Penetrating Neck Trauma: a Review (original) (raw)

Penetrating Neck Trauma: a Review

Tanya Anand 1⋅{ }^{1} \cdot Andrew Tang 1⋅{ }^{1} \cdot Bellal Joseph 1{ }^{1}

© Springer Nature Switzerland AG 2019

Abstract

Purpose of Review This review focuses on the management of penetrating neck trauma and its evolution over the last several decades. Recent Findings Our increased experience with high-resolution computed tomography has changed the management of penetrating neck trauma from an anatomically zone-based approach to a “no zone” approach. Physical signs and symptoms of vascular, airway, and digestive track injuries still guide the basis of further radiographic and surgical workup. With the advancement and greater availability of multi-detector computed tomography (MDCT) technology, assessment of injuries has become easier and far more accurate. The hemodynamically stable patient may now be approached in a “no-zone” manner, and in certain cases managed safely with conservative measures. Summary Wartime experience and improved technology played major roles in the evolution of penetrating neck injury management. Aggressive surgical exploration had given way to selective management based on anatomical neck zones, to most currently a “no zone” approach.

Keywords Penetrating ⋅\cdot Neck ⋅\cdot Trauma ⋅\cdot Review ⋅\cdot No-zone ⋅\cdot Injury

Introduction

Trauma is the leading cause of death in the USA in those under the age of 46 years of age [1]. Specifically, penetrating trauma to the neck comprises 5−10%5-10 \% of all trauma cases [2•]. The neck contains a dense assortment of nerves, vascular, and aerodigestive structures several centimeters below the surface which are vulnerable to injury. Injuries in this anatomically complex region are challenging because they can present diagnostic dilemmas and can lead to devastating outcomes with delayed recognition [3]. Because of these challenges, the last hundred years witnessed a swinging pendulum from expectant management to early aggressive surgical exploration. Over the last two decades, the pendulum has now settled toward selective management based on judicious assessment of physical findings and the use of high-resolution CT.

This article is part of the Topical Collection on Trauma to the Neck

Tanya Anand
tanya.anand17@gmail.com

[1]

History

The mortality rate of patients sustaining penetrating neck trauma in military conflicts prior to World War II was cited to be between 11 and 18%18 \% [4]. Due to immaturity of the surgical specialty, expectant management was the mainstay of therapy. Delayed complications such as arteriovenous fistulas and pseudoaneurysms became recognized with devastating consequences [4,5][4,5].

The surgical expertise progressed intimately with war and the evolution of weaponry. By World War II, the external skin wound was no longer seen as an accurate indicator of underlying internal injury. As a result, liberal early aggressive exploration of neck wounds became the new norm in the theater of war [5]. In 1956, Fogelman, et al. proposed early aggressive surgical intervention, citing the “devious paths which penetrating missiles may take” and “the variability of hemorrhage” offering the surgeon a “false sense of security as to the true extent of damage in the neck” [4]. This view stayed with the surgical psyche for several decades.

As the practice of liberal surgical exploration of all penetrating neck wounds propagated, some surgeons began to detect a high rate of negative explorations, some as high as 53%53 \%. This was the basis for the development of an anatomically

1. 1 The University of Arizona, Division of Trauma, Critical Care, Burns and Emergency Surgery, 1501 N. Campbell Ave., Rm. 5411, Tucson, AZ 85724, USA ↩︎

zone-based management approach to penetrating neck traumas. In this algorithm, the neck is divided into three anatomical zones. Zone I extends from the sternal notch to the cricoid cartilage, zone II from the cricoid to the angle of the mandible, and zone III from the mandibular angle to the skull base. The location of the external neck wound had served as the basis of triage, consisting of mandatory exploration of zone II injuries and invasive investigations, such as angiography, bronchoscopy, and endoscopy for stable patients with injuries in zones I and III [6].

Unfortunately, this zone-based approach was associated with a near 50%50 \% rate of non-therapeutic neck exploration in zone II [7]. This recognition along with the vast improvement in the speed and resolution of computed tomography technology led to the continued evolution of penetrating neck trauma management. Surgeons now rely on a combination of high-resolution imaging and physical examination to selectively dictate surgical intervention [8-11].

Methods

We performed a comprehensive PubMed search utilizing the terms ‘Penetrating Neck Trauma’, ‘penetrating neck injury’, ‘guidelines’, ‘management’, ‘history’, ‘imaging’, ‘no zone’. Articles written in English, focusing upon the history of neck trauma management, current trends, and guidelines were utilized. The focus remained on the historical evolution of penetrating neck trauma surgical management, as well as the current trends.

