Penetrating zone II neck injury: does dynamic computed tomographic scan contribute to the diagnostic sensitivity of physical examination for surgically significant injury? A prospective blinded study

Penetrating carotid artery injury by air rifle: a case report

BACKGROUND

Air rifle injuries can cause significant vascular injuries. This air rifle injury has resulted in a penetrating neck trauma traversing the common carotid artery. There is debate around the need for radiological investigation, the most appropriate investigational modality, and the need for surgical exploration versus a conservative approach. This case report aims to exemplify a successful approach to managing Penetrating Carotid Injuries (PCI) while shedding light on the rationale behind the management decisions.

PRESENTATION

An 18-year-old Caucasian man arrived at the hospital following an air rifle injury to the right side of the neck, with active bleeding and a moderate haematoma displacing the trachea. He was haemodynamically stable, with a Glasgow Coma Scale (GCS) of 15 and no evidence of bruit. Computed Tomography Angiography (CTA) showed Right common carotid (CCA) artery injury with associated post-traumatic pseudoaneurysm. The pellet trajectory traverses the right superior thyroid gland. A duplex ultrasound scan (USS) confirmed two areas of arterial blush at the right CCA. Management involved neck exploration under General Anaesthesia (G.A.), repair of right CCA, bullet extraction, and wound washout. He received antibiotics for ten days and a single agent of antiplatelets for three months and was discharged two days postoperatively with no complications. He was followed up for eight months with no evidence of any trauma sequelae.

CONCLUSION

Penetrating carotid artery injuries are a serious concern. The small-sized pellets carry the risk of embolization. Therefore, neck exploration remains the gold standard treatment for PCI. Appropriate operative planning is crucial and can be optimised using radiological diagnostic modalities in haemodynamically stable patients. CTA is a non-invasive, swift, and adequate alternative to arteriography, providing valuable diagnostic information on vascular and aerodigestive injuries and bullet trajectory. This enables appropriate preparedness to achieve excellent outcomes in such critical cases.

Natural history and nonoperative management of penetrating cerebrovascular injury

INTRODUCTION

There is a modern precedent for nonoperative management of select penetrating cerebrovascular injuries (PCVIs); however, there is minimal data to guide management.

PATIENTS AND METHODS

This study assessed treatments, radiographic injury progression, and outcomes for all patients with PCVIs managed at an urban Level I trauma center from 2016 to 2021 that underwent initial nonoperative management (NOM).

RESULTS

Fourteen patients were included. There were 11,635 trauma admissions, 378 patients with blunt cerebrovascular injury, and 18 patients with operatively-managed PCVI during this timeframe. All patients received antithrombotic therapy, but this was delayed in some due to concomitant injuries. Three patients had stroke (21%): two before antithrombotic initiation, and one with unclear timing relative to treatment. Three patients underwent endovascular interventions. On follow-up imaging, 14% had injury resolution, 36% were stable, 21% worsened, and 29% had no follow-up vascular imaging. One patient died (7%), one had a bleeding complication (7%), and no patient required delayed operative intervention.

DISCUSSION

Early initiation of antithrombotic therapy, early surveillance imaging, and selective use of endovascular interventions are important for nonoperative management of PCVI.

Penetrating vertebral artery injury treated by combining the "zone" approach and imaging tests: A case report

Patients with vertebral artery injury from penetrating neck trauma may not present with signs of vascular injury because of anatomical characteristics and concomitant conditions, such as hypothermia and shock. If patients are hemodynamically stable, imaging tests should be performed to examine the posterior components, including the vertebral artery.

Computed tomography angiography for aerodigestive injuries in penetrating neck trauma: A systematic review

OBJECTIVES

Management of hemodynamically stable patients with penetrating neck trauma (PNT) has evolved in recent years with improvements in imaging technology. Computed tomography angiography (CTA) encompassing all zones of the neck has become part of the standard diagnostic algorithm for PNT patients who do not require immediate surgical intervention for vascular or aerodigestive injuries (ADI). Several studies have demonstrated favorable operating characteristics for CTA at excluding arterial injuries; however, consensus as to CTA's ability to detect ADI is lacking. We conducted a systematic review (PROSPERO registration number CRD42019133509) to answer the question Is CTA sufficient to rule out ADI in hemodynamically stable PNT patients without hard signs?

METHODS

Investigators independently searched PubMed, EMBASE, and Web of Science from their inception to August 2020 for the search terms "penetrating neck injuries" and "CT scan." To be included, studies required sufficient data to construct a 2×2 table of CTA for ADI. The operating characteristics of CTA for detecting ADIs are reported as sensitivity, specificity, and likelihood ratios (LRs), with 95% confidence intervals (95% CIs). Bias in our studies was quantified by QUADAS-2.

RESULTS

Our search identified 1,242 citations with seven studies with moderate to high risk of bias meeting our inclusion/exclusion criteria and encompassing 877 subjects with an ADI prevalence of 13.4%. CTA for ADI had sensitivity of 92% (95% CI = 85% to 97%), specificity of 88% (95% CI = 85% to 90%), positive likelihood ratio of 12.2 (95% CI = 4.6 to 32), and negative LR of 0.14 (95% CI = 0.05 to 0.37). Of the 26 identified esophageal injuries across our studies that were diagnosed by either swallow studies or surgical exploration, five (19%, 95% CI = 8.1% to 38.3%) were initially missed by CTA.

CONCLUSION

CTA alone is not sufficient to exclude esophageal injuries in PNT. Because delayed diagnosis is associated with increased morbidity, additional diagnostic interventions should be undertaken if there is remaining concern for esophageal injury.

