Penetrating Neck Injuries, Management of

Authors

Samuel A. Tisherman, MD
Faran Bokhari, MD
Bryan Collier, DO
James Ebert, MD
Michele Holevar, MD
John Cumming, MD
Stanley Kurek, DO
Stuart Leon, MD
Peter Rhee, MD

Correspondence:

Samuel A. Tisherman, MD
Department of Critical Care Medicine
638 Scaife Hall
3550 Terrace Street
Pittsburgh, PA 15261
Phone: 412-647-9914
Fax: 412-802-3308
E-mail: tishermansa@upmc.edu

Statement of the problem

Penetrating wounds of the neck are common in the civilian trauma population. Risk of significant  injury to vital structures in the neck is dependent upon the penetrating object. For gunshot wounds,  approximately 50% (higher with high velocity weapons) of victims have significant injuries, whereas  this risk may be only 10-20% with stab wounds.

The management of injuries to the neck that penetrate the platysma is dependent upon the anatomic  level of injury. The neck has been decided into threes zones. Zone I, including the thoracic inlet, up to  the level of the cricothyroid membrane, is treated as an upper thoracic injury. Zone III, above the angle  of the mandible, is treated as a head injury. Zone II, between Zones I and III, is the area of controversy.  Because of the density of vital structures in this zone, multiple injuries are common ^[1] and can affect  length of stay ^[2]. Mortality, particularly for major vascular injuries may reach 50% ^[3]. Delayed  complications such as pseudoaneurysms or arteriovenous fistulae can affect long-term outcomes  ^[4]. Appropriate and timely management of these injuries is critical. For the patients with hard signs of significant injury, including active hemorrhage, expanding hematoma, bruit, pulse deficit,  subcutaneous emphysema, hoarseness, stridor, respiratory distress, or hemiparesis, operative  management is indicated. Controversy arises over management of the patient without significant symptoms. Our management of these patients has been evolving from an era of mandatory exploration, which led to many nontherapeutic explorations, to an era of more selective management based on clinical experience and new imaging capabilities. Is this justified? What are the specific  roles of physical examination and imaging in decision-making? Improved imaging modalities, such as high resolution computed tomography (CT) or specially-performed CT with angiography, might further improve management of these patients. In addition, some injuries to neck structures may not require operative intervention.

Goals of the Guideline

This guideline is designed to answer the following questions regarding the management of penetrating injuries to Zone II of the neck that penetrate the platysma:

1. Is operative management mandatory or is selective non-operative management appropriate?
2. Is physical examination adequate to rule out injuries to vascular structures or the aerodigestive tract?
3. Can duplex ultrasonography (US) or CT angiography rule out an arterial injury in patients with no hard signs of vascular injury on physical examination, thereby making arteriography unnecessary?
4. How should specific vascular injuries be managed?
5. Are both contrast studies (barium or gastrograffin swallow) and esophagoscopy needed to safely rule out esophageal injury?
6. Is there a need for immobilization of the cervical spine?

II. Process

The process utilized by this committee was developed by the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma (www.east.org). The committee agreed upon the questions to be considered. Literature for review included the following terms: human, trauma patients, penetrating, and neck; specific structures were also searched (larynx, trachea, esophagus, carotid artery, and jugular vein). Medline and EMBASE were searched from 1966 to 2006.

Articles were distributed among committee members for formal review. Each article was entered into a review data sheet that summarized the main conclusions of the study and identified any deficiencies in the study. Furthermore, reviewers classified each reference by the methodology established by the Agency for Health Care Policy and Research of the U.S. Department of Health and Human Services as follows: Class I: prospective, randomized, doubleblinded study; Class II:  prospective, randomized, non-blinded trial; Class III: retrospective series, meta-analysis.

An evidentiary table (Table) was constructed using the 145 references that were identified: Class I, 2 references; Class II, 26 references; and Class III, 105 references. Twelve of the references could not be classified. Recommendations were made on the basis of the studies included in this table. Level 1 recommendations, usually based on class I data, were meant to be convincingly justifiable on scientific evidence alone. Level 2 recommendations, usually supported by class I and II data, were to be reasonably justifiable by available scientific evidence and strongly supported by expert opinion. Level 3 recommendations, usually based on Class II and III data, were to be made when adequate scientific evidence is lacking, but the recommendation is widely supported by available data and expert opinion.

