Penetrating Neck Injuries

Penetrating Neck Injuries


• Case 1– 19 year old male in Casuarina– stabbed back of neck with steak knife (8cm)– Zone II injury– haemodynamically stable




• Case 2– 27 year old male– stabbed in anterior triangle– Zone I injury– required resuscitation at scene– fixed dilated pupils on presentation



• Epidemiology– stab wounds or low velocity missiles– young, otherwise healthy and intoxicated– carotid artery involved in 6%– account for 22% of all cervical vascular trauma


• Classification– Anterior/Posterior neck triangles– Zones

• I = Between clavicle and cricoid

• II = cricoid and angle of mandible

• III = angle of mandible to BOS


• Zone II most common (47%)

• Zone I (18%) and Zone III (19%)

• multiple zones (16%)


• Injuries– arterial– venous– neurological– oesophagus– airways


• Findings: airways– airways obstruction– haemoptysis– air bubbling through wound– subcutaneous emphysema– hoarseness– painful swallowing– haematemesis


• Findings: vascular– haemodynamic instability– haematoma– reduced pulses (CA, STA, RA)– bruit/thrill


• Findings: neurological– GCS– focal UMN signs– cranial nerves (VII, IX, X, XI, XII)– cervical spinal cord– Horner’s syndrome– Brachial plexus


• Management– ABCD– surgical exploration for ‘hard’ signs of vascular

injury (shock, active beeding, enlarging haematoma, bruit/thrill)

– stable patients with Zone I and III injuries: angiography with selective intervention


• Zone II Controversies– Mandatory versus Selective exploration – Accuracy of physical examination– investigation


• Mandatory exploration– Apffelstaedt et al. World J Surg 1994

• 393 consecutive patients over 20 months

• 30% of (+) neck explorations had absent clinical signs

• low morbidity/mortality in negative explorations

• investigations have false (-) and false (+) rates


• Selective exploration– Demetriades et al. World J Surg 1997

• 223 patients over 20 months, 176 had angiography

• 34(19%) had positive angiography, 8% required treatment

• 34 patients with soft signs, 8 had (+) angiogram but only 1 required treatment

• mandatory exploration leads to high rate (30-89%) of unnecessary operations


• Physical Examination– Sekharan et al, J Vasc Surg 2000

• 145 zone II injuries, retrospective chart review

• 31 had hard signs, 90% (+) exploration

• 23 had angiogram due to proximity to major structures or involving more than 1 zone.

• 91patients were observed without imaging or surgery with no evidence of subsequent vascular injury up to 2 weeks.


• Physical Examination– accuracy of 99% in diagnosing significant

vascular injuries with a false negative rate comparable to angiography.

– However most studies are prolonged retrospective studies with no uniform protocol

– May miss occult lesions such as smooth narrowings, intimal irregularities and small psedoaneurysms and AV fistulas


• Duplex Ultrasound– Demetriades et al. 99 patients had duplex

• 11 lesions correctly identified (6 VA, 4 CA, 1 SCA)

• 1 missed lesion (CCA/VA small intimal tears)

• sensitivity 91%, specificity 100%, PPV 100% and NPV 99%.


• CT– Mazolewski et al. J Trauma 2001

• 14 stable patients Level 2

• sensitivity 100%, specificity 91%, PPV 75% and NPV 100%


• vertebral artery injury– clinical presentation and outcome related to

associated injuries.– 72% have no evidence of arterial trauma– low incidence of brain stem ischaemia with

unilateral VA ligation


• oesophageal injury– very low prevalence– Demetriades et al

• only symptomatic or obtunded patients should undergo investigations


• venous injury– ligation for major cervicomediastinal venous

trauma is generally well tolerated

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Penetrating Neck Injuries