1 Introduction
The first reported nail gun injury was in the 1960s
[1], and since then cases of similar injuries have begun to be reported in the literature. These reported injuries usually involved puncture wounds to the hand or fingers
[2], while penetrating nail gun injuries to the neck are extremely rare. Due to the proximity of vital organs, tissues, and the spinal cord, neck injuries caused by multiple nail guns often involve multiple organs, causing hemorrhage, infection, or impaired organ function, and can easily be life-threatening if not treated promptly. Here, we report a case of a Chinese Tibetan youth with penetrating multi-organ neck injury due to multiple nail guns in Xizang, who at the time of presentation had neck pain, hoarseness, and swallowing pain, accompanied by local pain, forced neck position and limited movement in the left upper limb, and was successfully treated by a multidisciplinary team (MDT) without serious complications. Through this case report and literature review, we hope to propose a treatment strategy for this type of case.
2 Case Presentation
A 21-year-old Tibetan youth from Xizang, China, who had no dyspnea, hoarseness, or other discomfort, presented to a local hospital 10 hours earlier with an accidental neck injury from a nail gun at work, and was advised to go to a superior hospital for further treatment due to local medical limitations. The patient was fully conscious when he was shot with the nail gun, and gradually began to experience severe neck pain, hoarseness, and swallowing pain with salivation and nausea when he presented to our hospital about 7 hours later. At the time, the patient presented as an emergency conscious with a forced neck position, pain and limited movement in the left upper limb and presented with elevated white blood cells. In addition, during the evaluation of the patient, three pinpoint lesions were seen on the neck and no external bleeding or significant contusions were observed. A cervicothoracic computed tomography (CT) scan was performed immediately after admission and revealed three nails in the neck: one located in the right lobe of the thyroid gland, another on the left side of the fifth cervical vertebra, the third inserted from left to right into the spinal canal at the C5-C6 level, with the nail tip reaching the epidural/dural surface approximately 1 mm from the spinal cord but without dural penetration; no hemorrhage, hematoma, or vascular injury was observed (Fig. 1). The chronological clinical course is summarized in Table 1.
After admission, a multidisciplinary team evaluation was performed, including otolaryngologist-head and neck surgeons, orthopedic surgeons, and neurosurgeons. Emergency surgery was performed after completing the necessary preoperative tests. Before the onset of anesthesia, the larynx was examined using fiberoptic laryngoscopy, which showed poor mobility of the right vocal cord and swelling of the right arytenoid. After the onset of anesthesia, an incision was made at the level of the thyroid gland on the right side of the neck according to the preoperative CT findings. After separating the thyroid gland, it was revealed that a nail has been inserted into the right lobe of the thyroid gland from the bottom up, and part of the damaged thyroid gland was successfully removed and sutured after the excision. Next, the orthopedic surgeon separated the gap between the cervical vascular sheath and the trachea and esophagus along the incision, exposed the anterior C5-C6 vertebral body and exposed the nails, one on the left side of the C5 vertebral body and one entering the spinal canal from left to right, with the tip stopping approximately 1 mm from the spinal cord. The nails inserted into the vertebral body and spinal canal were successfully removed, and no hemorrhage and cerebrospinal fluid leakage were found. The damaged tissue in the operating area was cleaned and the drainage pipe was placed after washing with iodophor and saline several times. The trachea and esophagus were explored intraoperatively and no lacerations were seen. The neck was sutured layer by layer after the gastric tube was left in place.
3 Results
After surgery, the patient’s body temperature was normal, and he was given gastrointestinal decompression and a fluid diet with a gastric tube, methylprednisolone 40 mg qd for 5 days, ceftriaxone 2.0 g qd for 10 days of anti-infective treatment, and sodium tetrasaccharide monosialate ganglioside 20 mg qd for neurotrophic symptomatic treatment. On the 7th day after operation, the drainage volume of the cervical paraspinal drainage tube was reduced to less than 5 mL, then the drainage tube was removed, and the gastric tube was removed on the 10th day after operation. After surgery, the patient’s left upper limb pain and movement limitation improved significantly. Magnetic resonance imaging (MRI) of the neck on postoperative day 7 showed mild edema of the sixth cervical vertebrae, and the patient had no significant hoarseness and no other neurological symptoms or complications at discharge. At the post-discharge review and follow-up, there were also no neurological sequelae or other complications.
