Air-gun pellet at C1: a case report and literature review

Introduction

Almost all air-gun pellet injuries occur among children under the age of 18 years and very rarely among infants (1). Air-guns have been linked to brain (2-6), heart (7-10), eye (2,4,5,11), sinus (12,13), and abdominal (14) injuries and intrauterine fetal injury (15), with some injuries being fatal. In addition, air-gun pellets that impact the skull can cause a growing skull fracture, which is a rare but clinically significant complication of traumatic skull fractures (16). The literature contains infrequent descriptions of spinal injuries caused by these guns. Despite the risk of serious injury from air-guns, they remain widely available in toy stores and are sold in an unregulated manner. Even though these weapons are sometimes viewed as little more than toys, they are extremely dangerous and can cause significant serious and fatal injuries, particularly among children and adolescents (17). Unfortunately, the general population thinks that trauma caused by air-gun is negligible (17). However, the damage caused by pellets, particularly when it involves the brain or spine, can be significant. For example, in one case, a 2-year-old boy experienced fever and neck rigidity 4 days after being accidentally shot with an air-gun in the back of the neck; clinical examination revealed a pellet lodged in the C1 spinal vertebra (2). There are other injuries that can impact the C1 junction such as chiropractic manipulation, which is more in adults than pediatric population (18).

We report a case of a C1 foreign body after a history of air-gun injury. In this case, the patient was asymptomatic and did not have any neurological deficits. We present this case in accordance with the CARE reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-23-42/rc).

Case presentation

A 6-year-old boy with a history of Hirschsprung disease presented to the emergency department after an air-gun injury in June 2021. When playing with his siblings, the boy pointed the gun inside his mouth and accidentally shot himself. On examination the patient had stable vital signs and was conscious, oriented, and alert. In addition, he was completely neurologically intact with power 5/5 in C5–S1 and sensation 2/2 in C5–S1 with no wounds. Computed tomography (CT) of the cervical spine showed a foreign body at C1 (Figure 1). Since the patient was asymptomatic, and after discussing management options with the family, we opted for conservative management under close outpatient follow-up and analgesia only.

Figure 1 (A) Axial section, (B) sagittal section, and (C) coronal section of cervical CT showing that the pellet is at the C1 level. CT, computed tomography.

One week after the injury, the patient came to the clinic for follow-up and cervical X-rays were done at this time (Figure 2). The images showed no changes in the location of the pellet from the initial CT, and the patient was still asymptomatic. Given the family’s financial and social condition, and the fact that they lived in a rural area distant from our institute, close follow-up on a weekly basis was not possible for the family. Therefore, the patient was followed up over the phone call through telemedicine 6 months and 1 year after the injury. At the 1-year follow-up, the family was encouraged to visit the clinic for a follow-up CT, but they were unable to do so given the financial burden. The parents reported that there was no change in their son’s mental or physical status, and he is active and able to complete his daily activities without any issues or signs of weakness or pain. Multiple solutions were offered to the patient’s family to arrange for a final CT; however, the family declined the offers given their son’s apparently perfect condition. Telemedicine follow-up remains ongoing, and the patient’s family has been educated and encouraged to seek help immediately if any changes in the patient’s condition occur. Up to now, the patient is still asymptomatic without any new active issues. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent for publication of this case report and accompanying images was not obtained from the patient or the relatives after all possible attempts were made.

Figure 2 (A) Anterior-posterior view and (B) lateral view of cervical X-ray showing that the pellet is at the C1 level.

Discussion

Spinal injuries caused by air-gun have been described infrequently in the literature, but they do occur. These are preventable injuries that usually affect unsupervised male children who inflict the injury on themselves or a friend (19). In one case, a pellet was found to be lodged in the C1 spinal vertebra of a 2-year-old boy with fever and neck rigidity 4 days after he was accidentally shot with an air-gun in the back of the neck (2). In 1997, the largest case series reported 16 children injured while playing with air-guns (1). Entrance wounds included 10 through the orbit, 2 in the temporal region, 2 in the front of the neck, and 2 in the sub-occipital region. Complications were reported in several patients, including ocular globe wounds requiring exenteration, meningitis, cerebrospinal fluid fistulas, brain abscess, traumatic aneurysm, wandering intra-ventricular bullet, and carotid-cavernous fistula.

Between 1990 and 2000, the United States Consumer Product Safety Commission reported 39 deaths related to non-powder guns. Of those deaths, most resulted from cardiovascular or intracranial injuries and 32 occurred in children under the age of 15 years. In addition, long-term disabilities occurred, including hemiparesis and monocular blindness. The incidence of injury caused by these weapons is 12.9 per 100,000, with approximately 5% of the injuries requiring hospitalization. Injury from air-gun occurs approximately 21,000–37,000 times yearly in the United States, with a mortality rate of four cases per year (20). In 2009, another case series on non-powder firearm injuries was conducted with a population of 29 pediatric patients (21). Most of the patients were boys with a mean age of 11 years. Of the 29 patients, 9 required surgery, 6 sustained significant morbidity, and 2 died. These 17 patients had serious injuries as evidenced by the need for operation, the location (intracranial, solid organ, hollow viscus, or ocular), and the occurrence of permanent disability or death.

For assessing the extent of injury, plain X-rays are sufficient to locate the metallic body, but CT scans are required to determine the extent of damage and the course of the projectile (20,22). Angiography is needed in case of active bleeding, changes in neurological status, bruits, or enlarging hematoma (23). The presence of metallic foreign bodies of unknown physical nature preclude the use of magnetic resonance imaging.

The algorithm for managing such type of injury is highly controversial. The debate centers on the use of aggressive treatment, which is surgery, versus a more conservative approach, which is antibiotic use. Surgery is indicated if a patient presents with signs and symptoms such as cerebrospinal fluid leak, instability or worsening neurological condition, toxicity, or vascular injury, among others (21). Some authors advocate the use of early surgical management, including removal of any bone fragments and the foreign body, debridement of the wound, application of water-tight dural closure, and reconstruction if necessary (24,25). However, surgery may not be possible if there is a risk of aggravating the neurological damage. Currently, not removing the fragments from an otherwise healthy organ is an accepted approach (24,26). Prophylactic antibiotics and anticonvulsants as needed are common components of conservative management, in light of complications such as infection and epilepsy (20).

Our decision to pursue conservative treatment was guided in part by the family’s financial and social condition. Because they lived in a rural area far from our institute, close follow-up on a weekly basis was very costly for them and thus difficult to accomplish. Therefore, the patient was followed-up over the phone calls through telemedicine. The patient was ultimately unable to return to the clinic for follow-up cervical CT, but his parents reported that he appeared to be entirely normal and healthy.

Conclusions

We describe a case of a C1 foreign body after a history of air-gun injury. Despite the injury, the patient was asymptomatic and had no neurological deficits. Our patient was treated conservatively. Close follow-up was very costly and difficult for the family to adhere to owing to their financial status and distance from the clinic. After 1-year of follow-up, the patient was still asymptomatic and neurologically intact. The algorithm for managing such type of injury is highly controversial, as there is always a debate over the benefits of more aggressive treatment, which is surgery versus a more conservative approach, which is antibiotic use.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-23-42/rc

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-23-42/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-23-42/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are 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. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent for publication of this case report and accompanying images was not obtained from the patient or the relatives after all possible attempts were made.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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