Download RTC PENETRATING NECK INJURY

Transcervical Neck Injury
& Vertebral Artery Injury
Supparerk Prichayudh, M.D.
Fellow
Ryder Trauma Center, JMH
Anatomy
• Anatomy of the neck is unique  contains
many vital structures
– Great vessels
– Aerodigestive tract
– Endocrine
– Central Nervous System
Neck fascia
• 1. Superficial fascia  platysma muscle
• 2. Deep cervical fascia
– Investing  covers SCM
– Pretracheal  blends with pericardium
– Prevertebral  blends with axillary sheath
• Carotid sheath is formed by all 3 components
of the deep cervical fascia.
Zone of neck injury (anterior)
• 1. Zone I
– Clavicle  cricoid cartilage
– Thoracic outlet vessels, brachial plexus, trachea,
esophagus
• 2. Zone II
– Cricoid cartilage  angle of mandible
– CCA, IJV, larynx, pharynx
• 3. Zone III
– Angle of mandible  base of skull
– ICA, ECA, IJV, pharynx
Initial management: ATLS
Primary survey & resuscitation
• Airway with C spine protection first priority
– Orotracheal intubation
– Cricothyroidotomy
• Breathing
• Circulation
– Bleeding control
– Fluid resuscitation
• Disability/ Neurological status
• Exposure/ prevent hypothermia
Orotracheal intubation & Digital
pressure
Surgical cricothyroidotomy
Foley catheter balloon tamponade in a zone 2 neck
injury. The catheter is knotted on itself (black arrow) to prevent
flow of blood through the lumen, and the wound is sutured
around it (white arrow).
Navsaria P,et al. Foley Catheter Balloon Tamponade for Life-threatening Hemorrhage
in Penetrating Neck Trauma. World J Surg 2006:30;1265-8
Adjunct to primary survey
• Insertion of nasogastric tube before airway
establishment should be avoided  may
precipitate bleeding.
Secondary survey
• Obtain history, mechanism of injury
• PE
– Site of injury, wound tract (X-ray with marker)
– Vascular structures (bleeding, BP, hematoma,
pulses, bruit)
– Aerodigestive tract (hemoptysis, air bubbling,
subcutaneous emphysema, hoarseness, pain on
swallowing, hematemesis )
– Nervous system (GCS, pupil, CN, brachial plexus)
Signs of penetrating neck injury
Hard Signs
Soft Signs
1. Active bleeding
2. Expanding pulsatile hematoma
3. Massive subcutaneous emphysema or
air bubbling from wound
1.
2.
3.
4.
Dysphagia
Voice change
Hemoptysis
Widening mediastinum
Definitive care
• Unstable patients with hard signs 
Emergency operation.
• Stable patients
– Wound does not penetrate platysma muscle.
• Discharge or observe
– Wound penetrates platysma muscle.
• Selective management in stable patients
– Careful PE
– Appropriate diagnostic tests
• Reserve operation for patients with significant injury
Algorithm
Mansour et al 1991 retrospective study in 188 patients  63% non operative
treatment, 1.5% mortality rate.
Algorithm for evaluation of penetrating neck wounds
Hard signs
Yes
No
Soft signs
OR
Yes
CT/CTA
Bronchoscope
Esophagoscope
Yes
Injury present or
suspected
No
Observe
No
Transcervical Neck Injury
Mandatory exploration
VS.
Selective management
Hirshberg et al, 1994
• Retrospective study of 41 transcervical GSW patients.
• 34 patients (83%) sustained 52 major injuries.
– Most common  vascular 22 injuries and upper
airway 13 injuries
• Positive neck exploration 30 of 36 patients (83%)
• Transcervical injuries are excellent markers of
associated visceral injury.  Mandatory exploration.
Demetriades, Asensio, et al, 1996
• Prospective study of 33 patients underwent
selective management.
• Transcervical GSWs are more likely to involve
vital structure. (73% VS. 31%)
• Only 7 patients (21%) had a therapeutic
operation.
• Advice selective management (careful
examination combined with appropriate
diagnostic tests).  80% can be managed
nonoperatively.
CT scan in penetrating neck injury
• Combine with PE!
• Munera et al, 2000  CT had sensitivity 90%,
specificity 100% and PPV 100%.
• Woo, et al 2005  CTA
– Wound tract could be visualized.  assist in
further diagnostic study selection
– May demonstrate injury.
Tracks did not involve vital
structures.
Extravasation of contrast
CTA showed Rt CCA injury
Operative treatment: General
principle
• Position  Supine, towel roll under patient’s
shoulders.