III. Recommendations

A. Selective workup – operation vs selective non-operative management

Recommendations

Level 1:
Selective operative management and mandatory exploration of penetrating injuries to Zone II of the neck are equally justified and safe.

Level 2:
No recommendations.

Level 3:
No recommendations.

Scientific foundation

Nonoperative management of penetrating neck wounds was common in the early 20th century. Based on a review of civilian experience, Fogelman and Stewart ^[5] recognized in 1956 that mandatory exploration led to less mortality than a strategy of observation. A significant number of seemingly asymptomatic patients with penetrating neck injuries actually have injuries ^[6]. In addition, negative neck explorations have little morbidity, though the financial cost is noteworthy; in 1981, Merion et al ^[7] estimated the cost of a negative exploration at $1,930. Although an exploration under local anesthesia is appealing in terms of limiting recovery time and costs, Almskog et al ^[8] found that neck explorations under local anesthesia, compared to general anesthesia, resulted in more hematomas and missed injuries. Consequently, mandatory exploration under general anesthesia for injuries that penetrate the platysma seemed reasonable in the 70s and 80s ^[9]. Some small studies even later recommend mandatory exploration ^[10].  Slowly, uncontrolled studies began to suggest that patients without clear signs of vascular or visceral injury could be observed ^[11-29], though observation for up to 48 hours may be necessary ^[30], depending upon use of ancillary tests. Evidence of chest injury does not seem to be an indication for neck exploration ^[31]. Most experience with selective exploration strategies has been in major trauma centers. Some have specifically recommended that a well-staffed teaching hospital with a trauma service and immediate availability of radiologic and endoscopic evaluations is needed ^[32]. Even in community hospitals with experienced surgeons, however, selective management may be safe ^[33]. The need for ancillary studies during observation remains unclear.

Saletta et al ^[34] reviewed 240 patients at Cook County Hospital who underwent mandatory neck exploration. Sixty three percent had negative explorations and had minimal morbidity. Thirteen of the 90 patients who had positive explorations did not have any clinical signs of the injury. Elerding et al ^[35] reviewed 75 patients who had undergone mandatory explorations, of which 56% were negative. In this series, however, all patients who had injuries had positive physical exams. Bishara et al ^[36] similarly reported a 53% rate of negative explorations with mandatory explorations. Twenty-three percent of injuries were not suspected clinically, especially venous and pharyngoesophageal injuries.

In the early 1970s, data suggesting the safety of a selective approach began to emerge. Sheely et al ^[37] reported improved outcomes of patients with penetrating injuries to the neck over a 22 year period with a move toward early operation for patients with obvious vascular or visceral injury and careful observation based on lack of clinical suspicion of injury, recognizing greater awareness of potential esophageal injuries. Ayuyao et al ^[38] studied 134 patients who had undergone mandatory explorations. Sixty eight percent were negative. Because of this high rate of negative explorations, they managed the next 109 patients selectively. Sixty-nine of these patients were successfully observed without operations.

Jurkovich et al ^[39] compared the results of mandatory exploration (the preference of the attending surgeon) in 47 patients with a selective approach in 53 patients utilizing 43 angiograms and 14 endoscopies. In the mandatory exploration group, there were 25 negative explorations. Twelve injuries were found but only 5 patients benefited from the studies. Noyes et al ^[40] examined the accuracy of a selective management strategy. Arteriography and laryngoscopy/bronchoscopy were 100% accurate, whereas esophagograms were 90% accurate and esophagoscopy was 86% accurate.

Meyer et al ^[41] questioned this new approach of selective exploration for penetrating neck injuries. In a series of 113 patients, they obtained arteriograms, laryngotracheoscopy, esophagoscopy and esophagography in each patient prior to a mandatory exploration. Forty-eight injuries were identified in 35 explorations. Of concern was the fact that 5 patients had 6 major injuries that were not identified by the preoperative testing. Thus they believed that a mandatory exploration approach was indicated.

