Endoskopik Transoral Yaklaşımla Üst Servikal Omurgadaki Kurşun Çekirdeğinin Çıkarılması: Olgu Sunumu ve Literatür Değerlendirmesi
Özet
Servikal bölgedeki omurga ateşli silah yaralanmaları, ciddi komplikasyonlar ve yüksek mortalite riski taşır. Bu tür vakalarda cerrahi müdahale kararı, yabancı cismin yerleşimi ve potansiyel risklere göre alınmalıdır. Transoral endoskopik yöntem, minimal invaziv doğası ve düşük komplikasyon oranları ile güvenli bir tedavi seçeneği sunar. Bir ay önce ateşli silahla yaralanan 29 yaşındaki erkek hasta polikliniğimizde değerlendirildi. Nörolojik muayenesinde patolojik bir bulguya rastlanmadı. Yapılan nöroradyolojik tetkiklerde, C1 ön arkusu ve dens arasında lokalize olmuş kurşun çekirdeği ve mandibula fraktürü tespit edildi. Transoral endoskopik yöntemle kurşun çekirdeği başarılı bir şekilde çıkarıldı. Cerrahi işlem nöronavigasyon desteğiyle sorunsuz tamamlandı. Ameliyat 40 dakika sürdü ve postoperatif dönemde ciddi bir komplikasyon gözlenmedi. Hasta, minimal analjezik kullanımı ile kısa sürede iyileşme gösterdi ve iki yıllık takip sürecinde enfeksiyon, kurşun zehirlenmesi veya migrasyon gibi komplikasyonlar gelişmedi.
Transoral endoskopik yöntem, servikal omurgadaki yabancı cisimlerin çıkarılmasında etkili ve güvenli bir seçenektir. Minimal invaziv yaklaşım özelliğinden dolayı bu yöntem, uygun vakalarda komplikasyonları önlemekte ve hastaların yaşam kalitesini artırmaktadır.
Gunshot injuries to the cervical spine pose significant complications and high mortality risks. Surgical intervention decisions should be based on the foreign body's location and potential risks. The transoral endoscopic approach offers a safe treatment option due to its minimally invasive nature and low complication rates. A 29-year-old male patient who had sustained a gunshot wound one month ago was evaluated in our clinic. Neurological examination revealed no pathological findings. Neuroradiological investigations identified a bullet fragment localized between the anterior arch of C1 and the dens, along with a mandibular fracture. The bullet was successfully removed using the transoral endoscopic approach. The surgical procedure was completed without complications under neuronavigation guidance. The operation duration was 40 minutes, and the postoperative period was uneventful. The patient required minimal analgesic use and showed rapid recovery. During the two-year follow-up, no complications such as infection, lead poisoning, or bullet migration were observed. The transoral endoscopic approach is an effective and safe option for removing foreign bodies in the cervical spine. This technique minimizes complications and improves patient quality of life in suitable cases, thanks to its minimally invasive nature. It can be considered a valuable treatment option for similar complex cases.
Referanslar
Beaty N, Slavin J, Diaz C, Zeleznick K, Ibrahimi D, Sansur CA. Cervical spine injury from gunshot wounds. J Neurosurg Spine. 2014;21(3):442-449. doi:10.3171/2014.5.SPINE13522
Kumar A, Pandey PN, Ghani A, Jaiswal G. Penetrating spinal injuries and their management. J Craniovertebr Junction Spine. 2011;2(2):57-61. doi:10.4103/0974-8237.100052
Bono CM, Heary RF. Gunshot wounds to the spine. Spine Journal. 2004;4(2):230-240. doi:10.1016/S1529-9430(03)00178-5
Bumpass DB, Buchowski JM, Park A, et al. An update on civilian spinal gunshot wounds: treatment, neurological recovery, and complications. Spine (Phila Pa 1976). 2015;40(7):450-461. doi:10.1097/BRS.0000000000000797