Thoracic esophageal injury due to a neck stab wound: a case report

BACKGROUND

Traumatic esophageal injury leads to severe complications such as mediastinitis, pyothorax, and tracheoesophageal fistula. Although prompt diagnosis and treatment are required, there are no established protocols to guide diagnosis or treatment. In particular, thoracic esophageal injury tends to be diagnosed later than cervical esophageal injury because it has few specific symptoms. We report a case of thoracic esophageal injury caused by a cervical stab wound; the patient was stabbed with a sharp blade.

CASE PRESENTATION

A 74-year-old woman was attacked with a knife while sleeping at home. The patient was taken to the emergency room with an injury localized to the left section of her neck. She was suspected of a left jugular vein and recurrent laryngeal nerve injury from cervical hematoma and hoarseness. On the day following the injury, computed tomography revealed a thoracic esophageal injury. Emergency surgery was performed for an esophageal perforation and mediastinal abscesses. Although delayed diagnosis resulted in suture failure, the patient was able to resume oral intake of food a month later following enteral feeding with a gastrostomy. Esophageal injuries due to sharp trauma are rare, and most are cervical esophageal injuries. There are very few reports on thoracic esophageal injuries.

CONCLUSIONS

The possibility of thoracic esophageal injury should always be considered when dealing with neck stab wounds, particularly those caused by an attack.

Computed tomography angiography in the "no-zone" approach era for penetrating neck trauma: A systematic review

BACKGROUND

Penetrating neck trauma (PNT) continues to present a diagnostic dilemma. Practice guidelines advocate the use of computed tomography angiography (CTA) for suspected vascular or aerodigestive injuries in all neck zones. There is also an evolving evidence of "no-zone" approach where the decision to obtain a CTA is guided by physical examination findings and clinical presentation. The aim of this systematic review was to examine existing literature on the diagnostic accuracy of CTA as an integral component of the no-zone approach in stable patients with PNT.

METHODS

We performed a systematic review using an electronic search of three databases (PubMed, Medline, Cochrane Review) from 2000 to 2017.

RESULTS

A total of 5 prospective and 8 retrospective studies were included. The sensitivity of CTA ranged from 83% to 100%; specificity, from 61% to 100%; positive predictive value, from 30% to 100%; and negative predictive value, from 90% to 100%. Three studies reported high sensitivity and specificity for the detection of vascular injuries but low specificity for aerodigestive tract injuries. When stratified by clinical presentation, CTA had a sensitivity of 89.5% to 100% and specificity of 61% to 100% in stable patients presenting with soft signs (SSs). In a combined group of stable patients with either hard signs (HSs) or SSs, the sensitivity of CTA was 94.4% to 100% and the specificity was 96.7% to 100%. Among patients presenting with HSs, the sensitivity of CTA was 78.6% to 90% and the specificity was 100%.

CONCLUSIONS

This is the first systematic review to examine the role of CTA in PNT. In combination with physical examination, CTA demonstrated a reliable high sensitivity and specificity for detecting injuries in PNT in stable patients with SSs of injury and select patients with HSs of injury. These results support the management of PNT using no-zone approach based on physical examination and the use of CTA in stable patients.

LEVEL OF EVIDENCE

Systematic review, level IV.

Neurovascular trauma: Diagnosis and therapy

Traumatic cerebrovascular injuries are common in both military and civilian populations. Whether such injuries occur in the aftermath of blunt or penetrating trauma has major implications for characteristics, classification, diagnosis, and optimal management of these lesions. Advances in screening methods, including particularly the dramatic rise of high-quality CT angiography, have facilitated early detection of these lesions. Fortunately, these diagnostic advances have occurred alongside improvements in pharmacological treatment and endovascular intervention, which now play an important role alongside surgical intervention in reducing the likelihood of adverse clinical outcomes. While the management of victims of trauma remains challenging, improved understanding of and ability to appropriately manage traumatic cerebrovascular lesions promises to yield better clinical outcomes for these vulnerable patients.

Comparison of Nonoperative and Operative Management of Traumatic Penetrating Internal Jugular Vein Injury

BACKGROUND

Small case series have suggested that selective nonoperative management (NOM) of penetrating internal jugular vein (IJV) injuries is safe and feasible in select patients lacking "hard signs" mandating exploration. Therefore, we sought to compare NOM to operative management (OM) of penetrating IJV injury, hypothesizing that both strategies have similar patient outcomes and mortality when patients are appropriately selected.

METHODS

The Trauma Quality Improvement Program (2013-2016) was queried for patients with penetrating IJV injury with an abbreviated injury scale score of the neck ≥3. Demographics and patient outcomes were compared between patients undergoing NOM and patients undergoing OM, followed by a multivariable logistic regression model to analyze the risk of mortality.

RESULTS

A penetrating IJV injury was identified in 188 (0.01%) patients meeting inclusion criteria, and OM was performed in 124 (66.0%) patients, whereas 64 (34.0%) patients underwent NOM. Although the OM group had a higher rate of pneumothorax (8.9% vs. 0.0%, P = 0.01), there was no difference in any other concomitant injuries or demographic data (all P > 0.05). The OM group had a higher rate of ventilator days (3 vs. 2 days, P = 0.01) but no other significant differences in morbidity or mortality (P > 0.05). After controlling for covariates, OM was associated with similar risk of mortality compared with NOM of patients with penetrating IJV injury (odds ratio 1.05, confidence interval 0.23-4.83, P = 0.95).

CONCLUSIONS

The NOM of penetrating IJV injuries is associated with similar risk of morbidity and mortality compared with OM, suggesting that NOM may be used in appropriately selected patients. Future research is needed to determine the ideal patients suited for NOM and to identify risk factors and outcomes associated with failure of NOM.

Value of clinical examination in the assessment of penetrating neck injuries: a retrospective study of diagnostic accuracy test

Background

There are many high-volume trauma centers in limited resource environments where a thorough clinical examination of patients may contribute to a more economical, accurate, and widely applicable method of determining the proper management of patients with penetrating neck injuries. The purpose of this study was to validate thorough physical examination as a reliable diagnostic tool in these patients.