In a series of 128 asymptomatic patients who were observed by Biffl et al ^[42] primarily based on physical examination, only 1 patient had a missed injury (from an ice pick). Only 15% of these patients required adjuvant tests. Sriussadaporn et al ^[43] also successfully observed 17 asymptomatic patients. Only 2 of 40 patients who underwent exploration did not need the operation, though they appeared to have deep wounds. In asymptomatic patients, Nason et al ^[44] found that 67% underwent negative explorations. All Zone II vascular injuries were symptomatic.

Narrod and Moore (45, 46) reviewed their 10-year experience with penetrating neck trauma. In the first 6 years, mandatory exploration led to a 56% rate of negative explorations. In the next 4 years, a selective management strategy was employed. Forty-one of 48 patients who underwent exploration had significant injuries ^[46], whereas 29 asymptomatic patients were observed without any missed injuries. Few ancillary studies were performed in this group.  In a large, retrospective study from Johannesburg, South Africa, Velmahos et al ^[47] compared results with patients who underwent immediate surgical exploration vs constant monitoring. In the exploration group, 3% of the explorations were unnecessary; mortality was 4.2%. In the monitoring group, 9% had missed injuries; mortality was 4%. Criteria for observation vs exploration were not clear making the interpretation of the 9% missed injury rate difficult.

The only randomized trial comparing mandatory neck exploration with a selective approach based on physical examination and radiographs was performed by Golueke et al ^[48] in 160 patients. There was no difference in hospital stay, morbidity or mortality.  Management of transcervical gunshot wounds deserves separate consideration because of the high likelihood of major injury ^[49]. Hirshberg et al ^[50] explored 41 patients with transcervical gunshot wounds. Twenty-eight had more than one zone of the neck involved. Although 7 patients did not have major injuries, 34 patients had 52 major injuries to cervical structures mainly involving vessels and the upper airway. Sixteen presented with life-threatening problems. They recommended mandatory exploration. In contrast, Demetriades et al ^[51] found that a selective approach based upon physical examination, angiography,  sophagoscopy and esophagography was safe.

Management of neck wounds in the military setting may be different than that in the civilian world. Prgomet et al ^[52] found that injuries that did not penetrate the platysma did not cause significant injuries. Forty-nine of 84 patients who underwent immediate exploration had injuries to vital structures. They also found that it was safe to close the wound primarily if it was seen within 6 hours of injury. In their experience, even extensive laryngotracheal injuries could be repaired safely ^[53].

There is little data on selective management of penetrating neck injuries in children. Small studies (54, 55) suggest that a selective management strategy is safe. 

B. Diagnosis of arterial injury

Recommendations

Level 1: 
No recommendations.

Level 2: 
CT angiography or duplex ultrasonography can be used in lieu of arteriography to rule out an arterial injury in penetrating injuries to Zone II of the neck.

Level 3: 
CT of the neck (even without CT angiography) can be used to rule out a significant vascular injury if it demonstrates that the trajectory of the penetrating object is remote from vital structures. With injuries in proximity to vascular structures, minor vascular injuries such as intimal flaps may be missed.

Scientific Foundation

In the era of mandatory neck exploration for penetrating trauma, there seemed to be little need for angiography, though some ^[9] suggested that the angiogram could assist in operative planning and thereby minimize morbidity, or rule out the need for exploration (56, 57). Physical examination, however, seemed unreliable for ruling out arterial injury ^[58]. Delayed pseudoaneuryms and neurologic events have been described in originally asymptomatic patients, prompting some to advocate angiography in all such patients ^[59]. A negative arteriogram in a stable patient can rule out an arterial injury ^[60]. North et al ^[61] reviewed the records of 139 stable patients with penetrating neck trauma. Patients who had at least soft signs of vascular injury (absent pulse, bruit, hematoma, or altered neurologic status) had a 30% incidence of vascular injury by angiography, whereas only 2 of 78 asymptomatic patients had injuries (one minor and one that did not affect management). Gunshot wounds were more likely than stab wounds to cause vascular injury. Similarly, Hartling et al ^[62] found that 43 patients with stab wounds to the neck and minimal symptoms had no significant injuries by angiography. Even in the 18 patients with physical findings consistent with a vascular injury, only 2 had significant injuries. Rivers et al ^[63] similarly questioned the value of angiography. Of 63 angiograms in 61 patients, only 6 were abnormal. Three were thought to be spurious on subsequent review, two were clinically insignificant, and one required surgery. No significant arterial injuries were identified by  arteriography in the absence of suggestive physical findings. No major arterial injuries were  discovered during exploration that were missed preoperatively. Angiograms did not alter the course of management.

