Impalement with Spinal Cord Injury Requiring Intraoperative Division of a Reinforced Steel Bar

Abstract

European Journal of TraumaAb stract Impalement injuries result when a rigid object penetrates and remains lodged within the body. While these injuries are rare, and many patients die at the scene, they often produce complex surgical problems. Few case reports describe complete spinal cord transection due to impalement. No case reports have described intrathoracic division of a reinforcing steel bar to assist the removal. The authors report a case of impalement by a steel bar resulting in immediate spinal cord transection requiring intraoperative division of the bar with a pneumatic drill for removal. They also present a literature review on thoracic impalement and discuss the general management of these injuries. Case StudyA 27-year-old intoxicated man was on the roof of his house when he lost his footing and fell 10 feet, landing on a 1.6-cm diameter reinforced steel bar that was embedded vertically in concrete. Emergency services personnel arriving at the scene found the patient supine with the bar entering posteriorly in the right lumbar region, and protruding anteriorly just inferior to the left clavicle at the midclavicular line, without breaking the skin. The patient was alert with a Glasgow Coma Scale of 15; however, he lacked motor function or sensation in his lower extremities. The steel bar was cut by emergency medical service providers 15 cm from its entry point. The patient was taken to a nearby community hospital where he was breathing spontaneously, blood pressure was 116/52 mmHg, pulse 71/min, and oximetry 97% on room air. His abdomen was flat, nontender, with occasional bowel sounds. He had bilateral normal breath sounds. Portable chest radiograph showed a small left opacification without pneumothorax. He began complaining of mild difficulty breathing. Given the extended upcoming travel duration, the patient was intubated, sedated, and paralyzed. After intubation a left anterior thoracostomy tube was placed without output of air or blood. The patient was then transferred by fixed wing and helicopter approximately 300 miles to the Oregon Health and Science University (OHSU) Trauma Service.The patient arrived at the emergency department approximately 6 h after the injury intubated, sedated, and chemically paralyzed in the left decubitus position with a cervical collar in place. His heart rate was 79/min, blood pressure 129/78 mmHg, and oxygen saturation 98%. On examination, bilateral breath sounds were heard, and no blood had come out of the chest tube. His abdomen was soft and nondistended, lower extremity pulses were strong bilaterally, and there was no evidence of lower extremity venous engorgement. Examination of the patient's back revealed an entry wound 4 cm superior to the iliac crest, 3 cm to the right of the midline (Figure 1). Rectal exam revealed absent tone, and no gross blood or palpable bony fragments. His blood alcohol level on arrival was 147 mg/dl, and hematocrit was 43%. Chest radiography confirmed the presence of a foreign body in the left chest extending through the thoracic spin...