Methods

We performed an observational retrospective study of a diagnostic accuracy test where we compared clinical findings (symptoms and soft signs on admission of the patient) with the definitive findings according to the gold standard test for each particular situation (selective studies, clinical observation and surgical exploration). The study was conducted at Hospital Occidente Kennedy (HOK) between August 2009 and June 2010.

Results

The sample consisted of the clinical records of 207 (n = 207) patients who went to the emergency room for penetrating neck wounds at Hospital Occidente Kennedy (HOK). Of the total sample, 36.2% (n = 75) of patients were considered “asymptomatic” as they didn’t present with any soft signs of injury. Vascular soft signs were present in 57% (n = 118) of the patients, soft signs of the airway and the upper gastrointestinal tract were present in 15.9% (n = 33) and 21.3% (n = 44) of the patients respectively. The sensitivity and negative predictive value (NPV) of any soft sign to determine injuries which require surgical repair was 97.4% [CI] [86.5–99.5%] and 98.7% [CI] [92.8–99.8%] respectively, with a range of confidence [CI] of 95%.

Conclusions

Our study’s main findings suggest that patients with neck injuries and no vascular, airway, or gastrointestinal soft sign can be safely managed with a conservative approach. It is important to emphasize the value of the clinical examination since there are many contexts in the modern world where a considerable amount of the population is afflicted by neck trauma and treated under conditions where technological resources are limited.

The Tsukui (Japan) Yamayuri-en Facility Stabbing Mass-Casualty Incident

INTRODUCTION

In July 2016, a mass-casualty stabbing attack took place at a facility for disabled persons located in Sagamihara City (Kanagawa Prefecture, Japan). The attack resulted in 45 casualties, including 19 deaths. The study hospital dispatched physicians to the field and admitted multiple casualties. This report aimed to review the physicians' experiences and to provide insights for the formulation of response measures for similar incidents in the future.

REPORT

This incident involved 30 emergency teams and 12 fire department teams, including those from neighboring fire departments. Five physicians from three medical institutions, including the study hospital, entered the field. The Simple Triage and Rapid Treatment (START) method was used on the field. The final field triage category count was: 20 red, four yellow, two green, and 19 black tags. All the casualties (n = 26) except for the 19 black tag casualties were transported to one of six neighboring medical institutions.The median age of the transported casualties was 41 years (interquartile range [IQR] = 35.5 - 42.0). Three casualties (21.4%) were in hemorrhagic shock on arrival at the hospital. Twelve patients had multiple cervical stab wounds (median four wounds; IQR = 3.75 - 6.0). A total of 91.7% of these stab wounds were in mid-neck Zone II region. Of the 12 patients with cervical stab wounds, four (33.3%) required emergency surgery, and the rest were sutured on an out-patient basis. One patient had already been sutured on the field. All patients requiring emergency surgery had deep wounds, including those of the carotid vein, thyroid gland, nerves, and the trachea. Eight of the casualties were hospitalized at the study institution. Five of them were admitted to the intensive care unit. There were no deaths among the casualties transported to the hospitals.

CONCLUSION

Regional core disaster medical hospitals must take on a central role, particularly in the case of local disasters. Horizontal communication and interactions should be reinforced by devising protocols and conducting joint training for effective inter-department collaborations on the field.Maruhashi, T, Takeuchi, I, Hattori, J, Kataoka, Y, Asari, Y. The Tsukui (Japan) Yamayuri-en facility stabbing mass-casualty incident. Prehosp Disaster Med. 2019;34(2):203-208.

Computed Tomography Angiography is the Definitive Vascular Imaging Modality for Penetrating Neck Injury: A South African Experience

Background and Aims:

Computed tomography angiography has become central to the diagnostic algorithm for penetrating neck injury, but despite its widespread use the literature to support this adoption is limited. We reviewed our experience with computed tomography angiography for the identification of vascular trauma in hemodynamically stable patients with penetrating neck injury at a major trauma center in South Africa.

Materials and Methods:

A prospectively kept trauma registry capturing data in real time was retrospectively reviewed. All patients with penetrating neck injury investigated with computed tomography angiography as the initial vascular investigation during a 47-month period were included.

Results:

A total of 380 patients were included. Indications for computed tomography angiography were as follows: hard signs (13), soft signs (201), no signs but proximity/zone I or III wounds (141), and undefined signs of vascular injury (25). Of the 380 scans, 7 (1.8%) were indeterminate, 299 (78.7%) negative, and 74 (19.5%) positive for a vascular injury (54 arterial and 20 isolated venous injury). Eight were false positive and 4 false negative. The sensitivity, specificity, positive, and negative predictive values for detecting arterial injury were 93.9%, 97.5%, 85.2%, and 99.1%, respectively. Overall, the yield for demonstrating “true arterial injury” was 12.1% (46/380); hard signs: 76.9% (10/13), soft signs: 16.4% (33/201), and no signs: 2.1% (3/141) which all were secondary to gunshot wounds). Only 8.4% (32/380) required intervention for arterial injury and none for isolated venous injury (hard signs: 62.0%, soft signs: 11.4%, and no signs: 0.7%). No serious complications resulted from computed tomography angiography.

Conclusion:

Computed tomography angiography is a safe and effective imaging modality for the investigation of vascular trauma post penetrating neck injury. Asymptomatic patients with stab wounds do not need to be imaged regardless of proximity concerns. Symptomatic stable patients including a subgroup with hard signs should be imaged rather than explored. Computed tomography angiography provides an interventional road map and can identify injuries amenable to endovascular or conservative management.

"No zone" approach in penetrating neck trauma reduces unnecessary computed tomography angiography and negative explorations

BACKGROUND

The most recent management guidelines advocate computed tomography angiography (CTA) for any suspected vascular or aero-digestive injuries in all zones and give zone II injuries special consideration. We hypothesized that physical examination can safely guide CTA use in a "no zone" approach.

