**2. Non-missile-penetrating spinal cord injury**

Historically, the first non-missile-penetrating spinal cord injury (NMPSCI) was described by the Egyptians in 1700 BC. The Edwin-Smith papyrus was the first manual of military injuries in history and described different injuries and their proposed optimal treatment. Unlike other medical documents preserved from that era, the papyrus was based on medical procedures and not myths or prays [4]. In the second century AD, the Greek physician Galen reported his experiments on monkeys when a horizontal cut through their spine resulted in loss of sensation and motion below the level of the injury [5].

The largest series of NMPSCI was published by Lipschitz [6] with two case series in 1955– 1967. Other smaller series were described in 1977 and 1995 [7, 8]. These publications came all from the same country (South Africa), both at an era of severe violence that unfortunately flooded the country.

Unlike in the rest of the world, in South Africa penetrating SCI is still responsible to about 60% of all SCI (spread evenly between NMPSCI and MPSCI). MVA, which is the most common cause of SCI in the rest of the world, accounts only for one-third of the cases in South Africa today [2].

Most of the affected victims of these injuries are young men in their second and third decades [2, 3]. Generally speaking, while in the past, NMPSI was rare in females, today the trend is changing, and over the past decades, it is seen more, especially in North America. Yet, about 80% of the affected victims of these injuries are males [2].

Knife is by far the most common assault weapon causing NMPSI. It accounts for 84% of the cases [9]. Other sharp objects such as screwdrivers, scissors, garden forks, and bicycle spokes were reported as the assaulting weapon for NMPSCI as well [9]. Even a pencil was reported as a stabbing object that caused NMPSCI [10].

Previous reports described a series of NMPSCI caused by acupuncture needles [11]. The World Health Organization published a systematic review of acupuncture-related adverse events in 2010, in which 44 cases of dural and arachnoid bleeding, causing severe adverse events and death (three cases), were reported [11].

Most non-missile-penetrating injuries happened when victims were stabbed from behind with the thoracic spine being the most common site (up to 63%), followed with cervical spine (up to 30%) [12]. A recent study examined that there are no differences in stab wounds to the neck, between military personnel (during combat) and civilians. This probably emphasizes the role of incidence in this type of injuries [13].

Victims are usually stabbed once, and the attacker usually withdrawals the stabbing object from the victim's body. However, in some cases the stabbing object brakes inside the body, and retained material occurs (**Figure 1A** and **B**). In the case of knives, the most common brakeage occurs at the handle or blade wedging a bone. The first one is usually very prominent from the victim's body and raises the dilemma of removing it at the scene [14].

of the total penetrating injuries [3]. The incidence of missile-penetrating SCI varies, and difference exists between its incidence in civilian population and military personnel population, where the latter is naturally more prevalent and influenced by eras of military conflicts [3].

Historically, the first non-missile-penetrating spinal cord injury (NMPSCI) was described by the Egyptians in 1700 BC. The Edwin-Smith papyrus was the first manual of military injuries in history and described different injuries and their proposed optimal treatment. Unlike other medical documents preserved from that era, the papyrus was based on medical procedures and not myths or prays [4]. In the second century AD, the Greek physician Galen reported his experiments on monkeys when a horizontal cut through their spine resulted in loss of sensa-

The largest series of NMPSCI was published by Lipschitz [6] with two case series in 1955– 1967. Other smaller series were described in 1977 and 1995 [7, 8]. These publications came all from the same country (South Africa), both at an era of severe violence that unfortunately

Unlike in the rest of the world, in South Africa penetrating SCI is still responsible to about 60% of all SCI (spread evenly between NMPSCI and MPSCI). MVA, which is the most common cause of SCI in the rest of the world, accounts only for one-third of the cases in South Africa today [2]. Most of the affected victims of these injuries are young men in their second and third decades [2, 3]. Generally speaking, while in the past, NMPSI was rare in females, today the trend is changing, and over the past decades, it is seen more, especially in North America. Yet, about

Knife is by far the most common assault weapon causing NMPSI. It accounts for 84% of the cases [9]. Other sharp objects such as screwdrivers, scissors, garden forks, and bicycle spokes were reported as the assaulting weapon for NMPSCI as well [9]. Even a pencil was reported

Previous reports described a series of NMPSCI caused by acupuncture needles [11]. The World Health Organization published a systematic review of acupuncture-related adverse events in 2010, in which 44 cases of dural and arachnoid bleeding, causing severe adverse

Most non-missile-penetrating injuries happened when victims were stabbed from behind with the thoracic spine being the most common site (up to 63%), followed with cervical spine (up to 30%) [12]. A recent study examined that there are no differences in stab wounds to the neck, between military personnel (during combat) and civilians. This probably emphasizes

Victims are usually stabbed once, and the attacker usually withdrawals the stabbing object from the victim's body. However, in some cases the stabbing object brakes inside the body,

**2. Non-missile-penetrating spinal cord injury**

tion and motion below the level of the injury [5].