In contrast, Sclafani et al ^[64] found that 10 of 26 patients who had positive angiograms for  penetrating vascular injury to the neck had undergone the angiogram solely because of proximity. Physical examination had a sensitivity of 61% and specificity of 80%. They also found no differences in their results based upon mechanism of injury. They suggested that proximity should not be abandoned as an indication for angiography in these patients. Menawat et al ^[65] performed angiography for proximity or soft signs of vascular injury. Fifteen injuries were found on 45 angiograms. Forty-two patients without any signs of injury were successfully observed without angiography or operation. Overall, only 1 patient had a significant injury that was not predicted by  physical examination.

In contrast, Nemzek et al ^[66] found that proximity, based on the addition of plain films or CT of the neck showing prevertebral soft-tissue swelling, missile fragmentation, or missiles adjacent to major vessels can be useful but are nonspecific radiographic signs.

To examine the cost effectiveness of angiography, Jarvik et al ^[67] studied 111 patients with penetrating neck trauma. Forty five of the 48 patients with vascular injuries had abnormal clinical findings. Management in the other 3 patients was not altered by the angiogram. They calculated the cost of screening angiography in asymptomatic patients to be approximately $3.08 million per central nervous system event.

Demetriades et al ^[68] prospectively compared physical examination and duplex US imaging to angiography in 82 stable patients with penetrating neck injuries. Only 11 patients had vascular injuries by angiography and only 2 of these needed to be repaired. The serious injuries were detected or suspected on physical examination, but 6 lesions that did not require treatment were missed (sensitivity 100% for serious injuries, but 45% for all injuries). By duplex US imaging, 10 of 11 injuries, including all serious ones, were identified, for an overall sensitivity of 91% (100% for clinically important lesions) and specificity of 99%. Further studies by Demetriades et al ^[69] included 223 patients. Of the 160 asymptomatic patients, 11 had injuries that did not require treatment. Overall, duplex US was 92% sensitive (100% for findings that required an operation) and 100% specific for defining an injury. Bynoe et al ^[70] similarly found that duplex US was 95% sensitive and 99% specific for vascular injuries after both neck and extremity trauma. The only missed injuries were 2 shotgun pellet injuries that did not need repair.

In a prospective, double-blind study, Montalvo et al ^[71] found that US identified all 10 significant injuries in 52 patients with penetrating neck trauma. Duplex US did not identify reversible carotid narrowing in one patient and did not visualize 2 vertebral arteries. Another report by the same group ^[72] found in 55 patients that duplex US had 100% sensitivity and 85% specificity.

Corr et al ^[73] reported that duplex US picked up 2 intimal flaps that were not identified on angiography.

Helical CT angiography is the newest technology to be tested for identifying vascular injuries from penetrating neck trauma. Because it might also be useful for identifying or ruling out other injuries, e.g., aerodigestive tract injury, this modality is particularly intriguing as a “one stop shop” to evaluate asymptomatic patients for selective operative management. The speed and resolution of this modality continues to improve. Gracias et al ^[74] have already recommended that if a CT demonstrates trajectories that are remote from vital structures, the need for additional invasive studies can be eliminated.

Munera et al ^[75] prospectively studied 60 patients, who had 10 vascular injuries. There was one missed injury by CT angiography because the study actually did not include the entire neck. They later ^[76] suggested that patients with bruits or thrill at admission may be better treated by undergoing conventional angiography because of the potential for endovascular therapy. Helical CT angiography is limited by artifact due to metal, which may obscure arterial segments; therefore, these patients should undergo conventional angiography. In the setting of a mandatory exploration protocol, Mazolewski et al ^[77] found that CT angiography, compared to operative findings, was 100% sensitive and 91% specific in 14 patients.

C. Diagnosis of esophageal injury

Recommendations

Level 1: 
No recommendations.

Level 2: 
Either contrast esophagography or esophagoscopy can be used to rule out an esophageal perforation that requires operative repair. Diagnostic workup should be expeditious because morbidity increases if repair is delayed by more than 24 hours.