METHODS

An 8-year retrospective analysis of all adult trauma patients with penetrating neck trauma (PNT) was performed. We included all patients in whom the platysma was violated. Patients were classified into three groups as follows: hard signs, soft signs, and asymptomatic. CTA use, positive CTA (contrast extravasation, dissection, or intimal flap) and operative details were reported. Primary outcomes were positive CTA and therapeutic neck exploration (TNE) (defined by repair of major vascular or aero-digestive injuries).

RESULTS

A total of 337 patients with PNT met the inclusion criteria. Eighty-two patients had hard signs and all of them went to the operating room, of which 59 (72%) had TNE. One hundred fifty-six patients had soft signs, of which CTA was performed in 121 (78%), with positive findings in 12 (10%) patients. The remaining 35 (22%) underwent initial neck exploration, of which 14 (40%) were therapeutic yielding a high rate of negative exploration. Ninty-nine patients were asymptomatic, of which CTA was performed in 79 (80%), with positive findings in 3 (4%), however, none of these patients required TNE. On sub analysis based on symptoms, there was no difference in the rate of TNE between the neck zones in patients with hard signs (P = 0.23) or soft signs (P = 0.51). Regardless of the zone of injury, asymptomatic patients did not require a TNE.

CONCLUSIONS

Physical examination regardless of the zone of injury should be the primary guide to CTA or TNE in patients with PNT. Following traditional zone-based guidelines can result in unnecessary negative explorations in patients with soft signs and may need rethinking.

Learning from 2523 trauma deaths in India- opportunities to prevent in-hospital deaths

BACKGROUND

A systematic analysis of trauma deaths is a step towards trauma quality improvement in Indian hospitals. This study estimates the magnitude of preventable trauma deaths in five Indian hospitals, and uses a peer-review process to identify opportunities for improvement (OFI) in trauma care delivery.

METHODS

All trauma deaths that occurred within 30 days of hospitalization in five urban university hospitals in India were retrospectively abstracted for demography, mechanism of injury, transfer status, injury description by clinical, investigation and operative findings. Using mixed methods, they were quantitatively stratified by the standardized Injury Severity Score (ISS) into mild (1-8), moderate (9-15), severe (16-25), profound (26-75) ISS categories, and by time to death within 24 h, 7, or 30 days. Using peer-review and Delphi methods, we defined optimal trauma care within the Indian context and evaluated each death for preventability, using the following categories: Preventable (P), Potentially preventable (PP), Non-preventable (NP) and Non-preventable but care could have been improved (NPI).

RESULTS

During the 18 month study period, there were 11,671 trauma admissions and 2523 deaths within 30 days (21.6%). The overall proportion of preventable deaths was 58%, among 2057 eligible deaths. In patients with a mild ISS score, 71% of deaths were preventable. In the moderate category, 56% were preventable, and 60% in the severe group and 44% in the profound group were preventable. Traumatic brain injury and burns accounted for the majority of non-preventable deaths. The important areas for improvement in the preventable deaths subset, inadequacies in airway management (14.3%) and resuscitation with hemorrhage control (16.3%). System-related issues included lack of protocols, lack of adherence to protocols, pre-hospital delays and delays in imaging.

CONCLUSION

Fifty-eight percent of all trauma deaths were classified as preventable. Two-thirds of the deaths with injury severity scores of less than 16 were preventable. This large subgroup of Indian urban trauma patients could possibly be saved by urgent attention and corrective action. Low-cost interventions such as airway management, fluid resuscitation, hemorrhage control and surgical decision-making protocols, were identified as OFI. Establishment of clinical protocols and timely processes of trauma care delivery are the next steps towards improving care.

Thoracic trauma: principles of early management

Thoracic trauma remains an important cause of early and late mortality in the injured patient. This review provides an overview of the emergency room management of thoracic trauma, amplifying the approach and principles of Advanced Trauma Life Support. The presentation, pathophysiology, diagnosis and treatment of the 12 most significant thoracic injuries are described. Focusing on emergency room management, and using the concept of the ‘lethal six’ and ‘hidden six,’ appropriate management strategies are detailed.

Penetrating Cervical Trauma. "Current Concepts in Penetrating Trauma", IATSIC Symposium, International Surgical Society, Helsinki, Finland, August 25-29, 2013

Patients with penetrating wounds to the neck present with overt symptoms and/or signs or are asymptomatic or modestly/moderately symptomatic. With overt symptoms and/or signs, immediate resuscitation and an emergency operation are appropriate. Asymptomatic patients or those with modest or moderate symptoms and/or signs undergo observation or a diagnostic evaluation to avoid the 45% "negative" exploration rate documented in the past (denominator = all patients). Asymptomatic patients with penetration of the platysma muscle, but no signs of a visceral or vascular injury, should undergo serial physical examinations every 6-8 for 24-36 h before discharge. Noncontrast CT does not add to the accuracy of serial physical examinations. In stable patients with a variety of modest/moderate symptoms or signs possibly related to an injury to the carotid artery, CT-arteriography has become the diagnostic modality of choice. Patients with possible injuries to the cervical esophagus are often still evaluated with a Gastrografin swallow and, if needed, a "thin" barium swallow prior to fiberoptic esophagoscopy. CT-esophagograms are likely to replace these time-honored studies in the near future. Over 85% of patients with injuries to the trachea present with overt symptoms or signs, while the remainder have historically been evaluated with laryngoscopy and fiberoptic bronchoscopy. Again, cervical multislice CT is likely to replace these studies. Operative repair of the carotid artery with 6-0 polypropylene sutures requires heparinization and shunting on rare occasions. Both the trachea and esophagus are repaired with 3-0 absorbable sutures, and tracheostomy and esophageal diversion are used in only large and/or complex injuries. Sternal head or sternocleiodomastoid interposition flaps are used when combined visceral and vascular injuries are present.

