Traumatic injury to the neck can be a devastating injury due to the high density of crucial anatomical structures within the neck¹.

The neck has traditionally been divided into 3 anatomic zones². They are as follows:

• Zone 1 - from the level of the clavicles and sternal notch to the cricoid cartilage
  • Important structures here include the aortic arch, proximal carotid arteries, vertebral arteries, subclavian vessels, innominate vessels, lung apices, esophagus, 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, the jugular veins, larynx, hypopharynx and proximal esophagus.
• 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

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

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 hemorrhage
• Expanding hematoma
• Shock
• Airway compromise
• Massive subcutaneous hematoma

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.

Case contributed by A/Prof Pramit Phal.