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Fig 1: Operative findings. The nuchal, interspinous, and flavum ligaments between the fourth and fifth cervical vertebrae were ruptured. Major cerebrospinal fluid leakage and vertebral artery injury were absent. The white arrow indicates the perforated flavum ligament.
Fig 2: Computed tomography scan showing air in the spinal canal. The black circle indicates air in the spinal canal, suggesting dura mater perforation.
Fig 3: Self-inflicted penetrating posterior cervical column injury by a sickle. The posterior vertebral column was grossly exposed, and the lacerated soft tissues bled actively. a Lateral view and b craniad view.

A 63-year-old Japanese man attempted to cut off his head with a rusty sickle immediately after drinking a copious amount of alcohol. On admission to our emergency department (ED), he was in the supine position and manually immobilized by several paramedics. A physical examination revealed gross exposure of his posterior vertebral column and active bleeding from lacerated tissues (Fig. 3a, b; image obtained in the operating room). Manual pressure hemostasis was provided but was unsuccessful, and our patient developed serious hypovolemic shock. His initial vital signs recorded in our ED were as follows: body temperature, 34.0 °C; heart rate, 140 beats/min; blood pressure, not measurable (the femoral artery was faintly palpable but the radial artery was not); and respiratory rate, 30 breaths/min. He was restless, and his conscious level was 9 on the Glasgow Coma Scale (E2V2M5). His extremities were cool and wet, but no trauma was evident. Our patient was in obvious distress, preventing us from performing a detailed neurological examination. His breath smelled of alcohol. He was lean and did not have a short neck or micrognathia; he showed no signs of restricted mouth opening. The remainder of the physical examination, including assessment of his thorax, abdomen, and pelvis, was normal. He had no history of medication or allergies.

The need for immediate definitive airway management and surgical hemostasis was apparent. While several people maintained manual in-line stabilization and pressure hemostasis of his head and neck, anesthesia was induced in our ED. Alternative ventilation and intubation equipment, including a supraglottic airway device, video laryngoscope, and surgical airway device, was set up, and we performed rapid-sequence intubation (RSI) with intravenously administered fentanyl (1 μg/kg), ketamine (1 mg/kg), and rocuronium (1 mg/kg) using a conventional laryngoscope. Direct laryngoscopy provided a Cormack–Lehane grade 1 view and revealed neither airway distortion nor edema. An endotracheal tube (inner diameter, 7.0 mm) passed his vocal cords easily. Computed tomography revealed air in his spinal canal, suggesting that the dura mater was perforated (Fig. 2).

Surgical exploration revealed laceration of the interspinous and flavum ligaments between his fourth and fifth cervical vertebrae, and the dura mater was exposed (Fig. 1). Fortunately, neither major cerebrospinal fluid leakage nor vertebral artery injury was present. Therefore, surgical repair of the dura mater and large vessels was not required. The major source of bleeding was oozing from lacerations of the trapezius and splenius muscles of his neck; bleeding from both sites was surgically controlled. The facet joints were also intact, which convinced us that cervical stability could be ensured if wound repair and external fixation were provided. After copious irrigation, fascia and soft tissue repair, and cervical collar installation, our patient was admitted to our intensive care unit where he was maintained on controlled ventilation. An examination using a flexible fiberscope the following day revealed neither airway distortion nor edema, allowing successful extubation. His vocal cord movement was also normal. A neurological examination revealed no deficits. He was treated with intravenously administered cefazolin for 3 days to prevent surgical site infection.

On day 5, he was transferred to our psychiatric department. The cervical collar was removed on day 14. After further psychiatric evaluation and treatment, he was discharged home and returned to normal activity. At his outpatient follow-up appointment 6 months later, he was neurologically intact and had no neck deformity, including kyphosis or torticollis.