Penetrating traumatic neck injury

Penetrating traumatic neck injury can be a potentially devastating injury due to the high density of crucial anatomical structures within the neck. 

Epidemiology

Young males are highly represented in patients with a traumatic neck injury. In one study, 11:1 ratio of males to females were identified in patients with penetrating neck injury ³.

Pathology

Classification

The neck has traditionally been divided into three anatomic zones when describing penetrating neck trauma, which guides clinical management ²:

• zone 1: from the level of the clavicles and sternal notch to the cricoid cartilage

  • important structures include the aortic arch, proximal common carotid arteries, vertebral arteries, subclavian vessels, innominate vessels, lung apices, oesophagus, trachea, brachial plexus and thoracic duct

• zone 2: from the cricoid cartilage to the angle of the mandible

  • important structures include the common, internal and external carotid arteries, internal and external jugular veins, larynx, hypopharynx and proximal oesophagus

• zone 3: from the angle of the mandible to base of skull

  • important structures include the internal carotid artery, vertebral artery, external carotid artery, jugular veins, prevertebral venous plexus and facial nerve trunk

Injuries mostly (~80%) occur in zone 2. ~10% of injuries involve two zones ⁵. 

Radiographic features

Assessment of neck injuries has been aided by the use of CT angiography. Types of injury include vascular injury, oesophageal perforation, laryngeal trauma and neurological injury.

Treatment and prognosis

Treatment of neck injury depends on the severity of injury and the zones of the neck which are involved. Previously, zone 2 injuries penetrating the platysma were thought to require immediate surgical exploration. One current study suggests that thorough clinical examination can prevent unnecessary surgical exploration of zone 2 neck injuries. Clinical criteria which would indicate surgical intervention/exploration include:

• exsanguinating haemorrhage

• expanding haematoma

• shock

• airway compromise

• massive subcutaneous haematoma

Zone 1 and 3 injuries are evaluated more selectively, particularly due to the difficulty in their surgical accessibility ⁴.

While endovascular techniques have seen increasing use in other traumatic vascular injuries, open surgical repair is considered the gold standard for most vascular neck trauma. One study suggests that patients with stable, intimal, high zone 3 carotid injuries and vertebral artery injuries can be repaired endovascularly. Otherwise, surgical exploration is the intervention of choice.

See also

• blunt traumatic neck injury

• penetrating trauma