care to prevent urinary tract infection forms part of the standard postoperative management protocol in patients with SCI. Physiotherapy, occupational therapy and psychology consultations are sought post-operatively in patients with SCI as part of the multidisciplinary rehabilitation approach. Once patients are deemed stable they are discharged back to their local hospital for continuation of care. Results The ND at IALCH between January 2003 and February 2015 admitted a total of 338 patients with traumatic spinal injuries of whom 104 (31%) were as a result of stabs to the spine. Of those with stab wounds 51 (49%) presented with RKB (Table 1). Their mean age was 28 10.9 (range 14–69 years). There were 45 (88%) males and 6 (12%) females giving a male to female ratio of 7.5:1. The median Injury Severity Score (ISS) was 16 (range 4–26), interquartile range (IQR) 5–25. The median New Injury Severity Score (NISS) was 16 (range 4–34), IQR 5–25. In two females the injuries were following intimate partner violence (IPV). The spinal levels of RKB were cervical [9, 18%], thoracic [38,74%], lumbar [2, 4%] and sacrum [2,4%], examples of imaging is demonstrated in Fig. 3. The neurological impairment on admission was documented using the ASIA impairment scale, the results of which are shown in Table 2. Twelve (24%) patients had complete SCI, while in 21 (41%) it was incomplete. Of the patients with incomplete SCI 17 (81%) had features of Brown–Sequard syndrome. Eighteen (35%) patients were neurologically intact at presentation and these were the
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Fig. 2. Sagittal (A), coronal (B) and axial (C) CT scan views of the spine showing RKB in lower thoracic spine transecting the facet, extending through vertebral body abuting the posterior mediastinum. The blade has gone through the spinal canal and only a few millimetres separate the blade and the descending aorta (arrow).
patients in whom the blade did not go across the spinal canal (Fig. 4). CT scans of the spine were performed in all patients and MRI spine was performed in only two patients (Fig. 5), one had spinal sepsis while the other had progressive neurological deficit post removal of the knife. Eight (16%) patients had associated pneumothoraces (Fig. 6) of which seven were treated with insertion of intercostal drain. One (2%) patient sustained injury to the left vertebral artery (VA) confirmed via catheter directed angiogram revealing a vertebral–venous fistula (VVF) occurring
Table 1 A summary of patient characteristics.
Stabs with RKB Gender Male Female Injury severity ISS median (IQR) NISS median (IQR) Spinal level of RKB Cervical Thoracic Lumbar Sacrum Lumbar drain insertion Patients with associated injuries Mortality
Number
%
51/108
49
45 6 16 (5–25) 16 (5–25)
88 12 Range 4–26 4–34
9 38 2 2 12 9 1
18 74 4 4 24 18 2
IQR = interquartile range; ISS = injury severity score; NISS = new injury severity score; RKB = retained knife blades.
between the left VA and the epidural vertebral venous plexus (Fig. 7). The VVF was treated by endovascular occlusion by placement of detachable coils after the blade had been removed. A post-coiling angiogram showed successful occlusion of the VVF and the patient tolerated unilateral VA occlusion (Fig. 8). None of the patients had associated oesophageal and abdominal injuries in this cohort. Two (4%) patients had septic wounds at presentation and the organism cultured in both was Staphylococcus aureus. Forty-seven (92%) patients required a laminectomy to facilitate removal of the blade while in four (8%) patients it could be safely withdrawn without this procedure. Intra-operatively the dura mater was found to be breached in 40 (78%) patients and was primarily repaired under direct vision. A lumbar drain was inserted in 12 (24%) patients at the same setting. Four (8%) patients developed postoperative wound sepsis, which was associated with meningitis in three patients and cerebrospinal fluid (CSF) leakage in two. The organisms cultured were Staphylococcus aureus in three patients, of which one was methicillin resistant and a Streptococcus group in the other patient. These patients were taken back to theatre for wound debridement, repair of CSF leaks (with lumbar drain insertion) and were put on directed antibiotic therapy post-operatively. The average hospital stay was 10 7.1 days (range 1–27 days) and there were no readmissions. Assessment of the ASIA impairment scale at discharge revealed no neurological changes in category A and B patients. Only three patients improved from category C to D, these were patients who presented with features of Brown–Sequard syndrome who had partial recovery (18%), while four patients with similar type syndrome in category D had complete recovery (23%) and improved to category E. One patient deteriorated from category D to C
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Fig. 3. CT scans showing RKBs in the cervical (A), thoracic (B), lumbar (C) and sacral (D) spine in patients treated during the study period.
and MRI spine showed a tract haematoma with associated spinal cord oedema. Of the patients treated, one (2%) died during the admission period and this was a patient who had ASIA impairment scale C, following a stab to the thoracic spine, developed septic wound complication with associated CSF leak and meningitis post removal of the blade. The patient required subsequent admission to intensive care for pneumonia which did not respond to ventilation and medical therapy. The rest of the patients were discharged back to their base hospital for continued care.
commonly affects young males at the peak of their lives, with reports suggesting that Sub-Saharan Africa has the highest incidence of violence-related SCI in the world [20,21]. Two females in the current study were victims of IPV which accounts for 62% of
Discussion The annual incidence of SCIs is reported to vary from 11 to 50 cases per million population [18], with penetrating injury to the spine making up approximately 25% of all causes of SCIs [19]. The current study confirms the widely held view that spinal trauma
Table 2 ASIA impairment scale of the 51 patients presenting with RKBs. ASIA scale
Admission
Discharge
A B C D E
12 2 9 10 18
12 2 7 8 22
ASIA = American Spinal Injury Association.
