A stab in the back with a screwdriver: a case report
© Bhutta et al; licensee BioMed Central Ltd. 2008
Received: 23 October 2008
Accepted: 11 November 2008
Published: 11 November 2008
Stabbings infrequently produce spinal injury. However, the use weapons other than blades can overcome this natural defence barrier.
We present a spinal injury produced by a screwdriver, its management and a review of the literature.
This case highlights the need for clinical vigilance, including in those who appear stable and a senior multidisciplinary approach to each individual case.
Injuries of the spine as a result of direct stabbings are infrequent outside of South Africa from where previous literature has been produced. During such assaults the injury is often inflicted from behind, where normally blades are deflected away from the spinal cord. However, there is increasing use of alternative weapons to hide any criminal intent such as screwdrivers. These implements are less likely to break or be deflected and are capable of penetrating bone.
A 36 year old male was found lying on his back on a road by police in the early hours of the morning. He was confused and unable to recollect events but did not appear intoxicated. Minor soft tissue injuries were visible, but as a road traffic incident could not be excluded a paramedic unit placed him on a spinal board at the scene.
In the Accident and Emergency department, ATLS guidelines were followed where the airway, breathing and circulation where normal. The patient was now coherent with a GCS 15/15 and neurologically intact.
A multidisciplinary team of orthopaedic and vascular surgeons, anaesthetist and the patient were involved in the management decision. This was to remove the screwdriver under local anaesthetic with mild sedation in an operating theatre, thus allowing observations for any change in neurology, a vascular team was also scrubbed and ready on standby.
The screwdriver was successfully removed. The patient was given prophylactic antibiotics and discharged 3 days later. A follow-up Magnetic Resonance Imaging scan three months later revealed mild arachidonitis, with no thecal disruption and the patient remained clinically well.
Stabbings involving the back are relatively common, accounting for 12% of all stabbing fatalities in the UK, with a much higher incidence in other countries [1, 2]. Literature shows a higher incidence of stabbing in young men, with most to the thoracic spine (61%) and least to the lumbar spine (7%) .
Screwdrivers, however, are infrequently used in such assaults, and the few incidences reported are of varying intracranial injuries producing unique signs and symptoms [3–6]. As a weapon it is able to apply a concentrated force to a small area at the tip with a strong stem allowing it to penetrate bone as compared to a blade which tends to snap or slide. As for most stabbings wounds may be small externally but can often mask an arc of damage internally, which may not manifest itself immediately. Therefore, there is a need for a high index of suspicion even in patients who are haemodynamically stable.
Direct central back stabbings however, rarely produce injuries to the spinal cord and central retroperitoneal structures due to the protection provided by the layers of muscle and the spinal column, with the spinous and transverse processes deflecting blades laterally [7, 8]. In this case the unusual weapon and mechanism of injury were able to permeate this defence. On review of the imaging (Figures 2, 3) we postulate that during the assault, the assailant most likely thrust the weapon into the L2 lamina with partial penetration of bone. Following this the victim either collapsed or was pushed backwards resulting in the screwdriver being driven deeper, potentially exposing the spinal cord and retroperitoneal structures. The patient was extremely fortunate to avoid neural or vascular damage.
There is much debate regarding the management of stab wounds to the back/spine and flank. In a clinically stable patient, there is a trend towards non-operative management, with the use of triple contrast CT scan as a tool to ensure no serious sequale have been missed. Although this does not affect the cost per patient, they spend less time in hospital [7, 8]. The CT scan can also elucidate the track of the injury and aid any surgery that maybe required. In our case a plain CT was performed given the direct spinal penetration of the screwdriver visualised from plain radiographs, decreasing the probability of intestinal injury. The CT scan revealed the path of the screwdriver and that the tip was abutting the abdominal aorta. No focal haemorrhage was seen, and in this instance an arc of injury was not produced since the screwdriver was embedded in the lumbar vertebrae. Indications for laparotomy or exploration in a stable patient include a retained foreign body, radiological compression of the spinal cord, spinal cord herniation . Other complications which can occur are cerebrospinal fluid leak (occurring in up to 6% of injuries ), local abscess formation, osteomyelitis, pnemomyelogram and damage to the artery of Adamkiewicz .
This case report demonstrates an unusual injury produced by a screwdriver to the spine without neurological, vascular or bony consequence. It highlights the need for clinical vigilance in all trauma patients, even in those who appear stable. We would in retrospect recommend the use of CT scans with contrast to delineate occult injuries. It also demonstrates the use of a common sense approach within a senior multidisciplinary team to formulate the best management plan in each unique case.
"Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal."
- Ritchie DA: Stab injury to the lumbar spine. British Journal of Hospital Medicine. 1993, 49 (8): 574-5.PubMedGoogle Scholar
- Moulton C, Crawford R, Swann IJ: Cutaneous leakage of cerebrospinal fluid following a stab wound to the back. Injury. 1994, 5 (2): 118-9. 10.1016/0020-1383(94)90118-X.View ArticleGoogle Scholar
- Tutton MG, Chitnavis B, Stell IM: Screwdriver assaults and intracranial injuries. Journal of Accident & Emergency Medicine. 2000, 17 (3): 225-6.View ArticleGoogle Scholar
- Smrkolj V, Balazic J, Princic J: Intracranial injuries by a screwdriver. Forensic Science International. 1995, 76 (3): 211-6. 10.1016/0379-0738(95)01824-7.View ArticlePubMedGoogle Scholar
- Kim HS, Ko K: Penetrating trauma of the posterior fossa resulting in Vernet's syndrome and internuclear ophthalmoplegia. Journal of Trauma-Injury Infection & Critical Care. 1996, 40 (4): 647-9. 10.1097/00005373-199604000-00024.View ArticleGoogle Scholar
- Evans RJ, Richmond JM: An unusual death due to screwdriver impalement: A case report. American Journal of Forensic Medicine & Pathology. 1996, 17 (1): 70-2. 10.1097/00000433-199603000-00013.View ArticleGoogle Scholar
- Boyle EM, Maier RV, Salazar JD, Kovacich JC, O'Keefe G, Mann FA, Wilson AJ, Copass MK, Jurkovich GJ: Diagnosis of injuries after stab wounds to the back and flank. Journal of Trauma-Injury Infection & Critical Care. 1997, 42 (2): 260-5. 10.1097/00005373-199702000-00013.View ArticleGoogle Scholar
- Rubin G, Tallman D, Sagan L, Melgar M: An unusual stab wound of the cervical spinal cord: a case report. Spine. 2001, 26 (4): 444-7. 10.1097/00007632-200102150-00023.View ArticlePubMedGoogle Scholar
- Lee ST, Lui TN, Jeng CM: Spinal cord herniation after stabbing injury: case report. British Journal Of Neurosurgery. 1997, 11 (1): 84-86. 10.1080/02688699746780.View ArticlePubMedGoogle Scholar
- Rogers FB, Osler TM, Shackford SR, Wald SL: Isolated stab wound to the artery of Adamkiewicz: case report and review of the literature. Journal of Trauma-Injury Infection & Critical Care. 1997, 43 (3): 549-51. 10.1097/00005373-199709000-00031.View ArticleGoogle Scholar
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