A stab in the back with a screwdriver: a case report
Mohammed A Bhutta
Paul D Dunkow
Derick M Lang
Department of Trauma and Orthopaedics, South Manchester University Healthcare Trust
Department of Trauma and Orthopaedics, Blackpool Flyde and Wyre NHS Trust
North Western Deanery Trauma and Orthopaedics, South Manchester University Healthcare Trust
Background: Stabbings infrequently produce spinal injury. However, the use weapons other than blades can overcome this natural defence barrier. Case Presentation: We present a spinal injury produced by a screwdriver, its management and a review of the literature. Conclusion: 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
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.
The patient continued to complain of facial, skull and
back pain. Facial lacerations, abrasions and bruising could
be seen. However, when he was log-rolled the cause for
his back pain was found. A screwdriver 'inserted' to the
hilt at which there was a 90 degree bend (Figure 1).
A secondary survey did not reveal any other significant
injuries. Initial plain X-rays taken demonstrated a 12 cm
screwdriver at the 2nd lumbar vertebrae protruding
beyond the vertebral body by approximately 2 cm. After
discussion with a radiologist, a CT scan was performed
and confirmed the screwdriver entering at the level of L2,
right of the spinous process penetrating the lamina,
traversing the spinal canal and body of L2. It's path missing
the filum terminale and the tip abutting the abdominal
aorta. No evidence of haemorrhage was seen (Figure 2, 3).
PFhigoutorgera1ph of stabbing while in the emergency room
Photograph of stabbing while in the emergency
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
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
(FAig) uArPea2nd (B) Lateral CT scan of abdomen demonstrating position of screwdriver
(A) AP and (B) Lateral CT scan of abdomen demonstrating position of screwdriver.
aFCbiTgduoscmraeinn3adleamoortnastrating tip of screwdriver abutting the
CT scan demonstrating tip of screwdriver abutting
the abdominal aorta.
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."
The authors declare that they have no competing interests.
MAB major contributor to writing of manuscript. PDD
contributor to writing and editing manuscript. DL senior
author and manager of case and final editor.