• Patients that sustained penetrating neck trauma

• 12/2008-03/2011

• prospectively analyzed

• Location of the external wound(s) documented

• Internal injuries were then correlated with the external wounds

• An internal injury was defined as “unexpected” if it was located outside the borders of the neck zone corresponding to the external wound.

• Soft signs included venous oozing, nonexpanding hematomas, minor hemoptysis, dysphonia, and subcutaneous emphysema.

• Hard signs included active hemorrhage, pulsatile hematoma, bruit or thrill, shock unresponsive to fluid resuscitation, massive hemoptysis or hematemesis, and bubbling at the injury.

Background

The Utility of the Anatomic Neck “Zones” of the Neck in the Assessment of Penetrating Neck Injury

Garren Low, MS1, Kenji Inaba, MD2, Konstantinos Chouliaras, MD2, Bernardino Branco, MD2, Lydia Lam, MD2, Elizabeth Benjamin, MD2, Jay Menaker, MD2, Demetrios Demetriades, MD, PhD2

1Keck School of Medicine of USC, 2LAC+USC Medical Center, Division of Trauma Surgery and Surgical Critical Care, Los Angeles, CA, USA

Objective

Results

References

Traditionally, the anatomic zones of the neck have guided the diagnosis and treatment of penetrating neck trauma. Unfortunately, this resulted in a high rate of negative exploration.

The objective of this project is to characterize the association between external wounds and the corresponding internal injuries after penetrating neck trauma in order to identify the clinical utility of the anatomic zones of the neck.

Inaba K, Branco BC, Menaker J, et al. Evaluation of multidetector computed tomography for penetrating neck injury: a prospective multicenter study. J Trauma Acute Care Surg. 2012 Mar;72(3):576-83.

Inaba K, Munera F, McKenney M, et al. Prospective evaluation of screening multislice helical computed tomographic angiography in the initial evaluation of penetrating neck injuries. J Trauma. 2006;61:144–149.

Demetriades D, Theodorou D, Cornwell E, et al. Evaluation of penetrating injuries of the neck: prospective study of 223 patients. World J Surg 1997; 21:41.

Demetriades D, Salim A, Brown C, et al. The neck with complex anatomic features and dense concentration of numerous vital structures. Curr Probl Surg. 2007 Jan;44(1):6-10.

Materials and Methods

• The traditional approach to penetrating neck trauma utilizes the zones of the neck as the primary basis for management.

• Zone II injuries are explored

• Zone I and III injuries investigated by a combination of catheter-based angiography, bronchoscopy, esophagoscopy, and contrast swallow evaluation.

• Surgical accessibility of the underlying structures and the presumption that the external & internal wounds correlates.

• 27% patients with a documented internal injury were found to have an injury in an unexpected location. This brings into question the entire foundation of the traditional zone approach.

• Although this is the first study that evaluates the relationship between the external wound location and the internal injuries, collecting a sufficient number of patients remains difficult. Due to the complexity of neck anatomy, a greater sample size would be needed to provide more power.

• This would also show a larger spread of unexpected injuries.

In the 32 patients with hard signs, 27 (84%) had an internal injury. The mechanism of injury (MOI) was gunshot wound (GSW) in 15 (47%) patients & stab wound (SW) in 16 (50%). Twenty (74%) patients had an internal injury in an expected location. The remaining seven (26%) patients had unexpected injuries.

Zone 1

Zone 2

Zone 3

Penetrating Neck Injury

Hard Signs (n=32)

OR

Soft Signs (n=114)

CT Angio

No Signs (n=189) Observation

Discussion

2

1

1

1

2 0

2

4

6

8

10

12

14

16

Vascular Aerodigestive Vascular Aerodigestive Vascular Aerodigestive Vascular Aerodigestive Vascular Aerodigestive

Zone I Zone II Zone III Multiple Zones No External Neck Wound

Injuries resulting in Hard Signs

Expected Unexpected

In the 114 patients that had soft signs, only 10 (8%) had an internal injury. The MOI for this group was GSW in 54 (47%) & SW in 58 (51%). Seven (70%) of the 10 patients had expected injuries. The remaining three (30%) patients had unexpected injuries.

1 0

1

2

3

4

Vascular Aerodigestive Vascular Aerodigestive Vascular Aerodigestive Vascular Aerodigestive Vascular Aerodigestive

Zone I Zone II Zone III Multiple Zones No External Neck

Injuries Resulting in Soft Signs

Expected Unexpected