A suicide attempt with subtotal interruption of the high spinal cord without the involvement of any large vessels caused by a screwdriver in the neck: a case report

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BACKGROUND

Self-inflicted cervical spinal cord injuries are rare and pose significant clinical challenges. Although traumatic cervical spine injuries are common in trauma settings, self-inflicted penetrating injuries to the cervical spinal cord represent a small proportion of spinal cord injuries, accounting for approximately 1.6%–3% of cases, predominantly due to falls [1–3].

The C2–C3 vertebral level is particularly vulnerable owing to its proximity to critical vascular structures and spinal cord segments responsible for diaphragmatic innervation.

The present case illustrates the complexity of managing penetrating cervical spine injuries and underscores the importance of a coordinated multidisciplinary approach involving emergency medicine, radiology, neurosurgery, and interventional radiology [4–6].

CASE DESCRIPTION

Patient Information

A 40-year-old male with a recent cancer diagnosis and a history of suicidal ideation was admitted after self-inflicting a penetrating injury to his right lateral neck using a screwdriver. Upon arrival, the patient was alert (GCS score: 15) and hemodynamically stable (BP: 120/70 mmHg; HR: 90 bpm) and demonstrated intact motor strength in all four limbs. Oxygen saturation was 99% on room air, and the respiratory rate was 23 breaths/min. The cervical spine was immobilized with a collar; the screwdriver remained lodged laterally in the neck.

Diagnostic Assessment

Contrast-enhanced CT revealed the screwdriver penetrating transversely at the C2–C3 level, causing significant spinal cord injury and compression but sparing all major cervical vessels, including the carotid and vertebral arteries (Figs. 1–4). No active hemorrhage was observed.

 

Fig. 1. CT images in the scout phase, in coronal plane, on the left, and sagittal plane on the right, showed the screwdriver tip's metal portion deepening cauda-cranially and forward–backward toward the brainstem.

 

Fig. 2. VR images with views: from behind (a) shows the relationship of the screwdriver tip to the C1–C2 joint; from the right (b) and from the right and below (c) show the direction of the metal part of the screwdriver and that it did not take relationship with the carotid artery; and from the front (d) shows a frontal overview of the patient.

 

Fig. 3. CT images, without contrast medium, in coronal (a) and sagittal (b) axes: the screwdriver tip was within the spinal canal and involved the high spinal cord.

 

Fig. 4. Subsequent axial CT images, without contrast medium (a) and with contrast medium (b). Axial CT images before and after contrast administration illustrating the screwdriver's oblique course through the lateral neck soft tissues into the spinal canal, with no vascular enhancement abnormalities indicating vessel sparing.

 

Management

Owing to clinical deterioration with the onset of right-sided hemilateral paresthesia and hemodynamic instability progressing to shock, the patient was intubated under GlideScope guidance and urgently transferred to surgery. The foreign body was carefully removed under general anesthesia, with angiographic monitoring allowing for prompt control of potential vascular injury.

Follow-up and outcomes

Postoperative CT confirmed successful removal of the foreign body (Fig. 5). Despite initial stability, the patient developed worsening neurological deficits and respiratory failure attributed to high cervical spinal cord injury. Moreover, despite maximal supportive care, the patient died several days later because of respiratory arrest secondary to loss of ventilatory autonomy.

 

Fig. 5. Postoperative CT images of the coronal and sagittal planes confirm the absence of the foreign body and depict residual spinal cord injury and soft tissue changes post-extraction.

 

Postmortem diagnosis. Death due to respiratory arrest resulting from high cervical spinal cord damage (C2–C3 level) with complete loss of autonomous breathing, following a penetrating neck injury.

An autopsy was not performed owing to the family's wishes, limiting further pathological insight into spinal cord changes.

DISCUSSION

Penetrating cervical spinal cord injuries caused by self-inflicted trauma are extremely rare but carry a grave prognosis, especially at high cervical levels involving the C2–C3 segments. These injuries threaten respiratory function due to involvement of the phrenic nerve roots (C3–C5) responsible for diaphragmatic control [7–9]. The patient's initial preserved motor function was atypical given the injury severity, highlighting the heterogeneity of clinical presentations in such trauma.