Fig. 4. RKB in the thoracic spine. The blade missed the spinal canal and the patient was neurologically intact at presentation.
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Fig. 5. Sagittal T1—weighted (A), T2—weighted (B) and axial T2—weighted (C) MR images performed post removal of a RKB at T10 level showing blooming artefact representing intraspinal haemorrhage with associated oedema (arrows) in a patient with progressive neurological deterioration post removal of the blade.
Fig. 6. Axial (A and B) and coronal (C) CT scan images showing RKB with left sided pneumothorax (arrows).
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Fig. 7. Axial CT scan image showing RKB in the cervical spine (A). Anterioposterior (AP) left vertebral artery (VA) angiogram performed in the same patient showed a VA injury resulting in a vertebral–venous fistula (VVF).
documented cases of violence against women in SA [22], which unfortunately also has rate of 8.8 per 100 000 women murdered by an intimate partner [23]. RKBs in the spine are uncommon, but potentially life threatening, requiring prompt evaluation and management, which is essential in preserving neurological function. Jacobsohn et al. found only one patient presenting with a RKB in their series of 22 patients with stab injuries to the spine [24]. Other instruments used to inflict these injuries in the SA experience are bicycle spokes, screwdrivers, forks, and scissors [25]. The knife is typically lodged in the vertebral body, lamina or pedicle making it difficult for the perpetrator to remove it; with forceful attempts resulting in breakage of the blade [26]. In the current study the commonest site of injury was the thoracic spine a finding reported by other authors [3,25,27].
The mechanism of acute SCI is related to focal injury or transection of the cord, injury to the artery of Adamkiewicz (which provides major blood supply to the cord), in-driven bone fragments causing cord compression and, lastly, secondary to associated spinal haematomas following injury to vessels [7]. The SCI is further worsened by a sustained period of hypotension which can occur when there is associated major systemic blood loss [28] or even after neurogenic shock. SCI can occur in delayed fashion as a result of associated postoperative spinal sepsis, delayed CSF leak, spinal cord oedema, metallic blade fragments causing fibrosis and post-traumatic syrinx; hence the recommendation that all RKB be removed to prevent these complications [29,30]. Stabs of the spine typically cause a Brown–Sequard syndrome, a finding confirmed in the current study, which is caused by hemisection of the cord [31],
Fig. 8. AP view of the right VA angiogram injection (A) performed post-coiling showing retrograde flow from right VA to the intracranial segment of the left VA indicating that the patient would tolerate occlusion of the left VA. An angiogram (B) showing the coils (arrow) placed in the cervical segment of the left VA to occlude the VVF.
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while rarely patients present with isolated nerve root injury and cauda equina syndrome [11]. The diagnosis of RKB is straightforward when the knife protrudes outside the skin, whereas it can easily be missed when hidden within soft tissues, therefore, a simple X-ray of the spine is recommended in patients who present with the blade allegedly already removed, to avoid this mishap. A CT scan of the spine, in our opinion, is mandatory in patients with retained RKB for reasons mentioned earlier, however the only drawbacks are the artefacts caused by the metallic blades, which can obscure proper visualisation. In patients with complete SCI abdominal examination may be unreliable due to loss of sensation and can result in missed abdominal injuries. In these instances ultrasound and/or CT abdomen are invaluable tools in ruling out injuries when suspected. The associated injuries are a major factor in the management of these patients as shown in the current study where chest injuries were diagnosed in patients with mainly stabs to the thoracic spine due to proximity of the lung. Stabs to the cervical spine are frequently associated with vertebral artery (VA) injuries with a reported incidence of 7.4% [32,33]. VA injury can result in cerebral posterior circulation ischaemia and should be treated as a matter of urgency [34]. Park et al. [35] reported on a patient with cerebellar infarction as a result of VA injury following stab injury to the cervical spine which was managed by surgical repair, while Xia et al. [36] reported on a stab in the cervical spine where VA injury was confirmed on angiography and treated by endovascular embolisation. The endovascular treatment option was also used in the current study with good results [37]. MRI scan of the spine is contra-indicated in patients presenting with RKB as the magnetic fields may cause movement of the blade, further worsening the SCI [4,27]. In this unit we share the view of other authors, namely that MRIs should be reserved for patients with progressive neurological deficits to exclude cord oedema, epidural or subdural haematomas and empyemas of the spine [24]. It is our recommendation that RKB be removed in OT under a controlled environment as removal can result in bleeding from the epidural venous plexus, worsen damage to the cord and surrounding structures, and result in a CSF leak which requires proper repair of the dura. Intubation of these patients can be a challenge as the RKB prevents them from lying in a