Unusual Foreign Bodies of Surgical Discovery on a Traumatic Spine

Introduction: Para-spinal non-metallic foreign bodies (fabrics or plastics) are rare and poorly documented. They are often unknown and discovered at the stage of infectious complications and present big therapeutic challenges. We report a rare case of three para-spinal foreign bodies (fabric, plastic and postoperative gauze) discovered during surgery of a traumatic thoracic spine. Case report: A 32-year-old man admitted for a polytrauma (collision motor-cycle-cart). The admission examination noted closed trauma of the thoracic spine, an ASIA score of A, dyspnea, a penetrating wound of the left side of the chest. The CT scan showed a compressive left pleural effusion, multiple ribs fractures, pulmonary contusion, unstable fracture of fifth and sixth thoracic vertebrae associated with posterior epidural hematoma responsible for me-dullar compression. There was a rounded, para-spinal image, dotted with small areas of low density, air bubbles. We lifted the vital


Introduction
Para or intra-spinal metallic foreign bodies are often encountered mainly in ballistic traumas. Para-spinal foreign bodies, however, are rare and poorly documented in published journals [1] [2]. The rare cases described were observed after abdominal or thoracic surgery [2] [3] [4]. They are often unknown and discovered at the stage of infectious complications. They present big therapeutic challenges especially in the late forms. This observation illustrates a rare case of two post-traumatic para-spinal foreign bodies (fabric, plastic) and a postoperative foreign body (gauze or textiloma) discovered during surgery of a traumatic thoracic spine.

Case Report
A 32-year-old man, admitted at the third hour for a polytrauma after a road traffic accident. It is a Motorcyclist, which collided with an animal-drawn cart. A metal arm of the cart pierced through the left side of his chest during the accidental collision.
The admission examination noted a penetrating chest wound with dyspnea, a closed trauma of the thoracic spine with spinal cord injury syndrome. ASIA score was A with flaccid paraplegia and anesthesia going up to T10. The gibbosity of the thoracic spine was observed at the level of the fifth and sixth thoracic vertebrae.
The CT scan revealed multiple fractures of ribs associated with compressive left pleural effusion and pulmonary contusion, and an unstable fracture of the fifth (T5) and sixth (T6) thoracic vertebrae ( Figure 1) associated with posterior epidural hematoma responsible for bone marrow compression. There was a rounded isodense para-spinal image dotted with small areas of low density, air bubbles, without contrast enhancement.
We lifted the vital emergency by draining the left pleural effusion, debridement of the penetrating chest wound, and administering Broad-spectrum antibiotic therapy (Ceftriaxone and Metronidazole).  Given the infectious context, no implant had been put in place. We had opted for a thoraco-lumbar rigid orthosis to stabilize the spine. A chest tube has been put in place. Broad-spectrum antibiotic therapy was continued and later on adapted to the antibiogram result. Enterobacter spp. was isolated and susceptible to imipenem. The immediate post operative follow-ups were simple. The patient was then referred to thoracic surgery. The resolution of the pain was observed ten days after the removal of the foreign bodies. The neurological state remained stationary (ASIA A).

Discussion
The incidence of foreign bodies ranges from 1/1000 to 1/10,000, of which 80% are textiloma [1] [4] [5]. Foreign bodies were frequently connected to abdominal World Journal of Neuroscience In reaction to fibrous aseptic tissue, the formation of a fibrous capsule would lead to granuloma [1] [5] [7]. In this case, the patient may remain asymptomatic for days to years [4] [8]. Sometimes the foreign body can be accidentally discovered during a routine radiological examination [9]. The circumstances of discovery are often the appearance of a persistent infectious syndrome [10] preceded by persistent pain [1] [7]. This persistent characteristic pain described in the literature [3] [11] seemed more related to spinal trauma in our case. No clinical or biological infection syndrome was observed. This can be observed in some cases [12]. The absence of fever could be related to antibiotic therapy in-  [12]. It can be raised strongly on the periphery in injected T1-weighted [12].  [12]. Early surgery is recommended in the management of spinal cord injury. The rarity of implants in our practice justifies a long delay before surgery.

Conclusion
Traumatic or postoperative foreign bodies are much more common than they are reported. Imaging sometimes makes it possible to suspect the non-metallic foreign body. The diagnosis of these non-metallic foreign bodies is almost always an intraoperative surprise. These foreign bodies are sources of infection making their management difficult. Their best treatment is preventive. Careful exploration of penetrating wounds, labeling and counting of gauze used intraoperatively, and careful inspection of the surgical field before closure are still important basic rules in surgery. Complications caused by foreign bodies are source of mortality and serious medico-legal implications.

Informed Consent
Written Informed consent has been obtained from the patient for publication of this manuscript and all accompanying images.

Conflicts of Interest
The authors have no conflicts of interest to declare.