Selective management of penetrating neck injuries using "no zone" approach

INTRODUCTION

Selective management has been the standard management protocol in penetrating neck injuries (PNIs) since this approach has significantly reduced unnecessary neck exploration. The purpose of this study is to evaluate outcomes of selective management in PNIs using the "no zone" approach, in which the management is guided mainly by clinical signs and symptoms, not the location of the neck wounds.

MATERIALS AND METHODS

A retrospective study was performed in patients treated for PNIs at King Chulalongkorn Memorial Hospital (KCMH) from January 2003 to December 2013. The patients with hard signs of neck injury (i.e., active bleeding, significant haematoma, massive subcutaneous emphysema, and air bubbling through the neck wound) underwent emergency neck exploration. The asymptomatic patients and the patients with soft signs (other symptoms) were considered to be candidates for selective management. Data collection included demographic data, emergency department parameters, details of neck injury, and outcomes in terms of mortality, negative exploration rate, and missed injury rate.

RESULTS

Eighty-six PNI patients were treated at KCMH from 2003 to 2013, 64 of which sustained stab wounds, 12 gunshot wounds, 4 shotgun wounds, and 6 other causes. Thirty-six patients presenting with hard signs underwent immediate neck exploration and there were 2 negative explorations. Twenty-six patients with soft signs underwent selective investigations (including computed tomographic angiography in 21 patients), 5 patients required neck explorations due to positive results of the investigations with one negative exploration. All of the twenty-four asymptomatic patients were managed with close observation, none required subsequent neck exploration. There was no missed injury found in the present study. Successful non-operative management was carried out in 45 patients (52%). The overall negative exploration rate was 7% (3 in 41 patients undergoing neck exploration). Two patients with hard signs died from associated chest injuries (mortality rate 2%).

CONCLUSION

Selective management of penetrating neck injuries based on physical examination and selective use of investigations (no zone approach) is safe and simple with low negative exploration rate and no missed injury.

Cervical spondylodiscitis with epidural abscess after knife stab wounds to the neck: A case report

INTRODUCTION

Cervical spondylodiscitis is usually caused by pyogenic infections, associated with retropharyngeal abscesses, or due to the swallowing of foreign bodies. No cases of cervical spondylodiscitis caused by a penetrating neck injury have been published in the literature. We describe a case of cervical spondylodiscitis after multiple knife stab wounds to the lateral soft tissue of the neck.

MATERIALS AND METHODS

Case report and review of the literature.

RESULTS

A 54-year-old patient was brought to our clinic with destructive spondylodiscitis C3/4 with paravertebral and epidural abscesses. He had been involved in a fight and had suffered multiple stab wounds to his neck with a knife 1 month prior. The initial CT scan had revealed one deeper wound canal behind the sternocleidomastoid muscle on the left side without any injury to the vessels. The wound was cleaned and an antibiotic therapy with cefuroxime was given for 1 week. After an uneventful and complete healing of the wound the patient developed severe neck pain. Inflammatory laboratory parameters were elevated, and a MRI of the neck revealed a distinct spondylodiscitis C3/4 with paravertebral and epidural abscess formations. Surgery was performed and included debridement, abscess drainage, decompression of the spinal canal, fusion of the C3/4 segment using an autologous iliac crest bone graft and a plate osteosynthesis. A course of calculated antibiotic therapy was administered for 8 weeks. Normal laboratory parameters and no radiological signs of an ongoing inflammatory process were observed during follow-up examinations. The C3/4 segment was consolidated.

CONCLUSION

Stab wound injuries to the neck not only bear the risk of injuries to the nerves, vessels and organs of the neck but also increase the risk of developing secondary spondylodiscitis. Specifically, cervical spondylodiscitis can result in distinct neurological symptoms, and surgical intervention should be performed in a timely manner.

Imaging assessment of penetrating injury of the neck and face

Background

Penetrating trauma of the neck and face is a frequent presentation to acute emergency, trauma and critical care units. There remains a steady incidence of both gunshot penetrating injury to the neck and face as well as non-missile penetrating injury—largely, but not solely, knife-related. Optimal imaging assessment of such injuries therefore remains an on-going requirement of the general and specialised radiologist.

Methods

The anatomy of the neck and face—in particular, vascular, pharyngo-oesophageal, laryngo-tracheal and neural anatomy—demands a more specialised and selective management plan which incorporates specific imaging techniques.

Results

The current treatment protocol of injuries of the neck and face has seen a radical shift away from expectant surgical exploration in the management of such injuries, largely as a result of advances in the diagnostic capabilities of multi-detector computed tomography angiography (MDCTA), which is now the first-line imaging modality of choice in such cases.

Conclusion

This review aims to highlight ballistic considerations, differing imaging modalities, including MDCTA, that might be utilised to assist in the accurate assessment of these injuries as well as the specific radiological features and patterns of specific organ-system injuries that should be considered and communicated to surgical and critical care teams.

Teaching points

• MDCTA is the first-line imaging modality in penetrating trauma of the neck and, often, of the face

• The inherent deformability of a bullet is a significant factor in its tissue-damaging capabilities

• MDCTA can provide accurate assessment of visceral injury of the neck as well as vascular injury

• Penetrating facial trauma warrants radiological assessment of key adjacent anatomical structures

• In-driven fragments of native bone potentiate tissue damage in projectile penetrating facial trauma

Evaluation of multidetector computed tomography for penetrating neck injury: a prospective multicenter study

BACKGROUND

The purpose of this prospective multicenter study was to evaluate a clinical protocol integrating multidetector computed tomographic angiography (MDCTA) as the initial screening examination for the work-up of penetrating neck injury.

