with an incision along the midline extending from the junction with the hard palate to the base of the uvula. The uvula was tracted using a red rubber catheter. 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. There was no cerebrospinal fluid leakage and the C1 was not fragmented. Watertight closure of the posterior pharynx was performed in two layers. The soft palate is then carefully approx- imated in three layers (Fig. 2). At the 9-month follow-up, the pa- tient had no neurologic sequelae and dynamic (flexion and ex- tension) radiographs and CT scans did not reveal any instability. DISCUSSION 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 gen- eral, 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, includ- ing 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 clini- cal 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 tis- sue 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 compli- cations include migration of the bullet fragments, central ner- vous system infections, osteomyelitis, or abscess formation. Mi- gration 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 ex- tensive inflammatory reactions result in ligamentous laxity12). Romanick et al.10) reported frequent infection in civilians sus- taining 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 165 Gunshot Injury to the Anterior Arch of Atlas | JH Park, et al. Fig. 2. Postoperative axial computed tomographic scan demonstrates the complete removal of bullet. 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). These factors make the prompt surgical removal of bullets a reasonable treatment option. Therefore, ear- ly surgical removal of the bullet and debridement was per- formed in our patient without incurring any neurological com- plications. CONCLUSION 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. References 1. Bernards CM, Cullen BF, Powers KM : Effect of chronic cocaine expo- sure on the hemodynamic response to vasopressors in sheep. J Trauma 43 : 680-686, 1997 2. DeMuth WE Jr : Bullet velocity and design as determinants of wound- ing capability : an experimental study. J Trauma 6 : 222-232, 1966 3. DiMaio VJ, DiMaio SM, Garriott JC, Simpson P : A fatal case of lead poisoning due to a retained bullet. Am J Forensic Med Pathol 4 : 165- 169, 1983 4. Hopla DM, Mazur JM, Bass RM : Cervical vertebrae subluxation. La- ryngoscope 93 : 1155-1159, 1983 5. Kahraman S, Gonul E, Kayali H, Sirin S, Duz B, Beduk A, et al. : Retro- spective analysis of spinal missile injuries. Neurosurg Rev 27 : 42-45, 2004 6. Mangiardi JR, Alleva M, Dynia R, Zubowski R : Transoral removal of missile fragments from the C1-C2 area : report of four cases. Neurosur- gery 23 : 254-257, 1988 7. Medzon R, Rothenhaus T, Bono CM, Grindlinger G, Rathlev NK : Sta- bility of cervical spine fractures after gunshot wounds to the head and neck. Spine (Phila Pa 1976) 30 : 2274-2279, 2005 8. Nemzek WR, Hecht ST, Donald PJ, McFall RA, Poirier VC : Prediction of major vascular injury in patients with gunshot wounds to the neck. AJNR Am J Neuroradiol 17 : 161-167, 1996 9. Ozdemir N, Oguzoglu S : Spontaneous expulsion of a bullet, in the body of second cervical vertebrae, via the mouth. Eur J Emerg Med 14 : 165- 166, 2007 10. Romanick PC, Smith TK, Kopaniky DR, Oldfield D : Infection about