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Paper text:
gunshot wounds to the upper cervical spine are rare in south korea due to gun control . due to the location and nature of these injuries , patients can present with concomitant airway damage , esophageal perforation , vascular injury , or spinal cord injury6 ) .
therefore , gunshot wounds to the upper cervical spine without neurological deficits are rarely observed . to our knowledge ,
there is no published report that describes surgical removal of a bullet from the anterior arch of the c1 vertebra in south korea . in this report , we describe our experience with the surgical removal of a bullet located in the c1 anterior arch using a transoral approach .
a 48-year - old man was admitted to the emergency room because of a self - inflicted single gunshot wound to the mouth . the patient was awake and alert without dyspnea or broken teeth .
a review of the patient 's past medical history showed that he suffered from depressive disorder for 6 years and had received treatment for this condition . during the physical examination ,
aerodigestive involvement was not detected , and no neurologic abnormalities were found in the cranial nerves or cerebellar system .
the bullet had passed along the right side of the mouth and exit wound was on the dorsal portion of the hard palate .
a single bullet lodged in the anterior arch of c1 was found on the simple lateral radiograph and computed tomographic ( ct ) scans ( fig .
1 ) . fortunately , the dural sac , trachea , esophagus , and vertebral artery were undamaged .
the patient was placed on the operating table with the head in extension while under general anesthesia and with orotracheal intubation .
a self - retaining oral retractor was placed over the teeth and expanded to keep the mouth open . to obtain an operational view ,
the soft palate was divided with an incision along the midline extending from the junction with the hard palate to the base of the uvula .
an incision was made in the posterior pharyngeal mucosa from the base of the clivus to the upper border of the third cervical vertebra .
pharyngeal mucosa , pharyngeal constrictor musculature , and longus colli and longus capitis musculature were sequentially incised .
a lead bullet about 1 cm in length was removed from the c1 anterior arch .
the patient had no neurologic sequelae and dynamic ( flexion and extension ) radiographs and ct scans did not reveal any instability .
various clinical findings can accompany gunshot penetration into the cervical spine . in our patient , he had been injured by gunshot from an air pistol that used low velocity bullets . in general , low velocity bullets cause relatively little soft tissue trauma due to their low residual kinetic energy after penetrating the skin . if a bullet strikes a bone , most of its energy may be spent in fracturing that bone6 ) .
the consequences of gunshot entry into the upper cervical spine are frequently devastating , including spinal cord injury , vertebral artery injury , and even death resulting from airway dysfunction4,5,7 ) . moreover ,
a projectile can cause tissue trauma without coming into direct contact with the tissue through the concussive effect of the bullet2 ) .
the clinical presentation of patients with major vascular injury , multiple penetrating wounds , or other life - threatening injuries typically obscures subtle signs of aerodigestive penetration1 ) .
patients with cervical spine gunshot injuries rarely sustain a fracture alone without neurologic deficits or retain vertebral missile fragments .
some authors have recommended a non - surgical approach for treating gunshot wounds in the cervical spine with the belief that further manipulation increases the chance of additional tissue trauma subsequent infection11 ) .
however , missiles retained in the anterior portion of c1-c2 vertebrae can cause both short - term and long - term complications even in stabilized patients who do not show signs of neurological deficits4 ) .
these complications include migration of the bullet fragments , central nervous system infections , osteomyelitis , or abscess formation .
migration anteriorly would lead to possible aspiration of the foreign body , and dorsal migration would lead to possible spinal cord compression or inflammation of the epidural space6 ) .
atlanto - occipital subluxation is another possible complication if an extensive inflammatory reactions result in ligamentous laxity12 ) .
romanick et al.10 ) reported frequent infection in civilians sustaining colonic injury resulting from low velocity , low thoracic , and lumbar spinal gunshot penetration .
they recommended early bullet removal and debridement of the spine and missile tract because it was felt that the bullets could become coated with bacteria and serve as a nidus of infection4,10 ) .
moreover , lead poisoning can result from a retained bullet or missile although this is relatively rare3,8,9 ) .
therefore , early surgical removal of the bullet and debridement was performed in our patient without incurring any neurological complications .
we report a rare case of gunshot injury to the c1 anterior arch . early removal of bullets could prevent early or late complications despite the intact neurological status of the patient .
penetrating injuries to the upper cervical spine resulting from gunshots are rare in south korea due to restrictions of gun use . 
 moreover , gunshot wounds to the upper cervical spine without neurological deficits occur infrequently because of the anatomic location and surrounding essential structures . 
 we present an uncommon case involving the surgical removal of a bullet located in the anterior arch of first cervical vertebra ( c1 ) via a transoral approach without neurological complications or subsequent mechanical instability .