Contrast-enhanced CT angiography is critical for excluding vascular injury, guiding surgical planning, and enabling safe foreign body extraction under angiographic surveillance. Studies have confirmed that early imaging and multidisciplinary surgical intervention improve outcomes, although prognosis remains guarded in high cervical spinal cord trauma [10–12].

Despite successful removal of the foreign body without vascular complications, the patient succumbed to progressive respiratory failure consistent with high cervical cord damage. This indicates that anatomical preservation of vessels does not preclude fatal neurological outcomes in penetrating cervical injuries [13].

A multidisciplinary approach encompassing emergency care, neurosurgery, interventional radiology, and intensive care is needed. Additionally, psychiatric evaluation and support are crucial components of management in self-inflicted injuries to prevent recurrence [14].

CONCLUSION

Penetrating injuries at the C2–C3 cervical spine level are a complex clinical challenge owing to high risk of respiratory failure and irreversible neurological damage. The reported case demonstrates that even without major vascular injury, the prognosis remains poor. Early, accurate imaging and multidisciplinary management are critical, and mental health intervention is integral to comprehensive care in self-harm cases.

ADDITIONAL INFORMATION

Author contributions: M. Montatore: clinical assessment, data curation, literature review, writing — original draft; F. Masino: data curation, literature review, writing — review & editing; A. Zagaria: surgical data collection, clinical assessment, writing, review & editing; M. Balbino: radiological data acquisition, literature review, writing — review & editing; F.S. Guerra: clinical supervision, critical revision of the manuscript; G. Guglielmi: conceptualization, radiological supervision, critical revision of the manuscript. Thereby, all authors provided approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Ethics approval: Not applicable.

Consent for publication: No informed consent for publication could be obtained from the patient's legal representatives. Reason: despite reasonable efforts, the legal representatives or immediate family members could not be located (contact details were unavailable in the medical records, and no additional contact information could be retrieved). All data are fully anonymized, and no identifiable images have been included.

Funding sources: No funding.

Disclosure of interests: The authors have no relationships, activities, or interests for the last three years related to for-profit or not-for-profit third parties whose interests may be affected by the content of the article.

Statement of originality: No previously published material (text, images, or data) was used in this study or article.

Data availability statement: The editorial policy regarding data sharing does not apply to this work.

Generative AI: The authors used OpenAI's ChatGPT (GPT-4, https://chat.openai.com, developed by OpenAI, USA) in May 2025 to assist with grammar checking, sentence restructuring, and improving the fluency of English-language expression in the abstract and discussion sections of the manuscript. The AI was not used to generate medical content, clinical interpretation, or data analysis. All content was reviewed and revised by the authors for accuracy and appropriateness.

Provenance and peer review: This article was submitted unsolicited and reviewed following the standard procedure. The peer-review process involved two external reviewers and two members of the Editorial Board.

About the authors

Manuela Montatore

Foggia University School of Medicine

Email: manuela.montatore@unifg.it
ORCID iD: 0009-0002-1526-5047
Italy, Foggia

Federica Masino

Foggia University School of Medicine

Email: federicamasino@gmail.com
ORCID iD: 0009-0004-4289-3289
Italy, Foggia

Antonio Zagaria

“Dimiccoli” Hospital

Email: antoniozagaria2015@gmail.com
ORCID iD: 0009-0002-2678-3659
Italy, Barletta

Marina Balbino

Foggia University School of Medicine

Email: marinabalbino93@gmail.com
ORCID iD: 0009-0009-2808-5708
Italy, Foggia

Francesco S. Guerra

Foggia University School of Medicine

Email: francesco.rino@gmail.com
ORCID iD: 0000-0003-3923-3429
Italy, Foggia

Giuseppe Guglielmi

Foggia University School of Medicine; “Dimiccoli” Hospital; “IRCCS Casa Sollievo della Sofferenza” Hospital

Author for correspondence.
Email: giuseppe.guglielmi@unifg.it
ORCID iD: 0000-0002-4325-8330

MD, Professor

Italy, Foggia; Barletta; San Giovanni Rotondo

References

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