METHODS

All penetrating neck injuries assessed at two Level I trauma centers (January 2009-July 2011) prospectively underwent a structured clinical examination. Those with hard signs of injury (active bleed, instability, expanding/pulsatile hematoma, bruit/thrill, hemoptysis, hematemesis, and air bubbling) underwent exploration, those who were asymptomatic were observed. The remainder, with soft signs underwent MDCTA. Sensitivity and specificity were tested against an aggregate gold standard of operative intervention, clinical follow-up, and when obtained, conventional angiography, bronchoscopy, esophagogram, and esophagoscopy.

RESULTS

Four hundred fifty-three penetrating neck injuries were evaluated. Hard signs of vascular or aerodigestive tract injury were observed in 8.6% with an 89.7% incidence of clinically significant injury. 41.7% had no signs of injury and were observed with no missed injuries (follow-up, 2.6 days ± 1.1 days [1-58 days]). The remaining 225 (49.7%) underwent MDCTA (stab wound, 61.3%; gunshot wound, 37.8%; shotgun, 0.9%). The external wounds were in zone II (38.2%), multiple (28.9%), zone I (16.9%), and zone III (16.0%). Twenty-eight injuries were found in 22 patients (5 internal jugular-V, 2 external jugular-V, 1 vertebral-A, 7 common carotid-A, 2 internal carotid-A, 3 external carotid-A, 2 subclavian-A, 3 esophagus, and 3 tracheas). Five patients had false-positive findings (2 vascular and 3 aerodigestive tract). The 194 negative studies (follow-up, 5.5 days ± 7.5 days [1-27 days]) had no delayed diagnosis of injury. MDCTA was nondiagnostic in four patients (1.8%), secondary to artifact. One of these had a vertebral-A injury diagnosed at angiography. MDCTA achieved 100% sensitivity and 97.5% specificity in detecting all clinically significant injuries.

CONCLUSION

In the initial evaluation of patients who have sustained penetrating neck trauma, physical examination can safely reduce unnecessary imaging. If imaging is required, MDCTA is a highly sensitive and specific screening modality for evaluating the vascular and aerodigestive structures in the neck.

LEVEL OF EVIDENCE

II, prospective study.

Management of penetrating neck injuries

BACKGROUND

Routine surgical exploration after penetrating neck injury (PNI) leads to a large number of negative neck explorations and potential iatrogenic injury. Selective non-operative management (SNOM) of PNI is gaining favour. The present study assessed the feasibility of SNOM in PNI.

METHODS

Seventy-seven consecutive patients with PNI presenting to a tertiary trauma centre were included in this prospective study from September 2009 to December 2009. All patients were managed according to Advanced Trauma Life Support guidelines, and either underwent emergency surgery or were managed without surgery, based on clinical presentation and/or outcome of special investigations.

RESULTS

Eight patients (10 per cent) were haemodynamically unstable at presentation. Foley catheter balloon tamponade (FCBT) was successful in stopping active bleeding in six of these patients, and diagnostic angiography revealed an arterial injury in five. The remaining 69 patients were managed using SNOM. Angiography or computed tomography was done in 41 patients (53 per cent), and showed arterial injury in 15. These injuries were treated surgically (7 patients), radiologically (stenting in 3) or conservatively. Contrast swallow and/or endoscopy were performed in 37 patients (48 per cent) for suspected oesophageal injury, but yielded no positive results. During follow-up no missed injuries were detected.

CONCLUSION

FCBT was useful in patients with PNI and active bleeding. Stable patients should undergo additional investigation based on clinical findings only.

Imaging vascular trauma

Background

Over the past 50 years the management of vascular trauma has changed from mandatory surgical exploration to selective non-operative treatment, where possible. Accurate, non-invasive, diagnostic imaging techniques are the key to this strategy. The purpose of this review was to define optimal first-line imaging in patients with suspected vascular injury in different anatomical regions.

Methods

A systematic review was performed of literature relating to radiological diagnosis of vascular trauma over the past decade (2000–2010). Studies were included if the main focus was initial diagnosis of blunt or penetrating vascular injury and more than ten patients were included.

Results

Of 1511 titles identified, 58 articles were incorporated in the systematic review. Most described the use of computed tomography angiography (CTA). The application of duplex ultrasonography, magnetic resonance imaging/angiography and transoesophageal echocardiography was described, but significant drawbacks were highlighted for each. CTA displayed acceptable sensitivity and specificity for diagnosing vascular trauma in blunt and penetrating vascular injury within the neck and extremity, as well as for blunt aortic injury.

Conclusion

Based on the evidence available, CTA should be the first-line investigation for all patients with suspected vascular trauma and no indication for immediate operative intervention.

Conservative management of laryngeal perforation in a rural setting: case report and review of the literature on penetrating neck injuries

Penetrating neck injuries (PNIs) are infrequent but can result in significant morbidity and mortality. Although surgical management of unstable patients with penetrating neck trauma is the standard of care, management of stable patients remains controversial owing to the possibility of occult injuries. Recent studies suggest that physical examination and ancillary imaging may be sufficiently accurate to diagnose or rule out surgically significant injuries in PNI. We report a patient with a laryngeal perforation who was managed conservatively in a rural hospital without complications and review the literature pertinent to cases of this nature.

Blunt carotid injury from a penetrating stick: an unexpected injury

Unattended blunt carotid injury (BCI) has stroke high risk of stroke and screening based on injury probability is recommended. Penetrating forces are not considered high risk and concomitant BCI would go unattended. The authors report a case of a 48-year-old man who fell out of a tree on to an upright stick that penetrated his lateral neck. He presented with impalement, which was removed after surgically laying open the entire wound. The carotid sheath had been breached and the internal jugular vein was bleeding. The adjacent common carotid artery was intact and pulsating with no external evidence of injury. However, injury proximity led to vascular imaging that demonstrated intimal disruption without thrombus or stenosis. Although he remained asymptomatic on heparin, the injury progressed to cause significant lumen stenosis. Endovascular stenting re-established the vessel lumen and he remains well on aspirin 9 months later. Awareness that penetrating neck trauma may cause BCIs is important.

