Metal arrows are medieval weapons typically used for hunting and war. Currently, with the increase in gun and fire weapons, crossbows and metal arrows are mainly used in recreational hunting and sports [1], [2]. The incidence of metal arrow wounds has declined considerably since the sixteen centuries [3]. They are classified as low-velocity weapons, but can inflict serious damage to soft tissue and flat bones at fatal distance [4], [5]. Metals arrows differ according to the arrowhead type, ranging from pointed to sharp, barbed, and serrated [2], [4], [6]. Barbed and serrated metal arrows are most commonly found in African countries [2], [7]. In the literature, we found only cases of intracranial and cervical spine barbed arrow injuries in Nigerian series [7], [8], [9], [10]. The extraction of this type of arrow is challenging because of the possibility of extensive damage to surrounding structures.

To our knowledge, there is no guideline for Head and Spine penetrating metal arrow injury and extraction in the literature; most authors have referred to the common trauma injury principle [11], [12], [13], [14].

An increasing number of studies on metal arrow penetrating injuries in the literature have led to the emergence of some principles of best practice, including CT and angiography examination before extraction, to evaluate the structure and potential vessel involvement, and to avoid any attempt of blind extraction [4], [5], [6], [7], [15], [16], [17]. However, these studies failed to suggest guidelines for surgical extraction based on the arrowhead type and the anatomically impacted area. Some African studies on barbed arrowhead injuries have suggested dissection until the metal arrowhead, clipped the fangs, and then gently withdrawn [1], [6]; however, those authors applied this approach only in cases of penetrating neck injury. Therefore, we hypothesized that the extraction approach should be tailored according to location and arrowhead type.

In this study, we aimed to share our experiences with the surgical extraction of intracranial and spinal barbed arrowheads leading to penetrating injuries and to propose some directive guidelines for such lesions.