A case of attempted suicide with a subtotal interruption of the high spinal cord with the use of a screwdriver in the neck, without the involvement of any large vessels

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BACKGROUND:

Self-inflicted injuries are rare but can lead to devastating consequences for individuals attempting suicide. In the case of spinal cord injury, the consequences can be particularly severe, often resulting in permanent neurological deficits [1-2].

This case report describes the radiological results after a CT scan and the clinical consequences of an attempt at suicide with a weapon in the neck at the C2-C3 level after an inauspicious cancer diagnosis [3]. The patient avoided surprisingly many severe complications, due to the random angle used to insert the screwdriver, such as an involvement of the large and principal vessels that are in the neck or the complete and immediate resection of the spinal cord that would have caused immediate death [4].

 

DESCRIPTION OF THE CASE

Anamnesis:

A 40-year-old male patient arrived at the Emergency Department accompanied by the territorial emergency service, alert and conscious, with a history of suicidal ideation and a self-inflicted cervical spinal cord injury, transported with the help of a spoon stretcher and cervical spine immobilized with a collar [5].

When the patient arrived in the emergency room, he moved his four limbs without losing strength (GCS 15). Oxygen saturation was 99% in ambient air and spontaneous breathing, respiratory rate was equal to 23 breaths per minute. Blood pressure 120/70 mmHg and heart rate 90 beats per minute. Valid diuresis. Upon objective examination foreign body penetrating the right medial lateral part of the neck, screwdriver type. Upon objective examination, the foreign body appears to penetrate deep into the structures of the neck (Figure 1).

Figure 1. A) Macroscopic photo of the patient who came to the emergency department with a screwdriver laterally in the neck on the right, resulting in a full-thickness penetrating wound. CT images in the scout phase, in coronal B) and sagittal C) axes showed the screwdriver tip's metal portion deepening cauda-cranially and forward-backward toward the brainstem.

Diagnostic assessment.

After half an hour from access, they were reported by the patient, with right hemi lateral paresthesia. After resuscitation evaluation, the patient was intubated, using GlideScope and tube 7.5, after analgosedation, curing, and immobilization of the cervical spine through a support device. Resuscitative maneuvers were immediately initiated: the patient was promptly intubated and transferred to the Radiology Department for a CT, due to the worsening clinical condition into a complete shock status [6] (Figure 2).

Figure 2. VR-images with views: from behind (A) showed the relationship of the screwdriver tip to the C1-C2 joint; from the right (B) and from the right and below (C) showed the direction of the metal part of the screwdriver and that it did not take relationship with the carotid artery; from the front (D) showed a frontal overview of the patient.

 

Surprisingly, the radiological findings revealed that the weapon didn’t involve any vital vessels, including the high-spinal cord (Figure 3) (Figure 4).

Imaging revealed a screwdriver lodged in the spinal cord at the C2-C3 level, causing significant cord compression and damage, avoiding the large vessel of the neck [7].

Figure 3. CT images, without contrast medium, in coronal (A) and sagittal (B) axes: the screwdriver tip was clearly within the vertebral speculum and involved the high spinal cord.

Figure 4. Subsequential axial CT images, without contrast medium (A) and after the contrast medium administration (B). The first set of images (A) showed the screwdriver's tip deepening into the neck's tissues from the bottom to the top and from the outside to the inside. It ended up (passing between the vertebral bodies) inside the high spinal cord, causing its disruption. The second set of images (B) showed the opacification of the vessels given by the contrast medium revealing that the screwdriver did not involve any major vessels in the neck, thus avoiding massive hemorrhage following penetration.

The patient was very carefully transported to the Surgery Department to surgically remove the screwdriver, trying not to create damage in removal worse than that caused by its insertion. Due to the severity of the injury, the patient underwent emergent spinal cord resection to relieve the compression and prevent further neurological deterioration.

The intervention of removal of the penetrating foreign body was conducted under general anaesthesia. It consisted of removing the same under angiographic guidance, with the possibility of stopping possible bleeding of the vertebral artery by the endovascular route. No bleeding occurred and the surgery ended without complications; the screwdriver was successfully removed, and some days after this procedure, another CT was done to value the damage (Figure 5).

 

 

 

 

Figure 5. CT images acquired after surgery: Scout phase in coronal (A) and sagittal (B) plane; non-contrast images with soft window in coronal (C) and sagittal (D) plane. The screwdriver was no longer present.