Multidetector row computed tomography in the management of penetrating neck injuries

Penetrating neck trauma may occur from gun shots, stabbings, and accidental injury. Approximately 50% of gunshot and 10%-20% of stab-wound patients are reported as having severe injuries and the mortality from severe vascular injuries is reported as high as 50%. Penetrating traumatic neck injury is no longer best managed with exploratory surgery or conventional angiography in the stable patient. Computed tomography angiography has proven to be a useful, safe, and reliable means of diagnosis. Experience with interpreting and reconstructing computed tomography images, understanding the clinically important findings, and avoiding pitfalls is critical for successful patient care. Therefore, radiologists and clinicians who treat trauma patients need to familiarize themselves with the computed tomography angiography technique and appearances of vascular injury and know when to recommend further evaluation, such as interventional angiography or open surgery.

Thoracic and neck trauma. Part four

Previous parts to this series on thoracic and neck trauma discussed the anatomy and physiology of the thorax, assessment and initial nursing interventions, imaging and adjuncts to diagnosis. Part 2 described specific chest wall and lung injuries, types of pneumothoraces and their diagnosis and management. Section 3 examined other types of thoracic injuries and their management, such as trauma to the diaphragm and heart. This final part provides a brief but concise overview of neck anatomy, trauma and management.

Penetrating neck injuries in children

Penetrating neck injuries are uncommon in children, and when they do occur, they can be a challenge to manage. Injuries can be cardiovascular, aerodigestive, and neurovascular. In the past, injuries were explored surgically to evaluate the extent of the injury; studies are now showing that observation and less invasive studies have a positive outcome for the patient. Immediate surgical intervention remains mandatory for the clinically unstable patient, whereas stable patients have studies done that pertain to their signs and symptoms, thus having a conservative nonoperative approach to care.

Is exploration mandatory in penetrating zone II neck injuries?

BACKGROUND

A policy of mandatory neck exploration for zone II injuries deep to platysma was promoted in the 1950s and was associated with a reduction in mortality when compared with expectant or delayed exploration. Recently many trauma centres have been practising selective neck exploration using physical examination and imaging to stratify patients to different management strategies. In the Auckland region, patients with penetrating zone II injury deep to platysma have been managed with mandatory neck exploration. As penetrating injuries in the Auckland region are caused by a range of sharp objects, with gunshot wounds rare, outcomes of management of zone II neck injuries in this population warrant investigation. The aim of this study was to determine the rate of therapeutic neck exploration in patients with penetrating zone II neck injury in the Auckland region and to suggest optimum management strategies for such injuries.

METHODS

Retrospective audit of all patients presenting to Auckland and Middlemore Hospitals, Auckland, New Zealand, between 1995 and 2005 was carried out. Review of electronic clinical records and operation notes was also carried out.

RESULTS

An overall positive neck exploration rate of 25% was obtained (87% for patients with hard signs on physical examination). Physical examination had a sensitivity of 93% and a positive predictive value of 87% in this case series. Neck exploration was not associated with known complications or missed injuries.

CONCLUSION

In the Auckland setting, physical examination would appear to be a safe and reliable method for the stratification of patients for either operative or conservative management.

State of the art: noninvasive imaging and management of neurovascular trauma

Neurotrauma represents a significant public health problem, accounting for a significant proportion of the morbidity and mortality associated with all traumatic injuries. Both blunt and penetrating injuries to cervicocerebral vessels are significant and are likely more common than previously recognized. Imaging of such injuries is an important component in the evaluation of individuals presenting with such potential injuries, made all the more important since many of the vascular injuries are clinically silent. Management of injuries, particularly those caused by blunt trauma, is constantly evolving. This article addresses the current state of imaging and treatment of such injuries.

Prospective evaluation of screening multislice helical computed tomographic angiography in the initial evaluation of penetrating neck injuries

BACKGROUND

The optimal management strategy for patients sustaining penetrating neck injury without an urgent indication for operative exploration remains controversial. The objective of this study was to prospectively assess multislice helical computed tomography angiography (MCTA) as a stand alone screening modality for the initial evaluation of hemodynamically stable patients with penetrating neck injuries. Our hypothesis was that MCTA is a sensitive diagnostic screening test that could noninvasively evaluate the vascular and aerodigestive structures of the neck.

METHODS

After Institutional Review Board approval, all penetrating neck injuries assessed during a 16-month period were prospectively evaluated at a Level I trauma center. Patients without an indication for urgent neck exploration underwent MCTA screening. MCTA accuracy was tested against an aggregate gold standard of final diagnosis encompassing all imaging, surgical procedures and clinical follow-up obtained.

RESULTS

In all, 106 injuries penetrated the platysma; 15 required urgent exploration and 91 underwent MCTA (34 gunshot wounds/57 stab wounds). Nineteen external wounds were in zone 1, 39 were in zone 2, 10 in zone 3, and 23 traversed multiple zones. MCTA was nondiagnostic in 2.2% secondary to artifact from retained missile fragments. Follow-up was achieved in 84.5% of patients for a mean of 33.3 days (range: 2-150). MCTA achieved 100% sensitivity and 93.5% specificity in detecting all vascular and aerodigestive injuries sustained. MCTA correctly identified two tracheal and two carotid artery injuries requiring operative or endovascular repair in asymptomatic patients. No injuries requiring intervention were missed by MCTA.

CONCLUSION

In the initial evaluation of stable penetrating neck injuries, MCTA appears to be a sensitive and safe screening modality. Further investigation is warranted.

Management of cervical stab wounds in low volume trauma centres: systematic physical examination and low threshold for adjunctive studies, or surgical exploration

INTRODUCTION

In Nordic countries penetrating neck injuries (PNIs) are infrequent and management has traditionally been guided by surgeons' preferences. Some form of selective non-operative approach is currently practised in most urban trauma centres.