DeVivo MJ, Go BK, Jackson AB. Overview of the national spinal cord injury statistical center database. J Spinal Cord Med. 2002;25(4):335-338. doi:10.1080/10790268.2002.11753637
Jakoi A, Iorio J, Howell R, Zampini JM. Gunshot injuries of the spine. Spine J. 2015;15(9):2077-2085. doi:10.1016/J.SPINEE.2015.06.007
Zeynal M. Endoscopic Transoral Odontoidectomy of Craniovertebral Junction Rheumatoid Arthritis With the Help of Real-Time Fluoroscopy and Intraoperative Computed Tomography. J Craniofac Surg. 2023;34(8):2468-2469. doi:10.1097/SCS.0000000000009520
Shriver MF, Kshettry VR, Sindwani R, Woodard T, Benzel EC, Recinos PF. Transoral and transnasal odontoidectomy complications: A systematic review and meta-analysis. Clin Neurol Neurosurg. 2016;148:121-129. doi:10.1016/J.CLINEURO.2016.07.019
Jongekkasit I, Jitpratoom P, Sasanakietkul T, Anuwong A. Transoral Endoscopic Thyroidectomy for Thyroid Cancer. Endocrinol Metab Clin North Am. 2019;48(1):165-180. doi:10.1016/J.ECL.2018.11.009
Kahraman S, Gonul E, Kayali H, et al. Retrospective analysis of spinal missile injuries. Neurosurg Rev. 2004;27(1):42-45. doi:10.1007/S10143-003-0274-9
Syre P, Rodriguez-Cruz L, Desai R, et al. Civilian gunshot wounds to the atlantoaxial spine: a report of 10 cases treated using a multidisciplinary approach. J Neurosurg Spine. 2013;19(6):759-766. doi:10.3171/2013.8.SPINE12907
Sidhu GS, Ghag A, Prokuski V, Vaccaro AR, Radcliff KE. Civilian gunshot injuries of the spinal cord: a systematic review of the current literature. Clin Orthop Relat Res. 2013;471(12):3945-3955. doi:10.1007/S11999-013-2901-2
Maniker AH, Gropper MR, Hunt CD. Transoral gunshot wounds to the atlanto-axial complex: Report of five cases. Journal of Trauma - Injury, Infection and Critical Care. 1994;37(5):858-861. doi:10.1097/00005373-199411000-00028
Walter T, Schwabe P, Schaser KD, Maurer M. Positive Outcome After a Small-Caliber Gunshot Fracture of the Upper Cervical Spine without Neurovascular Damage. Pol J Radiol. 2016;81:134-137. doi:10.12659/PJR.895529
Womack R, Luther E, Perez-Roman RJ, Manzano GR. Heterotopic Bone Formation 20 Years After Gunshot Wound to the Cervical Spine: A Rare Cause of Progressive Cervical Myelopathy in a Previously Asymptomatic Patient. World Neurosurg. 2019;132:197-201. doi:10.1016/J.WNEU.2019.08.093
Bustamante ND, Macias-Konstantopoulos WL. Retained Lumbar Bullet: A Case Report of Chronic Lead Toxicity and Review of the Literature. J Emerg Med. 2016;51(1):45-49. doi:10.1016/J.JEMERMED.2016.02.025
DiMaio VJM, DiMaio SM, Garriott JC, Simpson P. A fatal case of lead poisoning due to a retained bullet. Am J Forensic Med Pathol. 1983;4(2):165-169. doi:10.1097/00000433-198306000-00013
Park JH, Kim HS, Kim SW, Do NY. Gunshot injury to the anterior arch of atlas. J Korean Neurosurg Soc. 2012;51(3):164-166. doi:10.3340/JKNS.2012.51.3.164
Benton JA, Rahme R, Krystal J, Holland R, Houten JK, Kinon MD. Retained bullet in the cervical spinal canal and the associated surgical management conundrum: case report and review of the literature. Spinal Cord Ser Cases. 2020;6(1). doi:10.1038/S41394-020-00326-W
Jones RE, Bucholz RW, Schaefer SD, Mumme M, Carder HM. Cervical osteomyelitis complicating transpharyngeal gunshot wounds to the neck. Journal of Trauma - Injury, Infection and Critical Care. 1979;19(8):630-634. doi:10.1097/00005373-197908000-00011
