Nail gun penetrating cervical spine injury at C4–5 with spinal canal violation, neurological deficit, and esophageal perforation treated by anterior cervical surgery: illustrative case

BACKGROUND: Penetrating cervical spine injuries caused by nail guns are rare. Associated esophageal injury and dural violation increase the risk of neurological and infectious complications. OBSERVATIONS: A 40-year-old man presented approximately 4 hours after a nail gun injury to the anterior neck. Imaging showed that the nail traversed the C4-5 disc space, entered the vertebral body, and violated the spinal canal. He had right-sided weakness with motor strength graded as 4/5. Anterior cervical exploration was performed approximately 14 hours after presentation. Intraoperatively, a traumatic dural defect with CSF leakage and a 0.5-cm esophageal perforation were identified. The dural defect was covered with gelatin sponge and fibrin glue, and the esophageal perforation was repaired primarily. At 1 year, his motor strength was grade 5/5 in all extremities. Follow-up MRI showed a small C4 intramedullary T2-hyperintense focus consistent with myelomalacia, without clinical or imaging evidence of delayed infection. LESSONS: CT-based trajectory assessment is critical in anterior cervical nail gun injury. Controlled anterior exploration can allow safe foreign body removal, dural defect management, esophageal repair, and surveillance for delayed infectious complications. https://thejns.org/doi/10.3171/CASE26301.