Level 3: 
No recommendations.

Scientific foundation

The problem with penetrating injuries to the esophagus is that there are frequently no findings on  physical examination. Esophagography can miss the injury ^[78]. This is of grave concern since late  referral and management can lead to significant morbidity and mortality ^[79-81]. Early diagnosis and management, often with primary repair, leads to good outcomes ^[82-84]. Even gunshot wounds can  be closed primarily ^[85]; more complex repairs may lead to strictures ^[86]. Location of the injury can affect outcome as injuries above the arytenoid cartilages can be managed without intervention, whereas more inferior injuries require neck drainage to prevent a deep tissue infection ^[87]. Madiba et al ^[88] also found that patients with small injuries and contained perforation on contrast studies could be observed without operation unless there was another indication for exploration. All 26 patients with injuries had odynophagia. Of 17 patients managed non-operatively, only 1 developed local sepsis. Six patients had associated tracheal injuries. In addition, patients with tracheal injuries have worse outcomes if they have concomitant esophageal injuries (89, 90).

Weigelt et al ^[91] utilized a strategy of esophagography followed by rigid esophagoscopy if the esophagogram were equivocal to identify esophageal injuries in patients who had no or minimal symptoms after penetrating neck trauma. All 10 injuries in 118 patients were identified. Wood et al ^[92] found that esophagography alone was 100% sensitive and 96% specific in 225 patients. Ngakane et al ^[93] reviewed 109 patients with penetrating neck trauma. All patients with gunshot wounds underwent esophagography, while patients with stab wounds were only studied if they had pain with swallowing. Twenty-nine studies were performed and 4 injuries were identified. All were observed without intervention. Repeat contrast studies demonstrated resolution of the injury.

In 23 patients with esophageal injuries, Armstrong et al ^[86] found that esophagography only identified 62% of the injuries whereas rigid esophagoscopy detected all injuries. Srinivasan et al ^[94] found reasonable accuracy with flexible endoscopy. In 55 patients, flexible endoscopy identified the only 2 injuries, but suggested an injury in 4 patients, resulting in 4 negative explorations, for an overall sensitivity of 100% and specificity of 92%.

D. Value of the physical exam

Recommendations

Level 1: 
No recommendations.

Level 2: 
No recommendations.

Level 3: 

1. Careful physical examination, including auscultation of the carotid arteries, is >95% sensitive for 
2. detecting arterial injuries that require repair. Given the potential morbidity of missed injuries,
   imaging is still recommended.
3. Physical examination is inadequate to rule out injuries to the aerodigestive tract.

Scientific foundation

Early reports suggested that the physical examination is unreliable to rule out a vascular injury. McCormick and Burch ^[95] found physical examination of neck and extremity injuries yielded a 20% false negative rate and a 42% false positive rate. Metzdorff and Lowe ^[96] found an overall 80% accuracy of physical examination. Apffelstaedt et al ^[97] found that clinical signs were absent in 30% of patients with positive neck explorations and in 58% of patients with negative neck explorations, support their approach of mandatory exploration.

More recently, Demetriades et al ^[98] studied 335 patients with penetrating neck injuries. Sixty patients underwent exploration for positive physical examination findings or a positive workup, whereas 269 asymptomatic patients were observed. Only 2 of the latter patients later required elective procedures. In a subsequent paper, this group demonstrated that physical examination did not miss any major vascular or esophageal injuries that required intervention; though minor injuries were identified by angiography (1 of 8 required intervention) and esophagography. Using a selective approach based upon careful and repeated physical examinations, Gerst et al ^[99] observed 58 asymptomatic patients without sequelae. Of the 52 patients who underwent prompt exploration based upon physical examination, 17% did not have significant injuries. Beitsch et al ^[100] similarly found that only 1 of 71 asymptomatic patients had a vascular injury detected by angiography. Thus, in this patient population physical examination ruled out 99% of vascular injuries and the yield for angiography was 1.4%. Atteberry et al ^[101] found that if patients did not have physical examination findings of arterial injury (active bleeding, expanding hematoma or hematoma larger than 10 cm, a bruit or thrill, or a neurologic deficit) no vascular injuries were present based on angiography, duplex ultrasound, or clinical follow-up. They observed patients for at least 23 hours.