Anatomy

The neck is divided into three zones (Fig. 1). These divisions have been used to guide surgical decision-making based on

Fig. 1 Zones of the neck
the location of the external skin wound [12]. Surgical approach, consideration of potentially injured structures, and comparison of outcomes between trauma centers have been guided by zone delineation. Zone I was arbitrarily designated between the sternal notch and the clavicles by Monson et al. in 1969 [13]. Roon and Christensen presented a modified classification of zonal delineation in 1979, with some ongoing debate between the two classifications [14]. Their depiction showed zone I to lie between the sternal notch and the cricoid cartilage. In this zone are the origins of carotid arteries, jugular-subclavian junctions, the left innominate vein, trachea, esophagus, spinal cord [15]. Zone 2 extends from the cricoid cartilage to the angle of the mandible. It contains the common carotid artery, its bifurcation, and the internal and external carotids. It also contains the internal jugular veins, vagus, spinal accessory, and hypoglossal nerves, as well as the cervical esophagus, trachea, and spinal cord. Finally, zone 3 of the neck starts at the angle of the mandible and continues cephalad to the skull base [16]. This zone contains the carotid and vertebral arteries, internal jugular veins, spinal cord, facial, glossopharyngeal, vagus, spinal accessory, and hypoglossal nerves [15].

Management

Initial Evaluation-ABCs

The evaluation of a patient with a penetrating neck wound begins with adhering to the principals of the primary and secondary surveys outlined in Advanced Trauma Life Support (ATLS) [17]. A talking patient indicates a patent airway. Though encouraging, this may be short lived secondary to worsening swelling from an expanding hematoma or a tenuous primary airway injury. Thus, one must be prepared for patient decompensation requiring a rapid sequence intubation, as well as the possibility of a difficult airway [17]. Because of the possibility of distorted airway anatomy, video laryngoscopy or fiberoptic intubation is recommended [2$\cdot$]. If a secure airway cannot be established with an endotracheal (ET) tube, then a surgical airway will be necessary.

Cricothyroidotomy and emergent tracheotomy are both surgical airway options, but a cricothyroidotomy is quicker and is the preferred method of immediate airway access [17, 18]. It consists of palpation of the cricoid cartilage and the cricothyroid membrane immediately cephalad. We advocate a vertical incision, taking care to stay midline in order to avoid injury to the anterior jugular veins. This avascular plan through the central raphe leads the surgeon directly to the cricothyroid membrane. A transverse incision is made along the cricothyroid membrane, followed by placement of a small caliber ET tube, such as a 5-O, into the airway. Correct placement is

indicated by misting of the ET tube and color change of an attached end-tidal CO 2 detector. If there is concern for laryngeal injury or if a cricothyroidotomy is contraindicated, then an emergent tracheotomy may be performed. A vertical incision low in the neck may be performed to avoid injury to the larynx. This incision may be extended caudad if further anatomic exposure is necessary [2$\cdot$, 18]. The tenuous airway established through a cricothyrotomy should be carefully secured with tape or sutures. It is also important to avoid the tendency to right main stem intubate by confirming bilateral breath sounds and obtaining a chest X-ray if the opportunity is available.

Breathing is assessed by observation of the patient’s chest rise and fall, examination for any penetrating injuries in the chest wall, as well as auscultation to ensure equal breath sounds. The unpredictable course of a high velocity missile may result in significant intrathoracic injury; thus, physical examination and a chest radiography are important diagnostic tools. If a hemothorax or pneumothorax is identified, then placement of a tube thoracostomy is warranted.

As a part of the circulatory assessment, adequate intravascular access for venous infusions and close arterial monitoring must be considered as the patient may be hemodynamically labile. Hemodynamic instability and/ or the presence of ‘hard signs’ upon clinical examination indicate injury to vital structures and dictates securing the airway followed by operative intervention [2$\cdot$, 3, 17]. Hard signs of neck injury are divided by between vascular and aerodigestive structures. Vascular hard signs include an expanding hematoma, pulsatile bleeding, and palpable thrill. While stridor, bubbling from the wound indicate an aerodigestive injury. Neurologic deficits suggest the possibility of a stroke from vascular occlusion or air embolus through the wound [2$\cdot$, 15]. The absence of these signs in a hemodynamically stable patient allows the opportunity for further imaging to define the injuries.