4 Discussion
Foreign body caused neck injuries are classified as traumatic or iatrogenic injuries
[12]. Nail guns are common equipment on construction sites, so injuries are not uncommon, and approximately 37,000 patients are treated for work-related nail gun injuries in the United States annually
[3], posing a significant number of hazards and risks. Injury sites are more common in the hands or fingers, followed by the lower legs, knees, thighs, feet, and toes, and less common sites are the neck, head, and trunk. Serious injuries from nail guns to the spinal cord, head, neck, eyes, internal organs and bones have also been reported, and injuries have also resulted in paralysis, blindness, brain damage, fractures and death. The special nature of nail guns, especially the rapid rate of fire, can lead to penetrating and compound injuries. The risk of nail gun injury is high, and it’s particularly dangerous in the neck because it can include damage to the esophagus, trachea, spinal cord and vital blood vessels, which can lead to paralysis and death. The presence of a foreign body in the neck can cause serious complications due to direct injury from the foreign body or indirect injury such as infected swelling. Direct injury to large blood vessels by a foreign body can cause hemorrhage; injury to nerves can cause complications such as impaired neck movement and difficulty in breathing and swallowing; injury to important organs and tissue structures in the neck such as trachea, esophagus, and pharynx can lead to breathing and pronunciation disorders, shock and even death. Infection caused by indirect injury from foreign body can cause neck abscess, and because of the communication between various interstices of the neck, inflammation can easily spread to the surrounding area to form serious complications such as mediastinitis, mediastinal abscess, rupture of large blood vessels, sepsis, and infectious shock
[4]. If the treatment is not timely, it can delay rescue efforts and even endanger the patient’s life. Timely salvage without complications is very important. In this case, three gun nails were inserted into the neck, with two injuring the cervical spine, and one of them entering the spinal canal at the C5-C6 level, with the nail tip reaching the epidural/dural surface approximately 1 mm from the spinal cord but without dural penetration. Multi-Disciplinary Treatment and accurate preoperative localization were the key to the surgery, assessing the surgical approach, as well as thorough debridement, cleaning the injured tissues, probing the injury and treatment. The patient had no significant spinal cord injury or esophageal and tracheal dissection injuries after surgery, and postoperative symptomatic antibiotic and nerve nourishing treatment was continued, and the patient had no serious complications. Therefore, careful intraoperative exploration of possible structural injuries, vascular and nerve injuries, and postoperative antibiotics are very important to prevent complications. Infectious lesions in the neck require fasting and fluid restriction, indwelling gastric tube, and nasal feeding diet on top of anti-infection to prevent further aggravation of pharyngeal and esophageal mucosal injuries.
Neck injuries due to nail guns are a relatively rare occurrence. Timely and accurate management is especially important. Accurate medical history collection and careful physical examination are necessary to determine the diagnosis and treatment. In addition, imaging is needed to localize the foreign body and assess the damage caused
[5]. Some metallic foreign bodies retained on superficial surfaces of the body can be removed under ultrasound navigation by slowly scanning the ultrasound probe over the surface and after identifying the site of the retained foreign body under a visualization screen, using hemostatic forceps or tissue forceps to accurately clamp out the metal foreign body after following the injury tract under ultrasound navigation and making contact with it. However, there are limitations to the complete removal of deep foreign bodies and small fragile foreign bodies, and this method was not used in this case because of the deep location of the gun nail and the degree of injury. Computed tomography (CT), on the other hand, provides the exact location of the foreign body and its relationship to nearby vital organs. In this case, CT accurately showed the location of the foreign body to help plan and refine the surgical plan. Although MRI can provide important information, its use in metallic foreign bodies is limited due to the ferromagnetic nature of the foreign body. For vascular assessment, preoperative non-contrast CT in this case showed no obvious hematoma, hemorrhage, or vascular injury, and the nails were not obviously adjacent to major vessels. Therefore, digital subtraction angiography (DSA) was not performed. This decision was based on the following considerations: (1) the patient had no clinical signs of vascular injury, such as expanding hematoma, active bleeding, bruit, pulse deficit, or hemodynamic instability; (2) CT imaging showed no direct contact or close proximity between the nails and the carotid or vertebral arteries; and (3) the surgical approach was planned with vascular control prepared, and intraoperative exploration would allow direct visualization of the relevant vessels. During surgery, the operative field was carefully explored layer by layer, and no vascular injury, major vessel laceration, or active hemorrhage was identified. The carotid sheath was inspected directly, and no hematoma or pulsatile bleeding was observed. However, we acknowledge that DSA or CTA should be considered when CT suggests vascular injury, when the foreign body is close to the carotid or vertebral artery, or when there are signs such as expanding hematoma, active bleeding, bruit, pulse deficit, neurological deficit, or unexplained hemodynamic instability