Conversely, Sekharan et al ^[102] found that only 2 of 30 patients who underwent exploration for hard signs of vascular injury did not have a significant injury. Twenty-three of 114 asymptomatic patients underwent angiography for proximity or involvement of another zone. Only one of these patients needed an operation. All 91 other patients with negative physical examinations were safely observed without imaging. Azuaje et al ^[103] found that 68% of patients with positive physical examination had a positive angiogram. Of the 89 patients with negative physical examinations, only 3 had positive angiograms, but none needed operations.

Overall, physical examinations had sensitivity of 93% and a negative predictive value of 97%. Both sensitivity and negative predictive value for injuries requiring operation were 100%.

Subcutaneous emphysema or crepitance are physical findings suggestive of aerodigestive tract injuries that may require operative intervention. Goudy et al ^[104] reviewed the cases of 19 patients with emphysema or crepitance. Twenty-one percent had dysphagia, 63% had stridor or hoarseness. Most underwent direct laryngoscopy and esophagoscopy. Patients without demonstrable injuries or small tears were successfully observed without exploration. The best study, though small, that attempted to determine if imaging adds to physical examination in the evaluation of patients with penetrating neck injuries was that by Gonzalez et al ^[105]. Forty-two patients who did not have obvious need for operation at admission underwent soft tissue dynamic CT of the neck and esophagography before mandatory exploration. All tracheal and carotid injuries were identified by physical examination. Two of 4 esophageal injuries (both from stab wounds) were missed by both CT and esophagography. CT was better than physical examination for identifying venous injuries, but most of these did not require intervention.

E. Management of specific vascular injuries

Recommendations

Level 1: 
No recommendations.

Level 2: 

1. Except for minimal intimal irregularities or small pseudoaneurysms without neurologic deficits, penetrating injuries to the internal carotid artery should be repaired, even when severe neurologic deficits are present.
2. Angiographic approaches to the vertebral artery are preferred to operative approaches for patients with bleeding from vertebral artery injuries.
3. Ligation of the jugular vein is appropriate for complex injuries or unstable patients.

Level 3: 
No recommendations.

Scientific foundation

Carotid artery injuries. The issues that arise regarding carotid artery injuries involve the questions of reconstruction, ligation or leaving the vessel occluded, vs non-operative management. In addition, operative strategies may include extending the incision beyond the neck via median sternotomy or anterior thoracotomy to obtain adequate vascular control ^[106]. Weaver et al ^[107] reviewed the results of reconstruction vs ligation vs non-operative management in 80 patients with penetrating carotid artery injuries. Arterial reconstruction provided the best outcome compared to ligation, except for non-occlusive minimal intimal injuries that required only observation. The main issue appeared to be ischemia. Concerns for hemorrhagic transformation of the ischemic brain in patients with pre-operative neurologic deficits ^[12] with reperfusion were unwarranted. Khoury et al ^[108] reviewed their experience with penetrating neck trauma in Beirut. Better outcomes were associated with early arterial repair, though hemodynamics also affected outcome.

Rao et al ^[109] advocated a selective approach to potential carotid artery injuries in stable patients. They recommended angiography for all injuries to zones I or III. For Zone II injuries, angiography was performed based on proximity. The carotid artery was ligated in 3 patients without neurologic deficits. All other carotid artery injuries were successfully repaired, some with polytetrafluoroethylene (PTFE).

Kuehne et al ^[110] examined the impact of a management algorithm for penetrating carotid artery injuries. Prior to implementation of the protocol, management was based on surgeon preference. Of 36 patients, 6 deteriorated, 6 improved, and 24 had no change after repair, ligation, or non-operative management. The new algorithm included routine angiography for stable patients and reconstruction of injured vessels, unless the vessel was already occluded or the injury was minimal. Except for 1 patient who died prior to carotid artery repair, all patients either stayed the same or improved with this management strategy. Mittal et al ^[111] proposed a grading scale for carotid artery injuries. In their series, all patients with internal carotid artery injuries were managed with interposition grafts. Common carotid artery injuries were treated either with primary repair or interposition grafts depending upon severity.

