www.jkns.or.kr http://dx.doi.org/10.3340/jkns.2012.51.3.164 J Korean Neurosurg Soc 51 : 164-166, 2012 Print ISSN 2005-3711 On-line ISSN 1598-7876 Copyright © 2012 The Korean Neurosurgical Society Case Report Gunshot Injury to the Anterior Arch of Atlas Jun Hee Park, M.D., Ph.D.,1 Hyeung Sun Kim, M.D., Ph.D.,2 Seok Won Kim, M.D., Ph.D.,3 Nam Yong Do, M.D.1 Departments of Otolaryngology Head and Neck Surgery,1 Neurosurgery,3 College of Medicine, Chosun University, Gwangju, Korea Department of Neurosurgery,2 Hurisarang Spine Hospital, Daejeon, Korea 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. Key Words : Gunshot injury · Atlas. INTRODUCTION 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). These conditions may present impending threats to the patient’s survival. Therefore, gunshot wounds to the upper cervical spine without neurological deficits are rarely observed. To our knowl- edge, there is no published report that describes surgical removal of a bullet from the anterior arch of the C1 vertebra in South Ko- rea. In this report, we describe our experience with the surgical removal of a bullet located in the C1 anterior arch using a tran- soral approach. CASE REPORT A 48-year-old man was admitted to the emergency room be- cause of a self-inflicted single gunshot wound to the mouth. The patient was awake and alert without dyspnea or broken teeth. There was no evidence of neurological deficits or major vessel injury. 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 ex- amination, the patient was alert and fully oriented. Aerodiges- tive involvement was not detected, and no neurologic abnor- malities 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 second entry wound was on the oropharynx at the C1 level. A single bullet lodged in the anterior arch of C1 was found on the sim- ple lateral radiograph and computed tomographic (CT) scans (Fig. 1). Fortunately, the dural sac, trachea, esophagus, and ver- tebral artery were undamaged. Emergent surgery using a transoral approach was performed to remove the bullet. The patient was placed on the operating ta- ble 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 Fig. 1. Preoperative simple lateral radiograph and axial computed tomo- graphic scan reveal a single lodged bullet in the anterior arch of C1. • Received : August 3, 2011 • Revised : September 20, 2011 • Accepted : March 12, 2012 • Address for reprints : Seok Won Kim, M.D., Ph.D. • Department of Neurosurgery, School of Medicine, Chosun University, 365 Pilmundae-ro, Dong-gu, Gwangju 501-717, Korea • Tel : +82-62-220-3120, Fax : +82-62-227-4575, E-mail : chosunns@hanmail.net • This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 164