‘No zone’ approach to the management of stable penetrating neck injuries: a systematic review

Abstract

Background Aim: to review outcomes of the ‘no zone’ approach to penetrating neck injuries (PNIs) with the advent of high‐fidelity computed tomography‐angiography (CT‐A) in order to determine the most appropriate management for stable PNIs. Design: Systematic review. Population: Retrospective and prospective cohort studies of patients who sustained penetrating neck trauma, as defined by an injury which penetrates the platysma, and whose initial management involved CT‐A evaluation. Methods An extensive literature search was performed in July 2019 using the following databases: Pubmed Central, EMBASE, Medline and Cochrane CENTRAL. Only studies published in English from the last 15 years were included. Results Nine cohort studies met inclusion criteria. There has been an increase in CT‐A focussed evaluation of PNIs in recent years. CT‐A is a highly sensitive and specific imaging choice and reduces negative neck exploration rates. A new management algorithm for stable patients involving initial radiological assessment using CT‐A, and subsequent selective surgical exploration, is safe and effective. Conclusion The results of this review provide level 2A evidence that the ‘no zone’ approach to PNIs, complemented by CT‐A and thorough clinical assessment, is a safe management strategy which reduces negative neck exploration rates.

Penetrating neck trauma: No zone, no problem?

“…In this issue of ANZ Journal of Surgery , Chandrananth et al present a review of observational data published between 2006 and 2019. The authors outline the role of CTA in the management of penetrating neck injuries extending beyond platysma 1 . Their results add to the current trend in the published literature supporting a no‐zone approach and advocating for selective interventions and less non‐therapeutic surgical explorations.…”

“…After decades of experience with zone‐based and gradually more selectively practiced surgical management of penetrating neck injuries, a rather radical change is evolving worldwide. Recent literature summarised by Chandrananth et al 1 is proposing to abandon the zone‐based selective management and to rely entirely on multidetector computed tomography (CT) angiography (CTA) in all haemodynamically normal patients with penetrating neck injuries as a guide for operative or non‐operative approach.…”

“…Results and discussion are focused on the chosen core concept of the CTA, the role of Zone 2 and the presence of hard signs. Zone 2 wounds have been an accepted indication for surgical exploration since inception of the zonal approach, regardless of symptoms 1 . This originated from the austere World War II combat environment where this approach was conceptualised 4 .…”

An Evaluation of Diagnostic Tests for Aerodigestive Injuries in Penetrating Neck Trauma

“…Penetrating neck trauma (PNT), defined as full thickness breech of the platysma muscle, account for about 5-10% of all trauma cases, with a mortality of up to 10%. 1 The risk of PNT comes from potential damage to vital vascular and aerodigestive structures. Historically, the risk for vascular and aerodigestive injuries in PNT was categorized based on the entry site of injury based on the 3 anatomical zones of the neck that was first described by Monson et al in 1969.…”

“…However, later studies demonstrated that the zone approach does not accurately predict injuries. 1 The current practice management guidelines for aerodigestive injuries in PNT from the Western Trauma Association, Eastern Association for the Surgery of Trauma, and World Society for Emergency Surgery vary and either call for multiple overlapping assessments or are dependent on physician discretion. [2][3][4] The tests for aerodigestive injuries include bronchoscopy, esophagoscopy (EGD), and esophagography.…”