Keywords
iron rod - cauda equina - lumbar spine - penetrating wound - child
Introduction
Penetrating spinal wounds causing cauda equina syndrome (CES) are unusual in contrast
to blunt trauma from motor vehicle accidents.[1] They are essentially of two types: gunshot wounds and stab wounds. Spinal gunshot
wounds are more frequently described and are associated with a higher incidence of
neurological damage. On the contrary, the prognosis is better for stab wounds where
surgery plays a more important role.[2] Very few cases have been reported on the occurrence of CES following stab wounds.
However, we did not find in the literature any cases of penetrating spinal wounds
with iron rods causing CES, especially in children.
We report the case of a 10-year-old boy with CES due to a penetrating iron rod wound
of the lumbar spine that occurred accidentally during a recreational activity and
discuss its management.
Observation
This is a 10-year-old boy with no particular history who was admitted to the emergency
room with a motor deficit of the lower limbs and a hemorrhagic penetrating lumbar
wound that had been evolving for 13 hours at the time of his admission and that occurred
accidentally during a recreational activity.
The neurological examination revealed a flaccid paraparesis (estimated at 3/5 in both
lower limbs on the Medical Research Council scale) without sensory or sphincter disorders
(anal sphincter tonic to the touch and no loss or retention of urine). Local examination
revealed a fixed iron rod, penetrating through the lumbar region ([Fig. 1]) with the emission of clear rock water liquid through the wound.
Fig. 1 Fixed iron rod penetrating through the lumbar region, left paraspinal.
Emergency radiography and computed tomography (CT) ([Fig. 2]) revealed an iron rod penetrating the spinal canal through the lamina of the L3
vertebra on the left. The preoperative blood test revealed anemia with 6 g of hemoglobin
requiring an emergency transfusion of OO+ rhesus iso group blood. The patient was
then immediately taken to the operating room.
Fig. 2 (A) Profile X-ray of the lumbar spine. (B) Lumbar CT 3D reconstruction. (C) Lumbar CT axial section: iron rod penetrating the spinal canal through the lamina
of the L3 vertebra on the left.
A classic posterior midline approach was used. Bilateral muscle disinsertion revealed
the iron rod penetrating through the lamina of the L3 vertebra on the left. The iron
rod was removed in the opposite direction of its entry trajectory after laminectomy
of the L3 vertebra demonstrating a breach of the dura. The dura mater was suspended
and intradural exploration did not reveal any macroscopic lesions of the cauda equina
roots. After irrigation and debridement with isotonic saline, we pulled all free roots
back into the dural sac and sutured it with nylon 4.0. Subsequently, the penetrating
wound and surgical incision were closed in three layers ([Fig. 3]).
Fig. 3 Intraoperative images. (A) Iron rod penetrating the spinal canal through the lamina of the L3 vertebra on the
left. (B) Suspension of the dura for exploration of the cauda equina roots. (C) closure of the penetrating wound and surgical incision.
After surgery, the patient was subjected to a broad-spectrum parenteral antibiotic
therapy made of third-generation cephalosporin (ceftriaxone 100 mg/kg/day) and imidazole
(metronidazole 30 mg/kg/day) for 3 weeks with a stable evolution without obvious wound
infection and symptom of cerebrospinal fluid leakage nor any complication with a postoperative
lumbar CT scan performed at D + 3 showing the L3 laminectomy focus without any other
particularities. He was subsequently referred to a rehabilitation facility.
At a 3-month follow-up, the patient showed complete recovery of his paralysis and
healing of the penetrating wound and surgical incision. He was subsequently seen in
consultation at 6 months and at 1 year of follow-up without any notable particularities.
Discussion
Spinal injuries are relatively uncommon in children. Pediatric spinal injuries account
for 1 to 10% of all vertebromedullary injuries.[3]
The most widely reported cause of penetrating spinal injury is gunshot wounds with
relatively few case reports describing glass or stab wounds.[1]
[2] Foreign bodies of wood and metal have been reported to penetrate the spine.[1]
[3] However, to our knowledge, there are no reports in the literature of penetrating
lumbar spinal iron rod injuries in children with or without the development of CES.
Penetrating injuries in children result from violence with firearms, knives, and play
objects (including air guns and sharp-tipped toys), and from falls on sharp objects
(especially glass and some toys).[3] Very few studies have been undertaken regarding the management of penetrating medullary
cone and ponytail injuries.[3]
CES is a complex neurological disorder with a myriad of symptoms such as low back
pain, unilateral or bilateral leg pain, paresthesias and weakness, perineal anesthesia,
sphincter incontinence, and other less common symptoms.[4] Traumatic cauda equina injuries most commonly cause sudden and acute neurological
deterioration. During the initial emergency evaluation, care should be taken to recognize
lower extremity sensitive and motor deficits.[1] CT and magnetic resonance imaging (MRI), as well as an electrophysiological workup,
allow an accurate diagnosis in the acute phase.[4] However, due to the low availability and high cost of MRI and electrophysiological
assessment in our socioeconomic context, the lesion assessment of our patient was
established on X-ray and CT scan, which were sufficient for surgical planning. A precise
clinical examination and a thorough analysis of the preoperative imaging are mandatory
to define upstream the objectives of the surgery.[1]
Treatment principles for penetrating injuries include irrigation and debridement,
suturing of the wound, and administration of antibiotics as soon as possible.[5] In cases of penetrating foreign body injuries to the cauda equina, many previous
reports recommend urgent surgery to perform decompression by removing foreign bodies,
bone fragments, or blood clots; debridement; repair of the dura mater to prevent persistent
infection and stop cerebrospinal fluid (CSF) leakage; and spinal stabilization in
cases of destabilizing injuries.[1]
[3]
[5]
In terms of prognosis, neurological recovery after cauda equina injury is unpredictable
and may be influenced by several factors, such as the age of the patient, the severity
of the primary injury, and the earliness of management.[1]
Our patient presented a rapid and complete resolution of the lower limbs motor deficit.
This could be explained in our opinion by the absence of macroscopic lesions of the
ponytail roots objectified intraoperatively and that the neurological symptoms would
be related to a compression effect of the ponytail roots by the iron rod. Hence, the
interest of an early decompression in these penetrating traumas.
Conclusion
To our knowledge, this is the first reported case of a penetrating iron rod injury
to the ponytail in a child. An emergency neurosurgical procedure is always a challenge
in such a setting. Neuronal decompression and foreign body removal must be performed
to prevent neurological deterioration, infection and possible CSF leakage. However,
many of these accidents can be avoided by monitoring children during sports and play
activities.