Spinal Immobilization

The question of whether spinal immobilization benefits patients with penetrating neck injuries has been asked for the last several years. In 2011, a review from the prehospital trauma life support committee showed no evidence that a cervical collar was beneficial [19]. Even with the placement of a cervical collar, “functional immobilization” is not achieved [20]. In addition, they indicated that it does not decrease mortality nor the occurrence of neurologic deficits [20]. A patient with a penetrating neck injury who presents without neurological deficits are unlikely to have sustained an unstable cervical spine injury where spinal immobilization would be helpful.

Surgical Management

Incisions

Proximal and distal control is the guiding principle of vascular injury in trauma [15, 21]. Keeping this in mind, the patient is prepped accordingly for possible extension of the initial incision onto the chest, and for graft harvest from the lower extremity. The surgical approaches for the neck zones are as follows [22]:

Zone I Injury A median sternotomy for proximal control of the common carotid artery will be required. For distal control, the median sternotomy incision can be continued with cephalad extension along the anterior border of the sternocleidomastoid (SCM) or superiorly along the clavicle to further expose the zone II structures.

Zone II Injury The initial incision is made along the anterior border of the SCM and can be extended cephalad or caudad to a median sternotomy depending upon the findings of the exploration. If bilateral zone II neck injury is suspected, then a collar incision will allow for adequate exposure of both sides with superior or inferior extension along the SCM as needed.

Zone III Injury The initial incision may be made along the anterior border of the SCM. If further cephalad exposure of vascular or aerodigestive structures is required, a mandibulotomy or mandibular subluxation and/or division of the posterior belly of the digastric muscle may be necessary [23].

Carotid Artery Injury

Exsanguination is responsible for up to 50%50 \% of mortality from penetrating neck injury [2$\cdot$]. As a result, temporizing this bleeding is important and can potentially allow for an emergent, but more coordinated approach to the operating room [2$\cdot$]. Direct pressure or Foley catheter placement in the wound tract are ways to tamponade the bleeding as the patient is being prepared for definitive management. To perform this maneuver, a Foley is placed through the wound, continued into the tract until resistance is met. The balloon is inflated with approximately 10−15ml10-15 \mathrm{ml} of water, again until resistance is reached. The foley is then clamped. If this gives a measure of tamponade, the skin is then sutured closed around the foley and the patient is taken to the operating room [2$\cdot$].

Management considerations for carotid artery injuries include open versus endovascular approaches. Zone of injury, hemodynamic stability, and prompt availability of endovascular techniques are important when choosing the best approach [21]. In zone III injuries, open surgical repair is possible, but a challenge due to the relative inaccessibility of

vasculature near the skull base. In this region, management is primarily focused on temporizing the injury to allow for endovascular control [2$\cdot$, 3, 17, 21].

Proximal and distal control of zone II injuries are commonly obtained from an open approach as described earlier. The incision begins near the sternal notch and extends superiorly along the anterior SCM border to the mastoid process. After incising through the skin and platysma, the SCM becomes visible and is retracted laterally [17]. The carotid pulsation guides the surgeon as the incision is extended deeper [17]. The facial vein runs across the carotid bifurcation and will need to be ligated to expose the underlying carotid artery. If the common or internal carotid artery is injured, the general consensus is to repair these injuries irrespective of preoperative neurologic findings [3, 21]. An intraluminal shunt, to continue perfusion to the brain, may be required if back bleeding is poor [15]. Repair methods are many and include primary repair, interposition grafting, and patch angioplasty. A total of 6-0 polypropylene sutures are typically used for this repair [15]. Materials commonly used for patching the arterial defect or inserting an interposition graft are autologous veins, bovine pericardium, and polytetraflouroethylene (PTFE) [15]. If the external carotid artery is injured, it may be ligated with little consequence due to the extensive collateral blood supply from the contralateral side.

Injury in zone I of the neck is essentially an injury to the thoracic inlet [17]. In addition to carotid artery injury, other vasculature that may be injured in this region are the subclavian vessels, innominate artery, and aorta. A median sternotomy is the single best incision to obtain access and is extended superiorly as needed for distal vascular control [15].

Vertebral Artery Injury

Vertebral artery injury has a comparatively low mortality rate of approximately 7%7 \% [17]. The type of disruption can manifest as an intimal tear, pseudoaneurysm, an arteriovenous fistula, or a transection [15, 24]. Despite being created to stratify management of blunt neck injury, the Denver criteria can be used to aid in management of penetrating injury to the vertebral artery [24]. The vertebral artery is anatomically divided into four segments [24]. The most accessible portion of the vertebral artery is V1 and the longest portion is V2.

