The traditional zonal approach to penetrating neck injury is being increasingly abandoned in favor of selective, imaging-based management to reduce non-therapeutic interventions, according to a comprehensive review published in Trauma Surgery & Acute Care Open.
Penetrating neck injuries account for up to 10% of trauma cases, with mortality reaching as high as 10%, and historically were managed using an anatomic zonal framework that often mandated surgical exploration—particularly for zone II injuries. However, this approach led to high rates of negative exploration and associated complications, prompting a shift toward selective evaluation based on clinical findings and imaging.
The researchers describe how multidetector computed tomography angiography (CTA) now guides evaluation in hemodynamically stable patients. CTA demonstrated 90% to 100% sensitivity and 98.6% to 100% specificity for vascular injuries, and 100% sensitivity with 93.5% to 97.5% specificity for aerodigestive injuries. These performance characteristics allow clinicians to safely observe patients when no injury is detected.
However, diagnostic limitations remain. Sensitivity for detecting pharyngoesophageal injuries may decrease to 53% when missile tracts are near these structures, requiring confirmatory studies such as contrast esophagram and esophagoscopy.
Clinical assessment includes evaluation of ‘hard’ and ‘soft’ signs of injury. Hard signs—including expanding hematoma, severe bleeding, shock, or airway obstruction—necessitate immediate surgical exploration. Patients without hard signs are evaluated with imaging and may be observed if no injury is detected.
Rapid sequence intubation was found to be effective, and cricothyroidotomy achieved success rates exceeding 80% in experienced hands. Hemostatic dressings were effective, and devices such as the iTClamp were more effective than manual pressure in controlling hemorrhage. Vascular injury occurs in up to 25% of cases, most commonly involving the carotid arteries, while aerodigestive injuries occur in 23% to 30% of cases. Stroke rates range from 6% to 12% for carotid injuries, with higher rates in internal carotid artery involvement.
Overall mortality for penetrating neck injury is estimated at 3% to 6%, with approximately half of deaths attributable to hemorrhage. Among patients with vascular injury, 40% develop complications, and aerodigestive injuries carry mortality rates of 11% to 17%.
“‘[W]e need to continue to improve our management strategies of PNIs with particular emphasis on hemorrhage control,’ first author Lindsey Loss of Oregon Health & Science University, and colleagues, wrote.”
The researchers reported no conflicts of interest.
Source: Trauma Surgery & Acute Care Open