80% of the affected victims of these injuries are males [2].

as a stabbing object that caused NMPSCI [10].

events and death (three cases), were reported [11].

the role of incidence in this type of injuries [13].

flooded the country.

68 Essentials of Spinal Cord Injury Medicine

**Figure 1.** Axial CT scan (A) and 3D CT reconstruction (B) demonstrating a screwdriver going through the T12 vertebra, through the cord, and coming out adjacent to the aorta. The patient was fully alert on arrival with no neurological deficits. The screwdriver was removed in theater without complications, and the patient was discharged 2 days later.

The possible neurological deficit ranges from asymptomatic dural tears through different nerve root injuries, ranging from neurapraxia to neurothemesis and ending in the worst cases with complete or incomplete spinal cord injury.

without contrast, and MRI. It must be remembered that imaging cannot replace clinical evaluation, judgment, or resuscitation. Imaging should be considered only in a hemodynamically

Penetrating Spinal Cord Injury

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http://dx.doi.org/10.5772/intechopen.76857

Enicker and his colleagues [12] published a large series of stab wounds that accounted for one-third of all SCI in their center. Forty-nine percent of these patients had retained foreign bodies where a knife blade was the most common object. Knife blades are easily identified by plain radiographs; however, the availability of CT scan in most ER in the developed world has shoved aside its role in cervical trauma. It still has a role in the evaluation of thoracic injury mainly for the evaluation of the associated lung injury and not for the demonstration of the

Computerized tomography is the mainstay in diagnosis of penetrating SCI. It is a fast and reliable modality that can scan any part of the body. It has the ability to demonstrate the thoracic or cervical column with the surrounding organs that may be involved in the injury. The main disadvantage of CT scan is its poor ability to demonstrate direct damage or pathologic

Saito and colleagues in their review [21] recommend CTA as the gold standard of imaging for penetrating SCI. It has all the advantages of CT plus the benefit of demonstrating blood vessels including extravasation, pseudoaneurysm, dissection, occlusion, and arteriovenous fistula. Angiography is still considered as the "gold standard" vascular imaging examination; however, CTA is gradually taking its place as an alternative. CTA has been proven to be as good as angiography and yet less invasive and faster which makes it suitable for diagnosis in such cases [21].

MRI is not used routinely as a diagnostic tool in these injuries. The main concern is potential migration of retained metal fragments that can further damage neurologic or other surrounding tissues. Other drawbacks are time, unavailability, and study quality in the presence of metal artifacts. On the contrary to its place in the acute setting, MRI has a major role in studying complications following the initial treatment. Patients who present with deteriorating neurological deficit, prolonged fever, CSF leak, or post-LP syndrome are expected to be

Other imaging studies may be used when clinical suspicion for specific collateral organ damage is raised. This may include sonography, Doppler, endoscopy, and barium contrast imaging studies. Those studies are not routinely used, and the need depends on the site of injury

stable patient.

foreign body.

*2.2.3. CTA*

*2.2.4. MRI*

*2.2.5. Others*

*2.2.2. Computed tomography*

changes of the neural tissue.

further evaluated with an MRI.

*2.2.1. Radiography*

The most common incomplete NMPSCI reported was the Brown-Sequard syndrome [15, 16]. This syndrome was first described by Charles-Édouard Brown-Séquard, in farmers cutting sugarcanes in Mauritius and sustaining hemisection of their spinal cord by long knives (1852) [17]. The syndrome is still the most common incomplete SCI [18].

Neurological injury to the spine may occur in two different mechanisms: immediate, through direct damage to neurological tissue, and delayed, following vascular injury to one of the feeding vessels in which a vessel that supplies the cord, most commonly the aorta or the Adamkiewicz perforant, is injured. The first one will cause most frequently an incomplete SCI, most commonly Brown-Sequard syndrome, while the last one is more likely to cause a complete SCI. The second pattern is the delayed onset which is caused most commonly from CSF leaks, edema, granuloma, scar formation, and infection. The delayed pattern can appear anytime from 2 years after the injury and up to 36 years as was described in a rare case of metal encrustation of a retained knife fragment in the spinal canal [19].