• Prepare skin from neck to knee.
• Standard neck exploration  incision along
anterior border of SCM muscle, with head
turned to the opposite side.
Incision for Neck Exploration:
Facial vein = gate keeper of the neck
Incisions for Neck Exploration:
Operative treatment: transcervical
injury
• Symptomatic side of the neck should be
explored first.
• If both sides require exploration.
– Bilateral neck incision
– Transverse (collar) incision
• Gives convenient access to anterior aspect of upper
airway
Conclusions: transcervical injury
• ABCs are crucial!!
• Selective management can also be done in
stable transcervical injury patients.
– Carefully repeat examination
– Appropriate diagnostic study
• Reserve operation in unstable patients or
patients with established injuries.
Vertebral artery injury
Incidence in penetrating trauma
1.0 – 7.4%
Blunt trauma – rare
Anatomy
• Vertebral artery (VA) is the first branch of
subclavian artery (SCA).
• 4 parts
– V1: SCA  C6 transverse process foramen (most
accessible)
– V2: C6  C2 (Interosseous portion)
– V3: C2  Foramen magnum
– V4: Foramen magnum  Basilar artery
V4
V3
V2
V1
Clinical manifestations
• Hard signs  50%
– Expanding hematoma, cervical bruit, pulsatile
hemorrhage
• Soft signs  30%
– Hx of bleeding, proximity wound, neurological
abnormality
• Asymptomatic  20%
Diagnosis
•
•
•
•
Clinical
Color-flow duplex  limited role
CTA, MRA  Noninvasive, screening tools
Contrast angiography
– Gold standard
– has therapeutic options (stent, embolization)
38-year-old man with both blunt carotid artery and blunt vertebral artery injuries resulting from
motor vehicle collision
Sliker, C. W. et al. Am. J. Roentgenol. 2008;190:790-799
Rt VA occlusion with pseudoaneurysm 
embolization with coil
CTA shows Lt VA occlusion
Treatment
• Majority of VA injuries do not require
treatment.
• Majority of VA injuries requiring treatment are
treated with angiographic embolization.
• Blunt VAI  antithrombotic treatment
• Indications for operation
– Active hemorrhage
– Failed angiographic treatment
Stein DM, et al 2009
• 147 patients identified with Blunt
cerebrovascular injuries (BCVI) detected by
routine CT scan.
• The incidence 1.2%, Mortality 13%.
• Treatments
– endovascular therapy (22%), antiplatelet
medications (36%), anticoagulation (10%), and
combination therapy (18%)
– 30% received no therapy, primarily due to
contraindications from concomitant injuries.
• Stroke rate 12% (18 patients  8 before
admission, 10 after).
– Treatment group = 3.9%
– Untreated group = 25.8% (p = 0.0003)
• Stroke-related mortality was 50%.
33 y/o female, MVC, GCS 15
Rt ICA thrombosis
MRA  Lt side weakness on the table
Angiogram  Rt MCA stroke
Embolectomy, stenting Rt ICA
 Improved motor function
Surgical treatment: V1
• Position patient’s head away from the injury.
• Incision
– Standard neck exploration  allow incision
extension
– Transverse supraclavicular approach
• Retract
– Carotid sheath medially , SCM laterally
– Anterior scalene m. (with phrenic n.) laterally
• +Cut omohyoid m., clavicular head of SCM
• VA is found posterior to Vertebral vein.
Surgical treatment:V2
• Same exposure as V1
• Sweep longus coli m. of transverse processes.
• Remove anterior rim of vertebral foramen by using
bone rongeurs.
• VA may be repaired or ligated.
• VV plexus bleeding  packing with hemostatic
agent.
• Do not blindly clip VA  cervical nerve root behind
VA may be injured.
Asensio, et al. Management of penetrating neck injury: the controversy surrounding
zone II injuries. Surg Clin North Am 1991:71;267-296.
Surgical treatment: V3, V4
• V3: posterior auricular approach.
• V4: suboccipital craniectomy
Asensio, et al. Management of penetrating neck injury: the controversy surrounding
zone II injuries. Surg Clin North Am 1991:71;267-296.
Conclusion: VA injury
• Rare
• Diagnosis  PE and CTA/angiography
• Majority of VA injuries do not require
operative treatment.
• Reserve operation for patients with
– Active hemorrhage
– Failed angiographic treatment
Case discussion
• 40 year-old male rode bicycle and fell down.
 sustained penetrating neck trauma from
wood stick.
• No LOC
• Could breathe spontaneously, but with
secretion sound and small amount of blood
from his mouth.
• Hemodynamically stable.