[6]. While the patient presented with hoarseness and painful swallowing before surgery, structural injury was considered. Preoperative fiberoptic laryngoscopy revealed poor mobility of the patient’s right vocal cord, which was related to the trauma caused by the foreign body, and the vocal cord movement could be evaluated again after removal of the foreign body. Postoperatively, the patient’s hoarseness improved significantly, and no repeat laryngoscopy was performed because the symptom had resolved clinically. Tracheal and esophageal injuries were excluded by direct intraoperative visualization. No postoperative contrast swallow was performed because the patient had no fever, cervical swelling, wound contamination, progressive dysphagia, or salivary leakage, and oral feeding was tolerated without choking after gastric tube removal. Except for some cases that can be treated conservatively, such as those without clinical symptoms
[7,
8], local abscesses caused by foreign bodies
[8,
9], or spinal gunshot wounds
[10], most patients require surgical treatment
[1,
11-
13], especially for iron foreign bodies. Timely surgical removal of foreign bodies is necessary, especially in the case of sharp foreign bodies (such as shot nails) in close proximity to vital organs
[14-
16], to avoid complications from residual foreign bodies. According to the literature, multidisciplinary teamwork is necessary in cases of compound injuries involving multiple systems and organs, as well as to reduce the riskiness of the procedure. Table 2 summarizes representative published cases of penetrating neck injuries caused by nail guns or other foreign bodies. In the present case, the multidisciplinary team successfully removed three nails from the neck (thyroid, vertebral body and intervertebral space) without any complications (hemorrhage and cerebrospinal fluid leakage). It is noteworthy that, as in this case, orthopedic surgeons and neurosurgeons were involved in the preoperative evaluation and in the same surgery. In this case, the patient already had preoperative hoarseness and limb movement disorders before the surgery. It is also important to preplan the surgery for the patient’s preoperative clinical presentation and examination. Timely surgical exploration and treatment can prevent complications. Laminectomy is a feasible surgical strategy for the treatment of intravertebral foreign bodies
[16], however, laminectomy may require fusion to stabilize the spine. Recent studies have also shown that laminectomy alone does not help with neurological symptoms
[10], and since cervical fusion was not the first choice for such a young patient. We explored and successfully removed the nail from the vertebral body, and the intraoperative examination was free of cerebrospinal fluid leakage and neurological damage. Therefore, a drainage pipe was placed after debridement. There was no cerebrospinal fluid leakage, infection or vascular damage after surgery. Anti-infective treatment and intensive wound dressing were continued, and the forced cervical position and limited movement of the left upper extremity were significantly relieved after the surgery.
At the same time, there were no complications during follow-up and review. Therefore, multidisciplinary team consultation plays an important role in the management of some compound injuries, which can achieve better treatment strategies and prevent complications.
5 Conclusion
This case demonstrates a rare presentation of multiple nail gun injuries simultaneously involving the thyroid gland, cervical vertebra, and spinal canal in a young patient. The third nail entered the C5-C6 spinal canal, with its tip reaching the epidural/dural surface approximately 1 mm from the spinal cord but without dural penetration. The successful multidisciplinary management, with complete removal of all three foreign bodies and absence of postoperative complications, highlights several key learning points: (1) accurate preoperative imaging (especially CT) is essential for surgical planning; (2) a multidisciplinary team approach involving otolaryngology, orthopedics, and neurosurgery is crucial for complex neck injuries; (3) meticulous intraoperative exploration of vital structures (esophagus, trachea, vessels, and spinal cord) helps prevent life-threatening complications; and (4) timely surgery with appropriate perioperative antibiotic and neurotrophic therapy leads to favorable outcomes. The novelty of this case lies in the unique combination of three penetrating nail gun injuries to distinct anatomical regions of the neck (thyroid, vertebral body, and intervertebral space with spinal canal penetration), with the nail tip stopping only 1 mm from the spinal cord without dural penetration, and the successful single-stage removal without neurological sequelae.
The Author(s). This article is published by Higher Education Press at journal.hep.com.cn.
This is an open access article distributed under the Creative Commons Attribution License 4.0 (CC BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
PDF
(6982KB)