Hećimović I, Vranković D, Rubin O, Maksimović Z, Rukovanjski M. Transoral missile removal from the anterior C1 region following transpharyngeal missile wound. Arch Orthop Trauma Surg. 1999;119(5-6):340-343. doi:10.1007/S004020050423
Schaefer SD, Bucholz RW, Jones RE, Anderson RG, Carder HM. “How I do it”--head and neck. A targeted problem and its solution. Treatment of transpharyngeal missile wounds to the cervical spine. Laryngoscope. 1981;91(1):146-148. doi:10.1288/00005537-198101000-00022
Williams DT, Chang DL, DeClerck MP. Penetrating spinal cord injuries with retained canal fragments. CJEM. 2009;11(2):172-173. doi:10.1017/S1481803500011155
Bumbaširević M, Lešíc A, Bumbaširević V, Rakočević Z, Djurić M. Gunshot injury to the face with a missile lodged in the upper cervical spine without neurological deficit. Dentomaxillofac Radiol. 2006;35(1):38-42. doi:10.1259/DMFR/29317043
Goswami S. A bullet in the maxillary antrum and infratemporal fossa. Indian J Dent Res. 2013;24(1):149. doi:10.4103/0970-9290.114947
Teng B, Yang J, Feng Q, Wang Y, Xin X. Removal of infratemporal fossa foreign body under C-arm. J Craniofac Surg. 2014;25(4):1313-1314. doi:10.1097/SCS.0000000000000781
Meco C, Tezcaner ÇZ, Tuna H, Gokcan K, Attar A, Anadolu Y. Transfacial transsphenoidal gunshot wound: endonasal endoscopic management. J Trauma. 2010;68(4):E94-E98. doi:10.1097/TA.0B013E3181B5DA43
Tekin AM, Elsamanody AN, Ali IM, Topsakal V. Endoscopic Endonasal Removal of Stray Bullets in the Fossa Pterygopalatine in Innocent Young Bystanders of Conflicts in Somalia in a Period of Six Months. J Craniofac Surg. 2022;33(2):E130-E133. doi:10.1097/SCS.0000000000008030
Jang S, Eom KS. Endoscopic Endonasal Removal of a Bullet Lodged in the Anterior Lower Clivus: A Case Report. Korean J Neurotrauma. 2024;20(2):108-112. doi:10.13004/KJNT.2024.20.E15
Mangiardi JR, Alleva M, Dynia R, Zubowski R. Transoral removal of missile fragments from the C1-C2 area: report of four cases. Neurosurgery. 1988;23(2):254-257. doi:10.1227/00006123-198808000-00025
Promsopa C, Prapaisit U. Removal of intraconal bullet through endoscopic transnasal surgery with image-guided navigation system 8 months after injury: a case report. J Med Case Rep. 2019;13(1). doi:10.1186/S13256-019-2007-X
Li Q, Jiang Z, Zhuo X, Zhang X. Endoscopic removal of bullets from the cranial ridge junction region via transoral and transnasal approaches: Two case reports and review of literature. Medicine. 2016;95(24). doi:10.1097/MD.0000000000003918
Dumberger LD, Chao TN. Transoral management of pharyngeal ballistics. Am J Otolaryngol. 2022;43(5). doi:10.1016/J.AMJOTO.2022.103490
Erinjeri NJ, Udelsman R. Transoral Endoscopic Thyroidectomy Vestibular Approach. Adv Surg. 2019;53:179-193. doi:10.1016/J.YASU.2019.04.009
Joaquim AF, Osorio JA, Riew KD. Transoral and Endoscopic Endonasal Odontoidectomies – Surgical Techniques, Indications, and Complications. Neurospine. 2019;16(3):462-469. doi:10.14245/NS.1938248.124
Zhang Q, Kong F, Yan B, et al. Transoral endoscopic odontoidectomy to decompress the cervicomedullary junction. Spine (Phila Pa 1976). 2013;38(14). doi:10.1097/BRS.0B013E3182941735
Referanslar
Beaty N, Slavin J, Diaz C, Zeleznick K, Ibrahimi D, Sansur CA. Cervical spine injury from gunshot wounds. J Neurosurg Spine. 2014;21(3):442-449. doi:10.3171/2014.5.SPINE13522
Kumar A, Pandey PN, Ghani A, Jaiswal G. Penetrating spinal injuries and their management. J Craniovertebr Junction Spine. 2011;2(2):57-61. doi:10.4103/0974-8237.100052