Advances in endovascular therapy may significantly change our strategies for management of  vascular injuries. Diaz-Daza et al ^[112] demonstrated good results with embolization and/or stents in 8 patients with 17 vascular injuries of the head and neck resulting in pseudoaneurysms, fistulae, or hemorrhage.

Vertebrals. Studies of vertebral artery injuries have not compared management strategies. They have focused mainly on the potential benefits of radiologic embolization (113, 114). Golueke et al ^[115] suggested that occlusion of the vessel was rarely an issue as long as the posterior inferior cerebellar  artery was intact. If intervention was needed, proximal and distal, if possible, embolization simplified  management. Complex pseudoaneurysms and arteriovenous fistulae can be managed with this  approach ^[116]. Even when surgical approaches were incomplete or unsuccessful, embolization could still be successful ^[117]. Yee et al ^[118] and Demetriades et al ^[119] similarly found embolization to be successful. Surgical approaches were recommended for severe hemorrhage. Non-operative management was appropriate for minimal injuries. In 43 patients with vertebral artery injuries, Reid and Weigelt ^[120] reported no issues of neurologic sequelae secondary to vertebral-basilar ischemia after proximal and distal control was attained operatively. Minor injuries were successfully observed.

Venous. If arterial injuries are managed non-operatively, or by radiologic embolization, there is a possibility of missing a significant venous injury. Sclafani and Sclafani ^[121] reported on successful angiographic embolization of penetrating vascular injuries to the face and neck. Even though 18% of the injuries involved arteriovenous fistulae, no clinically significant venous injuries were missed by angiography.

Regarding the operative management of venous injuries, Robbs and Reddy ^[122] and Nair et al ^[123] demonstrated the safety of ligation for injuries to the great veins of the neck or thorax, particularly if the patient were unstable or the needed repair would be complex. Although transient edema occurred, chronic venous stasis was not seen.

F. Cervical Spine Immobilization

Recommendations

Level 1: 
No recommendations.

Level 2: 
Immobilization of the cervical spine is unnecessary unless there is overt neurologic deficit or an adequate physical examination can not be performed, e.g., the unconscious victim.

Level 3: 
No recommendations.

Scientific foundation

The question arises as to whether or not routine immobilization of the cervical spine is indicated in patients with penetrating neck trauma and no obvious injury to the spine. Arishita et al ^[124] reviewed the experience during the Vietnam War with penetrating neck injuries. No immobilization was performed. Of these 472 patients, only 4 might have benefited from immobilization. They pointed out, however, that the risk of performing immobilization in a hazardous environment like this is substantial as 10% of casualties occur while helping other victims.

Barkana et al ^[125] pointed out that an immobilization device could cover up critical physical examination findings. In their review of military casualties in Israel, 8 of 36 patients who survived to hospitalization had important findings covered by the collar. Although 12 patients had fractures of the cervical spine, none of these were unstable and none needed surgical stabilization. Given this very low risk of an unstable spinal fracture, they recommended only immobilizing patients with neurologic deficits, patients for whom one can not obtain a physical examination, and patients with concomitant blunt trauma.

In a review of civilian trauma victims who had been assaulted, Rhee et al ^[126] found that neurologic deficits from penetrating assault were established and final at the time of presentation. They felt that concern for protecting the neck should not hinder the evaluation process or life saving procedures.

IV. Future Directions

Selective management of penetrating injuries to Zone II of the neck has become common for asymptomatic patients. The roles of physical examination, arteriography, duplex US, CT angiography,  esophagography, and esophogoscopy remain unclear. At the moment, the single imaging modality that holds the greatest potential for ruling out vascular, tracheal, and esophageal injuries is CT  angiography. Additional trials are needed to confirm this hypothesis. As the resolution of CT images  improve, accuracy will surely increase. Rapid definitive imaging studies may allow early discharge of patients with neck injuries.

The management of arterial injuries has been evolving as interventional radiologists gain experience  ith manipulation of the carotid arteries with balloon angioplasty and stent placement for non-trauma  ituations, such as strokes. Endovascular intervention is already standard for vertebral injuries. Ideally  andomized clinical trials should be considered to demonstrate the benefits of these approaches. As  nterventional radiologists and vascular surgeons become more adept with these techniques and  ase series accumulate, randomization may become unethical. Perhaps now is the time to do the definitive trials.

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