supine position. Unnecessary movements can push the blade deeper, worsening SCI hence special precautions should be taken with regards to proper positioning of patients. Some authors have proposed use of two trolleys at induction of anaesthesia with the area with the RKB positioned in-between the two trolleys or use of the lateral position both of which are adequate strategies in dealing with this dilemma [26]. After intubation the patient is rolled on—to a prone position to facilitate removal of the blade. We do not subscribe to administration of steroids as they have shown no benefit in patients with penetrating SCIs and increase the risk of post-operative infections [38,39]. Post-operative antibiotics should be routinely administered as prophylaxis for those patients with penetration of the dura with associated CSF leaks and as directed therapy for those with suspected wound sepsis. Rehabilitation is crucial post-operatively and involves physiotherapy and occupational therapy. Referral to a psychologist is a vital, but often overlooked, component in the treatment paradigm, as often patients with permanent disability require assistance in accepting and adjusting to their new circumstances. Patients with penetrating SCI following stabs have a better prognosis when compared to patients who sustain blunt or gunshot injuries to the spinal cord [39,40] especially if they have Brown–Sequard syndrome which has a recovery rate ranging from 70 to 90% [17]. The overall rate of improvement of patients with features of Brown–Sequard syndrome in the current study was 41%
at discharge, however there is limited long-term follow-up of patients in our unit. Recovery is poor in patients with complete SCI as shown in the current study and associated morbidity remains a major social problem, which is compounded by lack of adequate rehabilitation facilities in SA. The reported mortality rate of patients with penetrating SCIs is 4–7% [3,15,24,25,41]. However there should be a sustained effort to reduce the mortality rate. Conclusions Stab injuries to the spine presenting with RKBs are prevalent in SA, but were associated with low mortality in this series. These injuries can cause devastating neurological deficits and resources should be allocated to prevention strategies that decrease the incidence of inter-personal violence in SA. When confronted with these injuries it is crucial to prevent further SCI, which exert pressure on the already overburdened health care facilities, since these patients require long-term rehabilitation. Limited bed availability in the public health care sector in SA makes longterm admission and intense rehabilitation a difficult goal to attain, due to high turnover of bed occupancy. All RKBs should be removed in a controlled environment in theatre by experienced surgeons to minimise complications. Missed blades should not be underestimated, as these are associated with progressive neurological deterioration and sepsis. Patients with SCI require a multidisciplinary team management as this approach offers the best chance at recovery and re-integration into society. Limitations of the study The study was retrospective in nature and there was no followup of patients to assess their long-term ASIA impairment scales and morbidity in terms of incidence of pneumonia, urinary tract infections, deep vein thrombosis and pressure sores. In order to ascertain these, a prospective study is warranted. In contrast, while it is a single centre study, it emanates from the only public neurosurgical unit at the primary Level 1 Trauma Centre for the 11 million people of the KZN Province. Conflict of interest statement The authors had no conflict of interest when preparing this manuscript and the research was not externally funded. References [1] Kowalski RJ, Ferrara LA, Benzel EC. Biomechanics of the spine. Neurosurg Q 2005;15:52–9. [2] Ozsoy KM, Menekse G, Okten AI, Guzel A. Cerebrospinal fluid fistula due to penetrating trauma. IJNT 2013;10:52–4. [3] Waters RL, Sie I, Adkins RH, Yakura JS. Motor recovery following spinal cord injury caused by stab wounds: a multicenter study. Paraplegia 1995;33:98–101. [4] Gumus H, Tekbas G, Onder H, Ekici F, Gocmez C. Penetrating cervical spinal cord injury: CT and MRI findings. EJR Extra 2011;78:43–4. [5] Gulamhuseinwala N, Terris J. Evolving presentation of spinal canal penetrating injury. Injury 2004;35:948–9. [6] Schulz F, Colmant HJ, Trubner K. Penetrating spinal injury inflicted by a screwdriver: unusual morphological findings. JCFM 1995;2:153–5. [7] Dogan S, Kocaeli H, Taskapilioglu MO, Bekar A. Stab injury of the thoracic spinal cord: case report. Turk Neurosurg 2008;18:298–301. [8] Frangos SF, Ben-Arie E, Bernstein MP, Miglietta MA. Thoracic stab wound with impaled knife. J Trauma 2006;60:1379. [9] Held M, Laubscher M, Kruger N, Navsaria P, Dunn RN. An unusual case of a transbdominal, transdiscal stab wound to the spine. SAOJ 2012;4:61–4. [10] Kong V, Bruce J, Naidoo L, Oosthuizen G, Laing GL, Clarke D. Missed retained knife blade injury: a potentially lethal trap for the unwary. IJCRI 2013;4:507–10. [11] Bhatoe H. Stabbed in the back? IJNT 2007;4:9–10. [12] Sobnach S, Nicol A, Nathire H, Khan D, Navsaria P. Management of the retained knife blade. World J Surg 2010;34:1648–52. [13] Hardcastle TC, Samuels C, Muckart DJ. An assessment of the hospital disease burden and the facilities for the in-hospital care of trauma in KwaZulu-Natal, South Africa. World J Surg 2013;37:1550–61.
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