Bono CM, Heary RF. Gunshot wounds to the spine. Spine Journal. 2004;4(2):230-240. doi:10.1016/S1529-9430(03)00178-5
Bumpass DB, Buchowski JM, Park A, et al. An update on civilian spinal gunshot wounds: treatment, neurological recovery, and complications. Spine (Phila Pa 1976). 2015;40(7):450-461. doi:10.1097/BRS.0000000000000797
DeVivo MJ, Go BK, Jackson AB. Overview of the national spinal cord injury statistical center database. J Spinal Cord Med. 2002;25(4):335-338. doi:10.1080/10790268.2002.11753637
Jakoi A, Iorio J, Howell R, Zampini JM. Gunshot injuries of the spine. Spine J. 2015;15(9):2077-2085. doi:10.1016/J.SPINEE.2015.06.007
Zeynal M. Endoscopic Transoral Odontoidectomy of Craniovertebral Junction Rheumatoid Arthritis With the Help of Real-Time Fluoroscopy and Intraoperative Computed Tomography. J Craniofac Surg. 2023;34(8):2468-2469. doi:10.1097/SCS.0000000000009520
Shriver MF, Kshettry VR, Sindwani R, Woodard T, Benzel EC, Recinos PF. Transoral and transnasal odontoidectomy complications: A systematic review and meta-analysis. Clin Neurol Neurosurg. 2016;148:121-129. doi:10.1016/J.CLINEURO.2016.07.019
Jongekkasit I, Jitpratoom P, Sasanakietkul T, Anuwong A. Transoral Endoscopic Thyroidectomy for Thyroid Cancer. Endocrinol Metab Clin North Am. 2019;48(1):165-180. doi:10.1016/J.ECL.2018.11.009
Kahraman S, Gonul E, Kayali H, et al. Retrospective analysis of spinal missile injuries. Neurosurg Rev. 2004;27(1):42-45. doi:10.1007/S10143-003-0274-9
Syre P, Rodriguez-Cruz L, Desai R, et al. Civilian gunshot wounds to the atlantoaxial spine: a report of 10 cases treated using a multidisciplinary approach. J Neurosurg Spine. 2013;19(6):759-766. doi:10.3171/2013.8.SPINE12907
Sidhu GS, Ghag A, Prokuski V, Vaccaro AR, Radcliff KE. Civilian gunshot injuries of the spinal cord: a systematic review of the current literature. Clin Orthop Relat Res. 2013;471(12):3945-3955. doi:10.1007/S11999-013-2901-2
Maniker AH, Gropper MR, Hunt CD. Transoral gunshot wounds to the atlanto-axial complex: Report of five cases. Journal of Trauma - Injury, Infection and Critical Care. 1994;37(5):858-861. doi:10.1097/00005373-199411000-00028
Walter T, Schwabe P, Schaser KD, Maurer M. Positive Outcome After a Small-Caliber Gunshot Fracture of the Upper Cervical Spine without Neurovascular Damage. Pol J Radiol. 2016;81:134-137. doi:10.12659/PJR.895529
Womack R, Luther E, Perez-Roman RJ, Manzano GR. Heterotopic Bone Formation 20 Years After Gunshot Wound to the Cervical Spine: A Rare Cause of Progressive Cervical Myelopathy in a Previously Asymptomatic Patient. World Neurosurg. 2019;132:197-201. doi:10.1016/J.WNEU.2019.08.093
Bustamante ND, Macias-Konstantopoulos WL. Retained Lumbar Bullet: A Case Report of Chronic Lead Toxicity and Review of the Literature. J Emerg Med. 2016;51(1):45-49. doi:10.1016/J.JEMERMED.2016.02.025
DiMaio VJM, DiMaio SM, Garriott JC, Simpson P. A fatal case of lead poisoning due to a retained bullet. Am J Forensic Med Pathol. 1983;4(2):165-169. doi:10.1097/00000433-198306000-00013
Park JH, Kim HS, Kim SW, Do NY. Gunshot injury to the anterior arch of atlas. J Korean Neurosurg Soc. 2012;51(3):164-166. doi:10.3340/JKNS.2012.51.3.164
Benton JA, Rahme R, Krystal J, Holland R, Houten JK, Kinon MD. Retained bullet in the cervical spinal canal and the associated surgical management conundrum: case report and review of the literature. Spinal Cord Ser Cases. 2020;6(1). doi:10.1038/S41394-020-00326-W
