CASE REPORT Tetraplegia following cervical spine cord contusion from indirect gunshot injury effects SS Goonewardene 1 , KS Mangat 1 , ID Sargeant 1 , K Porter 1 , I Greaves 2 1 South Birmingham Trauma Unit, Selly Oak Hospital,Raddlebarn Road B29, 2 James Cook University Hospital, Marton Rd, Middlesbrough TS4 3BW Introduction T he high tempo of deployed operations over recent years has resulted in a large spectrum of injuries varying both in their mechanism of injury and severity. Each case is clearly a potential tragedy for the patient, but it might be argued that for the first time since World War II, clinicians in field hospitals and at the Royal Centre for Defence Medicine (RCDM) are being enabled to develop genuine expertise in the management of battlefield injuries based on considerable clinical exposure. This must be of benefit to patients. Acute spinal cord injury can be life threatening and result from both blunt and penetrating trauma. Gunshot injuries to the spinal cord itself account for up to 25% of all such injuries, with neurological deficit resulting from direct trauma to the nervous tissue as a result of direct impact by the bullet, bone, or displaced disc fragments (1,2). Fracture of bone by the close passage of a missile without direct contact is well recognized (3,4), and it is possible that a similar mechanism may injure the spinal cord. We present a case of spinal cord injury associated with the near passage of a high energy round but without direct injury to the cord manifest by delayed onset of tetraplegia – only one similar such injury to the spinal cord has previously been reported (1). Case presentation A 31 year old British soldier was wounded by enemy fire whilst on active duty in Afghanistan. He sustained a high energy gunshot wound to the neck. T he bullet entered on the right side of the neck and exited from the left side. The path of the bullet was horizontal, with the track lying posterior to the cervical vertebral bodies (Figure 1). T he patient himself reported a delay of a few minutes after the initial injury before he developed tetraplegia (loss of sensation and motor function in all four limbs). He was managed in accordance with the Battlefield Advanced Trauma Life Support (BAT LS) (5) guidelines and transferred via the evacuation chain to designated neurosurgical facilities in Muscat. Initial neurological examination revealed intact cranial nerves, with pupils equal in size and reacting to light. He had 0/5 power in all four limbs on the Medical Research Council (MRC) scale (6). Upper and lower limb reflexes were absent and there was disparity of the sensory level - C5 on the right and T2 on the left. No anal tone was present and the bulbocavernosus reflex was negative. T here was no priapism and the patient was haemodynamically stable. CT imaging revealed a fracture of the spinous process of C5, but without any obvious compromise of the spinal canal and there was no evidence of retained bullet fragments. Steroids were not administered. He was transferred by aeromedical evacuation to the RCDM, Selly Oak Hospital, Birmingham. In the U.K. repeated neurological examination showed 1/5 right shoulder abduction power now, but otherwise it remained 0/5 throughout the rest of the limbs. T he sensory level bilaterally was now C5. T he cervical spine injury was deemed stable and Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiogram (MRA) assessment were undertaken. T he MRA demonstrated a non-haemorrhagic cord contusion from C2 to C7 (Figure 2), but no other vascular abnormality. 52 JR Army Med Corps 153(1): 52-53 Correspondence to: Prof Keith Porter MBBS FRCS(Ed) FRCS (Eng) FIMCRCS(Ed) MFSEM (Ed) Honorary Professor of Traumatology and Consultant Trauma Surgeon, South Birmingham Trauma Unit, Selly Oak Hospital,Raddlebarn Road B29 We present the case of a 31 year old British soldier who sustained a high energy gunshot injury to the neck with delayed onset tetraplegia. The bullet’s transcervical track was subsequently shown to have had no direct contact with the spinal cord, but four to five minutes after injury the patient developed tetraplegia. Subsequent Magnetic Resonance Imaging confirmed this to be due to contusion of the cervical spinal cord. This case illustrates the high levels of energy potentially transferred to surrounding tissues by the passage of a high available energy projectile, causing significant injury to nearby structures not actually impacted by the missile. Abstract Figure 1. Coronal section of the MRI performed after arrival in UK showing the path of the missile away from the spinal canal and cord. 52-53_Case Report 1/5/07 09:02 Page 52