• V1 (ostial), subclavian origin to C6 transverse foramen
• V2 (foraminal segment), from C6 to C2 transverse foramen
• V3 (suboccipital segment), from C2 transverse foramen to dural entry
• V4 (intradural segment), from dural entry to vertebrobasilar junction

Most injuries to this artery can be managed with angiographic embolization or stent placement [17]. However, stent placement requires anti-platelet therapy and must be weighed against the risks of further bleeding and concomitant injuries [17]. An actively bleeding vertebral artery requiring urgent intervention can be exposed through the standard incision along the anterior border of the SCM. The carotid sheath and its contents are retracted medially, and the scalene fat pad retracted laterally to expose the contents posterior to the carotid triangle. The inferior thyroid artery is divided and the scalene muscle further retracted laterally to allow exposure of the V1 segment of the vertebral artery. A lacerated bleeding vertebral artery at this level can be managed by ligation, or repair. An attempt to safely preserve the vertebral artery should be made, but given its small caliber, limited access, and the risk of cervical root damage, ligation is usually safer [17, 24]. Injuries to V2-V4 are surgically accessible, but time consuming and requires unroofing of the bony canal. Such exposure is best left for the spine subspecialty colleague. For the exsanguinating patient where immediate actions need to be taken, packing the wound channel with bone wax may be used to occlude the transverse foramen [17].

Laryngotracheal Injury

Laryngotracheal injury is uncommon and accounts for 1 in every 30,000 emergency room visits [25$\cdot$]. Those who present with such injuries usually require operative management [26]. Clinical signs of injury include subcutaneous emphysema, air bubbling through an open wound, inability to phonate, and persistent air leak after chest tube is placed [25$\cdot$, 26]. If the patient is hemodynamically stable, pre-operative investigations with anteroposterior (AP) chest and lateral neck films and a computed tomographic angiography (CTA) of the neck may be performed [26]. In the operating room, a panendoscopy should also occur prior to surgical exploration [2$\cdot$]. These studies will ultimately determine the need for exploration and guide placement of the surgical incision [2$\cdot$, 25⋅]25 \cdot].

When describing laryngotracheal injuries, the site, tissue type, and severity have been used to describe such injuries. Non-displaced fractures to the hyoid bone, thyroid, and cricoid cartilages are typically managed non-operatively once endoscopy confirms no internal damage [25$\cdot$]. Management further includes head of bed elevation, voice rest, cool humidified air to facilitate ciliary function, and anti-reflux medications [2⋅,25⋅][2 \cdot, 25 \cdot].

Thyroid cartilage fractures tend to be located over the anterior prominence and typically require an open reduction via a collar incision. Approximation is via a plate, wire, or suture [25$\cdot$]. If internal injury is noted, the outer structure must be repaired first to allow for a stable scaffold on which to repair the internal structures [25$\cdot$]. Unstable cricoid cartilage

fractures tend to be associated with thyroid cartilage injuries and require wiring and placement of a stent for about 6 weeks [25$\cdot$, 26]. Grafting or rotational flaps may be necessary [26].

Stents are usually placed when massive disruption to the laryngeal complex has occurred or when the anterior commissure is disrupted [25$\cdot$]. This is to prevent mucosal disruption or the development of anterior glottic webs [25$\cdot$]. However, stent placement is still somewhat controversial and surgeon dependent given the complications of pressure necrosis, scarring, infection, and granulation tissue formation [25$\cdot$].

Tracheal injuries range from small wounds, where edges are well apposed, to complete transections. When operating, the surgeon should be careful at the 3 and 9 o’clock positions as to preserve the tracheal blood supply and minimize tracheal devascularization during dissection [15, 25$\cdot$]. Well approximated, small lacerations to the trachea can heal without surgical management by temporary tracheal intubation [25$\cdot$]. Larger perforations to the anterior or lateral wall and tracheal transection injuries may be closed with 3-0 interrupted absorbable sutures several millimeters apart [2, 15]. Injury to the membranous portion of the trachea may involve placement of a muscular pedicle flap to close the defect, and also avoid the development of trachea-esophageal fistulas [15, 25$\cdot$]. If the tracheal injury extends into the thoracic cavity, a median sternotomy approach is recommended. Alternative exposure, albeit more awkward, can be gained through a high right posterolateral thoracotomy through the fourth or fifth intercostal space [15,25∙][15,25 \bullet].

