brown - squard syndrome ( bss ) , which occurs due to dysfunction of the spinothalamic tract , typically reflects the hemisection of the spinal cord at the cervical or thoracic level .
the syndrome mainly occurs as a result of penetrating trauma , syringomyelia , hematomyelia , tumor , severe discs , or blunt trauma . among the multiple etiologies , the most common cause is penetrating trauma , such as a gunshot7,8 ) .
therefore , most management guidelines focus on penetrating cervical injuries and/or vertebral artery ( va ) injury12 ) . non - missile penetrating spinal cord and
va injuries are rare because of the bony structures that protect the spinal cord and va14 ) .
thus , the treatment approach for wounds caused in non - missile penetrating spinal injuries such as a knife , a power drill bit , or even a pen could be different from common missile penetrating injuries5,6,13,17).to our knowledge , there are few reports in the literature of complete obstruction of the va due to penetration of a foreign body through the neural foramen into the spinal canal .
herein , the authors report on va dissection and bss caused by penetration of an electric screw driver bit .
a 25-year - old machine operator was involved in a violent episode and was stabbed in his right neck with an electric screw driver bit that was thrown by the opponent . on arrival at the emergency department ,
the electric screw driver bit was placed in the right lateral aspect of the neck at zone i ( fig .
the tip of the electric screw driver bit was located at the center of the vertebral canal of c3 ( fig .
he was given high - dose methylprednisolone ( bolus dose of 30mg / kg followed by 5.4mg / kg / hour for 23 hours ) according to the protocol for spinal cord injury .
an immediate interventional angiography was undertaken without general anesthesia due to the nature of the emergency .
the angiography revealed a total occlusion with dissection of the right va at the level of c3 .
immediate coil embolization at both proximal and distal ends of the injury site was performed ( fig .
an attempt at manual extraction of the electric screw driver bit failed with great resistance .
after the patient was moved to the operating room , the electric screw driver bit was removed manually with muscle dissection under general anesthesia .
venous blood spilled out and was controlled easily by application of several pieces of gelatin sponge .
no postoperative complications such as wound dehiscence , cerebrospinal fluid ( csf ) leakage , or infection were observed .
the neurological motor function of the right upper and lower extremities recovered to 3/5 and 4/5 , respectively , with persistent decreased sensory function after one year .
fortunately , the patient experienced no neck swelling , auscultation of a neck bruit , or delayed ischemic complications .
penetrating injury is the third most frequent cause of spinal cord injury in adults , surpassed only by traffic accidents and falls3,18 ) .
stab wounds are associated with lesser surrounding tissue injury than gunshot wounds because the former delivers less energy than missile injuries9 ) .
although vascular injury is the most common sequel of penetrating neck trauma , va injury is rare because it is well protected by the transverse foramen4,10 ) .
therefore , penetrating injury of the va is mostly caused by gunshot wounds which deliver large kinetic energy , depending upon the bullet 's mass and speed12 ) . in this article , we report a rare case of va penetration by an electric screw driver bit with spinal cord insult , consequently presenting as bss . moreover ,
surgical exploration of the va can cause additional damage to the spine and surrounding tissues .
therefore , it may be reasonable to embolize an occluded artery , because the unilateral ligation of the va rarely results in brainstem ischemia11,16 ) .
there are a few reports regarding the treatment of traumatic va injury such as the arteriovenous fistulas and pseudoaneurysms2 ) .
emergent surgical exploration is necessary for patients with hard signs of vascular injury , such as hemodynamic instability , hemorrhage exsanguinations , or expanding hematoma15 ) .
patients that are hemodynamically stable and who are without respiratory compromise should undergo further diagnostic imaging evaluation15 ) . as presented in this case ,
endovascular techniques were a safe and effective method of treatment and were not associated with significant morbidity or mortality1 ) .
airway management , intubation methods , and surgical positions can be points of debate between anesthesiologists and surgeons9 ) . if a lacerated va can be successfully obliterated , a penetrating electric screw driver bit may be extracted without general anesthesia .
nevertheless , the authors recommend that surgeons should be prepared for conversion to open surgery and extraction should be performed with the support of a surgical team .
we initially tried to extract the electric screw driver bit manually without general anesthesia in the intervention theater after va embolization .
however , the electric screw driver bit was positioned firmly in the neural foramen , and the patient complained of severe pain when the electric screw driver bit was being pulled out .
in addition , there was more important rationale that justified surgical exploration for extraction of the electric screw driver bit . on extraction of the electric screw driver bit ,
the authors describe a rare case of penetrating cervical injury caused by an electric screw driver bit with accompanying va penetration and bss .
 there are few reports in the literature of complete obstruction of the vertebral artery ( va ) due to an electric screw driver bit penetration through the neural foramen into the spinal canal with brown - squard syndrome ( bss ) . 
 a 25-year - old man was admitted to the emergency department with a penetrated neck injury by an electric screw driver bit after a struggle . 
 the patient presented the clinical features of bss . 
 computed tomography scan revealed that the electric screw driver bit penetrated through the right neural foramen at the level of c3 - 4 , and it caused an injury to the right half of the spinal cord . 
 emergent angiography revealed va dissection , which was managed by immediate coil embolization at both proximal and distal ends of the injury site . 
 after occlusion of the va , the electric screw driver bit was extracted under general anesthesia . 
 bleeding was minimal and controlled without difficulties . 
 no postoperative complications , such as wound dehiscence , csf leakage , or infection , were noted . 
 endovascular approaches for occlusion of vertebral artery lesions are safe and effective methods of treatment . 
INTRODUCTION
CASE REPORT
DISCUSSION