 

The patient died a few days later when his clinical conditions deteriorated very fast, because of the worsening neurological pattern and impaired respiratory function, possibly due to the spinal cord resection, which no longer made the patient autonomous in breathing until death from respiratory arrest, which came first.

 

 

 

DISCUSSION

Suicide attempts involving self-inflicted spinal cord injuries are rare but can have devastating consequences. In this case, the insertion of a screwdriver into the cervical spinal cord led to immediate paralysis and required emergent surgical intervention [8]. Spinal cord injuries can cause severe consequences and the surgery is a drastic but necessary approach in cases of severe cord compression and damage, as in the case reported.

The C2-C3 level of the spinal cord is a critical region responsible for controlling vital functions such as breathing and neck movement [9-10]. A traumatic injury at this level can result in significant impairment of these functions, leading to a range of life-threatening complications. In this case, the insertion of a screwdriver into the spinal cord at the C2-C3 level caused severe damage and complete paralysis of the body below the neck [11-12, 7]. Furthermore, the injured individual experienced loss of sensation, muscle weakness, and difficulty breathing, swallowing, and speaking. The extent of the injury and its long-term effects depend on the severity of the damage caused by the screwdriver and the promptness of medical intervention [13].

The removal of the screwdriver from the spinal cord at the C2-C3 level is a delicate and high-risk surgical procedure that requires the expertise of a team of neurosurgeons and spinal cord specialists. The primary goal of the surgery is to carefully extract the foreign object without causing further damage to the spinal cord or surrounding tissues.  During the surgery, the neurosurgeons made a small incision in the neck to access the spinal cord and carefully extracted the screwdriver using specialized instruments. They closely monitored the patient's vital signs and neurological function throughout the procedure to ensure optimal outcomes and minimize the risk of complications [14].

The long-term prognosis for patients undergoing spinal cord injuries is often poor, with significant functional deficits and ongoing rehabilitation needs. Unfortunately, the clinical conditions worsened because of impaired respiratory function, perhaps specifically due to the high spinal cord resection and the patient died a few days later.

 

CONCLUSION

The story of the cervical spinal cord excision that occurred after a screwdriver suicide attempt serves as a stark reminder of the grave repercussions of self-inflicted spinal cord injuries. In these situations, early diagnosis and surgical intervention are essential to stop more neurological degradation and improve the prognosis for those who are affected. Reducing the frequency of such terrible incidents requires preventative measures, such as access to crisis intervention programs and mental health care.

Declarations

Ethical approval No ethics committee approval was sought for this ex vivo animal cadaveric study. No human subject was involved in this study.

 

Funding: No funding was received for conducting this study.

 

Conflict of Interest: The authors have no competing interests to disclose.

 

Authors' Contribution: All Authors have contributed to the final manuscript.

 

Informed Consent: Informed consent was obtained.

 

Clinical trial number: not applicable.

 

Об авторах

Manuela Montatore

Department of Clinical and Experimental Medicine, Foggia University School of Medicine, Viale L. Pinto 1, 71122 Foggia, (FG) Italy.

Email: manuela.montatore@unifg.it
ORCID iD: 0009-0002-1526-5047
Италия

Federica Masino

Department of Clinical and Experimental Medicine, Foggia University School of Medicine, Viale L. Pinto 1, 71122 Foggia, (FG) Italy.

Email: federicamasino@gmail.com
ORCID iD: 0009-0004-4289-3289
Италия

Antonio Zagaria

Department of Intensive Care and Anaesthesiology, “Dimiccoli” Hospital, Viale Ippocrate 15, 70051, Barletta (BT), Italy

Email: antoniozagaria2015@gmail.com
Италия

Marina Balbino

Department of Clinical and Experimental Medicine, Foggia University School of Medicine, Viale L. Pinto 1, 71122 Foggia, (FG) Italy

Email: marinabalbino93@gmail.com
ORCID iD: 0009-0009-2808-5708
Италия

Francesco Saverio Guerra

Department of Clinical and Experimental Medicine, Foggia University School of Medicine, Viale L. Pinto 1, 71122 Foggia, (FG) Italy.

Email: francesco.rino@gmail.com

Giuseppe Guglielmi

University of Foggia

Автор, ответственный за переписку.
Email: giuseppe.guglielmi@unifg.it
ORCID iD: 0000-0002-4325-8330

Доктор медицины, профессор.

Кафедра клинической и экспериментальной медицины.

 

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