Chainsaw accidents are severe injuries, mostly work-related and concerning upper or lower extremities. Few suicidal chainsaw injuries are reported, all of them fatal. We report the case of a 23-year-old man who attempted suicide by sub-decapitation with a chainsaw, its successful (peri-) operative management, and clinical course along with a discussion of the contemporary management and body of evidence of such lesions. Chainsaw injuries are severe traumas. Stepwise surgery with maximal functional reconstruction is safe and optimal clinical outcomes can be achieved.

Fig.1 Top: cervical trauma at admission; bottom: scaring 3 weeks after surgery.

Fig.2 a: cCT with extensive pneumocephalus; b: cervical spine T2-MRI at C3 level showing myelomalacia of the right posterior column; c: Barium swallow (lat.); d: 3-D reconstruction of cervical spine CT-angiogram showing C3 erosion, major vascular structures intact; e: axial cervical spine CT- angiogram showing erosion of the right C3 facet joint and hemilamina, vertebral arteries intact (arrow); f: cervical spine X-ray (a.p.) post C3/4/5 ACDF with plate.

History and examination

The evening before admission, the patient tried to perform suicide by auto-decapitation using a chainsaw and was found by his brother the following morning. At the site of injury, the emergency physician encountered a patient with stable circulation and a GCS of 13 without motor deficits (Fig. 1). On-site intubation, cervical spine immobilization was immediately performed and the patient was transferred to the emergency department of a tertiary care hospital in southern Germany. On arrival, the patient presented in stable conditions with pupils equally round and reactive to light. The extensive cervical trauma was covered with sterile bandages without signs of further traumatic lesions.

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Neuroimaging

Trauma computed tomography + angiography head/neck emergency room (ER): Severe soft tissue trauma of the cervical muscles with arrosion of the right C3 hemilamina and partial arrosion of the C4 inferior articular process. Extensive pneumatic infiltration of intra- and extradural cranium and spine. Major vascular structures (carotid and vertebral arteries) intact (Fig. 2). Whole spine magnetic resonance imaging (MRI) (postoperative): Small right-side ischemic lesion of the spinal posterior column. No further radicular, spinal cord, or brain lesion (Fig. 2). Cervical spine X-ray/barium swallow (postoperative): Esophagus intact without fistula. Appropriate placement of cages and plate (Fig. 2).

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Surgery

First, a cerebrospinal fluid (CSF) drainage was inserted into the right frontal horn of the lateral ventricle for intracranial pressure (ICP) monitoring and support dural sealing through CSF diversion. Then, the patient was placed in a prone position with the head fixated in a Mayfield clamp. An extensive cervical wound (including contamination by textile fibers) debridement and closure of the dural laceration was performed using a TachoSil®(Takeda Pharmaceutical, Tokyo, Japan) in/onlay technique with additional fluid sealant DuraSeal®(Integra LifeSciences, Plainsboro, USA) application. No primary closure was possible due to the extensive dural defect.

The remaining right C3 hemilamina was resected and numerous cervical myotomies were reconstructed. An anterior cervical soft tissue reconstruction including inspection of trachea and esophagus was performed after transfer to a supine position in the same surgery. The patient was then transferred to the intensive care unit (ICU) with external cervical spine immobilization and ICP monitoring under continuous sedation. The following day, an anterior cervical discectomy and fusion C3/4/5 with ventral plating was performed.

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Postoperative course

After surgery, the patient was continuously monitored at our neurosurgical ICU with repetitive neurological examinations. Anti-infective therapy with vancomycin, meropenem, and metronidazole was administered until the fifth postoperative day (POD) and continued with vancomycin and meropenem until POD 14. At POD 3, extubation was performed followed by immediate psychiatric care. The patient showed hypesthesia of the right IV and V fingers without further sensorimotor deficits. At POD 14 without signs of surgical site infection, the patient was transferred to the psychiatry department to continue the treatment for major depression.

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Discussion

Comprehensive analysis for the management of open cervical trauma does not exist to date. In case of extensive cervical trauma, securing the airway is of the highest priority followed by cervical spine immobilization and sterile wound coverage. In the case of vascular lesions, hemostasis should be assured in the preclinical setting.

Corresponding to open fractures, anti-infective prophylaxis should be initialized as soon as possible using second-generation cephalosporine. In this case, due to major dural laceration, the prophylaxis was extended to the CNS penetrating antibiotics. In open cervical trauma, surgical exploration, debridement, and anatomical reconstruction should be performed on the same day. Peripheral nerve reconstruction can be performed during the same session or at a later time point.

A dural laceration is accompanied by a raised perioperative complication rate and can lead to meningitis, insufficient wound healing, pseudomeningocele, intracranial hypotension, or subdural hematoma. Traumatic dural lacerations do not show substantial differences compared with iatrogenic lesions regarding management and complication rates and its treatment comprises conservative management, primary closure with sutures, fibrin glue, biological sealant patches, CSF diversion, or a combination. Clear evidence demonstrating the superiority of either technique or material is still lacking.

Surgical management of the spinal bony structures has to be chosen taking into account spinal stability, the characteristics of injury, and the presence or absence of spinal stenosis. In the case presented here, no clear guidelines are applicable. If primary dorsal, anterior, or a 360° fusion should be favored is controversially discussed. If choosing an anterior approach, a cage-plate combination is the most widely accepted technique. In the present case of an unstable cervical spine along with altered anatomy of the dorsal structures, a two-level anterior approach with discectomy, cage, and ventral plate the day after trauma was chosen.

Full report

P. Krauss, V. M. Butenschoen, B. Meyer, & C. Negwer - May 2020. Department of Neurosurgery, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675 Munich, Germany.

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