OBJECTIVE

To examine demographic features and treatment outcome of non-ballistic penetrating neck injuries in southern Finland and provide management guidelines for centres with low volume of penetrating neck trauma.

MATERIALS AND METHODS

Retrospective analysis of 85 platysma penetrating neck injuries in two southern Finland hospitals (Helsinki University Central Hospital, HUCH and Tampere University Hospital, TaUH) was carried out using the ICD-10 based hospital databases to identify PNI-patients.

RESULTS

The incidence of admitted patients with penetrating neck injuries was 1.3/100000/year. Fifty-two (61%) injuries were caused by random acts of violence, 28 (38%) were self-inflicted and 5 (6%) were accidents. Of all 85 patients, 52 (61%) underwent operative exploration with a negative exploration rate of 65%. Hard signs for vascular or aerodigestive trauma were present in 23 (27%) patients and all of these were operated with a negative exploration rate of 30%. Two patients had no hard signs on physical examination but were operatively explored and significant injuries were found in both patients. The hospital mortality rate was 0% and the overall complication rate for operated patients was 7.7%.

CONCLUSIONS

Trauma centres managing PNIs infrequently should have an individually tailored management protocol for penetrating neck injury patients. If mandatory exploration is not practised, a systematic physical examination should be the mainstay of diagnostic work up but the threshold for adjunctive studies should be low. Although not evident by the current data, protocol-based management could be useful in decreasing treatment variation and enhancing residency training.

The nonoperative management of penetrating internal jugular vein injury

OBJECTIVE

The objective of this study was to review the outcome of nonoperative treatment for penetrating internal jugular vein (IJ) injuries in a continuous series of prospectively identified, hemodynamically stable patients.

METHODS

All penetrating neck injuries assessed from February 1, 2004, to August 31, 2004, were prospectively identified. Patients without an indication for urgent neck exploration underwent diagnostic assessment with multislice helical computed tomographic angiography with or without vascular ultrasonography. All IJ injuries with no other indication for surgical exploration were treated nonoperatively. All patients were discharged home and followed up for a minimum of 1 week to document outcomes.

RESULTS

From 51 neck injuries penetrating the platysma, 7 required urgent neck exploration, during which 2 IJ injuries were ligated. Forty-four patients underwent multislice helical computed tomographic angiography. Eight IJ injuries (two gunshot wounds and six stab wounds) with no other indication for neck exploration were identified and managed nonoperatively. One external wound was in zone 1, five were in zone 2, one was in zone 3, and one traversed all three zones. The average length of stay was 4.5 days. At follow-up, ranging from 1 week to 5 months, all patients were asymptomatic, and no patient required delayed operation for IJ injury.

CONCLUSIONS

In hemodynamically stable patients with no other indication for exploration, the nonoperative management of penetrating jugular vein injuries should be considered as a safe alternative.

CT Angiography in Penetrating Neck Trauma Reduces the Need for Operative Neck Exploration

The evaluation of penetrating neck injury has evolved dramatically from mandatory operative exploration of Zone II injuries that penetrate the platysma to selective management based on physical examination and adjunctive studies. More recently, CT angiography has emerged as an efficient, noninvasive method of evaluating penetrating neck injury. We retrospectively reviewed our experience over 10 years with the management of penetrating neck injury. One hundred thirty cases were reviewed with 34 undergoing CT angiogram (Group CTA) and 96 with no CT angiogram (Group nCTA). Group CTA had significantly fewer neck explorations, 1 (3%) versus 32 (33%), P < 0.001. Negative explorations were significantly higher in nCTA as well, with a rate of 22 per cent versus 0 in CTA ( P < 0.01). The use of angiogram and esophagram was also significantly lower in CTA versus nCTA ( P = 0.02 and P = 0.04). Of the 34 patients in CTA, 4 (12%) also underwent angiography and 4 (12%) received a contrast esophagram. Of the 64 patients in nCTA who did not undergo a neck exploration, 19 (29%) underwent angiography, and 17 (26%) received a contrast esophagram. The use of CT angiogram increased over time with a concomitant decrease in the rate of neck explorations.

Penetrating Injuries of the Neck: Use of Helical Computed Tomographic Angiography

The diagnostic evaluation of stable patients with penetrating trauma to the neck remains controversial. Conventional angiography has traditionally been considered the gold standard for evaluation of vascular injuries. The use of angiography for stable patients with penetrating neck trauma has been questioned because of its invasive nature and reported low yield. In recent years, there has been a renewed interest in the use of noninvasive techniques such as helical computed tomographic (CT) angiography for the evaluation of these patients. Helical CT angiography, a low-risk, rapid, accurate, noninvasive, reproducible technique, is less expensive than conventional angiography. Helical CT angiography also can provide information about potential lesions of associated vital structures such as the cervical spine and the aerodigestive tract. This review evaluates the authors' current protocol for penetrating neck wounds and identifies indications for helical CT angiography.

Penetrating injuries of the neck and the increasing role of CTA

Vascular injuries of the neck are most frequently the result of penetrating trauma. Diagnostic evaluation of hemodynamically stable patients who have suffered penetrating neck wounds is challenging and remains controversial. In order to reduce morbidity and mortality, prompt diagnosis and subsequent treatment of these injuries is critical. Traditionally, these patients undergo direct contrast angiography. However, this technique has limitations including its invasive nature and potential complications. The use of routine screening angiography has also been questioned because of the low rate of positive examinations. More recently, helical and multislice CT angiography (CTA) has emerged as a fast, minimally invasive accurate study to evaluate penetrating neck injuries. CTA is not operator-dependent and the results can be reproduced easily by using established technical parameters. It is readily available in most centers and allows the simultaneous evaluation of the extravascular soft tissues and bones.