Penetrating Neck Trauma: A Review of Management Strategies and Discussion of the ‘No Zone’ Approach

Abstract

The evaluation and management of hemodynamically stable patients with penetrating neck injury has evolved considerably over the previous four decades. Algorithms developed in the 1970s focused on anatomic neck “zones” to distinguish triage pathways resulting from the operative constraints associated with very high or very low penetrations. During that era, mandatory endoscopy and angiography for Zone I and III penetrations, or mandatory neck exploration for Zone II injuries, became popularized, the so-called “selective approach.” Currently, modern sensitive imaging technology, including computed tomographic angiography (CTA), is widely available. Imaging triage can now accomplish what operative or selective evaluation could not: a safe and noninvasive evaluation of critical neck structures to identify or exclude injury based on trajectory, the key to penetrating injury management. In this review, we discuss the use of CTA in modern screening algorithms introducing a “No Zone” paradigm: an evidence-based method eliminating “neck zone” differentiation during triage and management. We conclude that a comprehensive physical examination, combined with CTA, is adequate for triage to effectively identify or exclude vascular and aerodigestive injury after penetrating neck trauma. Zone-based algorithms lead to an increased reliance on invasive diagnostic modalities (endoscopy and angiography) with their associated risks and to a higher incidence of nontherapeutic neck exploration. Therefore, surgeons evaluating hemodynamically stable patients with penetrating neck injuries should consider departing from antiquated, invasive algorithms in favor of evidence-based screening strategies that use physical examination and CTA.

Penetrating neck trauma and the need for surgical exploration: six-year experience within a regional trauma centre

“…Burgess' guidelines echo the 'no zone' approach advocated by Shiroff et al in 2013, in which neck zone differentiation is eliminated from management. 22 With the increasing accuracy of computed tomography (CT) angiography to diagnose injury to vital structures, along with careful clinical assessment, safely triaging patients for intervention or observation is becoming remarkably precise. This essentially eliminates the need to classify the injury into zones in order to riskstratify patients and divert them along a pathway of unnecessary investigations and operations.…”

ACR Appropriateness Criteria ® Penetrating Neck Injury

“…Rating Comments RRL CTA neck with IV contrast 9 This procedure is the imaging study of choice. See references [2,5,6,8,[11][12][13][14][15][16][17].…”

“…B Arteriography neck 5 This procedure is usually used as a follow up test/treatment to a CTA or MRA. See references [2,6,11,20,21].…”

How Do I Manage Penetrating Neck Trauma?

“…CTA has replaced angiography as the initial study of choice in the vascular evaluation of neck injuries (16). Comprehensive physical examination with CTA is adequate for identifying and excluding vascular and aerodigestive injuries after PNTs (17). As the accuracy of CTA in the diagnosis of critical structural damage increases, the choice of the clinical decision, especially the decision of the surgical exploration is getting easier (7).…”

“…As the accuracy of CTA in the diagnosis of critical structural damage increases, the choice of the clinical decision, especially the decision of the surgical exploration is getting easier (7). At a trauma center with experienced staff, the frequency of negative exploration for PNTs can be minimized by the selective neck exploration (16,17).…”