Pharyngo-esophageal Injury

Injuries to the cervical esophagus are uncommon, but if recognition is delayed, the complications can range from local abscess, pharyngo-esophageal cutaneous fistula, to devastating mediastinitis [2$\cdot$, 15, 27$\cdot$]. Clinical examination is important but it tends to be unreliable as it identifies only 80%80 \% of injuries in the cervical esophagus [2$\cdot$, 27$\cdot$]. Thus, in a hemodynamically stable patient soft signs of esophageal injury, our initial evaluation must rely on clinical suspicion and imaging, such as CT scan of the neck and chest. If injury is suspected based on CT findings of extraluminal air, hematoma, or proximity to the wound trajectory, then further evaluation is warranted with water soluble contrast esophagogram and endoscopy [27・].

The surgical approach to the cervical esophagus occurs along the medial border of the left SCM. Intraoperative endoscopy is helpful in locating a small, difficult to find defect, and to check the strength of the repair [27$\cdot$]. Methylene blue may also allow for identification of multiple perforations [27$\cdot$]. Endoscopic insufflation can also be used with the neck wound submerged under saline to assist in identification of the point of extravasation.

Prior to repair, the wound edges must be debrided to healthy tissue to allow for a viable primary repair. Delayed presentation after proximal esophageal perforation does not necessarily imply an inability to approximate tissue. Primary repair can still be attempted as long as tension free repair can be achieved with healthy tissue, preferably with muscle flap buttress. Single or double layered closure is recommended, buttressed by vascularized tissue, such as a strap muscle or the SCM [15, 27$\cdot$]. A drain also may be left in place. During this time, a feeding tube should be placed as it will facilitate enteral nutrition until the patient is able to tolerate oral feeding.

Post-operatively, the patient should be nil per os (NPO) with close hemodynamic monitoring. Fevers, increased drain output, and signs of sepsis are risks with esophageal injuries. Intravenous fluids, antibiotics, and tube feeds should be started. An esophagram with gastrograffin followed by barium is performed approximately 1 week after the index operation to assess for leak [27$\cdot$]. Once the contrast study shows no leak, the patient may be slowly advanced to a liquid diet [21].

Destructive wounds to the cervical esophagus may require complete mobilization of the cervical esophagus and a side esophagostomy. Care must be applied to ensure that the recurrent laryngeal nerves are not injured in the process [27$\cdot$]. With resolving edema and inflammation, the esophagus may then be closed transversely in a delayed fashion [27$\cdot$].

Management of the Hemodynamically Stable Patient Without Hard Signs

Trends

A purely zone-based management algorithm led to a significant rate of negative neck explorations, as well as increased resource utilization and accompanying risks with secondary diagnostic procedures [6]. The major question was how to improve the triaging process of the stable patient with soft or minimal signs of injury. This process has recently become more efficient with improvements in multidetector computed tomography (MDCT) technology [28]. Diagnostic imaging has undergone considerable advancement over the last several decades [28]. The speed, resolution, and wide availability of computed tomographic angiography (CTA) has improved our

Table 1 Soft signs of neck injury

Table 2 Hard signs of neck injury
Pulsatile bleeding or expanding hematoma
Audible bruit or palpable thrill
Wound bubbling
Stridor
Neurologic deficitis
ability to reliably evaluate soft tissue and vascular injuries [6, 28]. Several studies have assessed MCTA as a reliable standalone screening modality in the initial evaluation of hemodynamically stable patients with penetrating neck injuries, with a sensitivity and specificity greater than 90%90 \% in detecting all vascular and aerodigestive injuries. CTA is an effective triaging method that has allowed the transition of management from a zone-based approach, in which a patient with a zone II injury immediately underwent operative exploration, to a “nozone” method [6, 29]. Hemodynamically stable patients with soft signs or minimal clinical signs of injury (Table 1), regardless of anatomical zone of injury, are now triaged with a CTA to further define the trajectory, injuries, and guide subsequent care. [6]. The patients are then allocated to either observation, directed investigation of aerodigestive structures, or an operation. zone delineation does not play a role in the initial triage of the stable patient with minimal signs of injury.

Conclusion

Accurately triaging a patient with penetrating neck injury and ensuring the safest treatment pathway has been the primary challenge for the last 100 years. Combat and civilian experience with penetrating neck trauma, as well as the technological advancement and widespread availability of MDCT has redefined the algorithm to one where “hard signs” (Table 2) still mandate immediate operative intervention, but patients with “soft signs” of injury can be initially evaluated by imaging to guide further therapy, regardless of anatomical zone of injury.

Compliance with Ethics Guidelines

Conflict of Interest The authors declare no conflicts of interest relevant to this manuscript.

Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

Papers of particular interest, published recently, have been highlighted as:

• Of importance
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