Jones RE, Bucholz RW, Schaefer SD, Mumme M, Carder HM. Cervical osteomyelitis complicating transpharyngeal gunshot wounds to the neck. Journal of Trauma - Injury, Infection and Critical Care. 1979;19(8):630-634. doi:10.1097/00005373-197908000-00011
Hećimović I, Vranković D, Rubin O, Maksimović Z, Rukovanjski M. Transoral missile removal from the anterior C1 region following transpharyngeal missile wound. Arch Orthop Trauma Surg. 1999;119(5-6):340-343. doi:10.1007/S004020050423
Schaefer SD, Bucholz RW, Jones RE, Anderson RG, Carder HM. “How I do it”--head and neck. A targeted problem and its solution. Treatment of transpharyngeal missile wounds to the cervical spine. Laryngoscope. 1981;91(1):146-148. doi:10.1288/00005537-198101000-00022
Williams DT, Chang DL, DeClerck MP. Penetrating spinal cord injuries with retained canal fragments. CJEM. 2009;11(2):172-173. doi:10.1017/S1481803500011155
Bumbaširević M, Lešíc A, Bumbaširević V, Rakočević Z, Djurić M. Gunshot injury to the face with a missile lodged in the upper cervical spine without neurological deficit. Dentomaxillofac Radiol. 2006;35(1):38-42. doi:10.1259/DMFR/29317043
Goswami S. A bullet in the maxillary antrum and infratemporal fossa. Indian J Dent Res. 2013;24(1):149. doi:10.4103/0970-9290.114947
Teng B, Yang J, Feng Q, Wang Y, Xin X. Removal of infratemporal fossa foreign body under C-arm. J Craniofac Surg. 2014;25(4):1313-1314. doi:10.1097/SCS.0000000000000781
Meco C, Tezcaner ÇZ, Tuna H, Gokcan K, Attar A, Anadolu Y. Transfacial transsphenoidal gunshot wound: endonasal endoscopic management. J Trauma. 2010;68(4):E94-E98. doi:10.1097/TA.0B013E3181B5DA43
Tekin AM, Elsamanody AN, Ali IM, Topsakal V. Endoscopic Endonasal Removal of Stray Bullets in the Fossa Pterygopalatine in Innocent Young Bystanders of Conflicts in Somalia in a Period of Six Months. J Craniofac Surg. 2022;33(2):E130-E133. doi:10.1097/SCS.0000000000008030
Jang S, Eom KS. Endoscopic Endonasal Removal of a Bullet Lodged in the Anterior Lower Clivus: A Case Report. Korean J Neurotrauma. 2024;20(2):108-112. doi:10.13004/KJNT.2024.20.E15
Mangiardi JR, Alleva M, Dynia R, Zubowski R. Transoral removal of missile fragments from the C1-C2 area: report of four cases. Neurosurgery. 1988;23(2):254-257. doi:10.1227/00006123-198808000-00025
Promsopa C, Prapaisit U. Removal of intraconal bullet through endoscopic transnasal surgery with image-guided navigation system 8 months after injury: a case report. J Med Case Rep. 2019;13(1). doi:10.1186/S13256-019-2007-X
Li Q, Jiang Z, Zhuo X, Zhang X. Endoscopic removal of bullets from the cranial ridge junction region via transoral and transnasal approaches: Two case reports and review of literature. Medicine. 2016;95(24). doi:10.1097/MD.0000000000003918
Dumberger LD, Chao TN. Transoral management of pharyngeal ballistics. Am J Otolaryngol. 2022;43(5). doi:10.1016/J.AMJOTO.2022.103490
Erinjeri NJ, Udelsman R. Transoral Endoscopic Thyroidectomy Vestibular Approach. Adv Surg. 2019;53:179-193. doi:10.1016/J.YASU.2019.04.009
Joaquim AF, Osorio JA, Riew KD. Transoral and Endoscopic Endonasal Odontoidectomies – Surgical Techniques, Indications, and Complications. Neurospine. 2019;16(3):462-469. doi:10.14245/NS.1938248.124
Zhang Q, Kong F, Yan B, et al. Transoral endoscopic odontoidectomy to decompress the cervicomedullary junction. Spine (Phila Pa 1976). 2013;38(14). doi:10.1097/BRS.0B013E3182941735
