Neck ( Non Spinal ) Injuries

Introduc   tion This chapter aims to discuss the manage ment of soft tissue neck injuries. It is specifical ly directed away from the manage ment of the cervical spine and spinal injury in trauma patients. We mainly refer to penetrati ng neck injuries, however the assessm ent and manage

ment of any neck soft tissue injury should follow a common pathway in our opinion. Specific consider ation of skin involvem ent in these injuries is also left to other texts. Soft tissue injuries in the neck are difficult to assess and manage. This compact, important anatomic al area contains a dense concentr

ation of vital vascular, aerodigestive and nervous system structure s; many of which are not accessibl e to physical examinat ion and surgical exposure is a challeng e. There has been a shift away from early aggressi ve operative manage ment to a more selective and conserva tive approach , however controver

sy still exists. (Demetri ades et al. 1996) A thorough review of current literature has been made to give the best available evidence base; the referenc es are included at the end of the chapter.

General Points about soft tissue injuries of the neck

 

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Difficult to assess

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Difficult to manage

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Surgical exposure is a challenge

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Controversy regarding mandatory exploration or selective

 

conservatism  

 

History •

First documented treatment of vascular injury in the neck – Ambrose Pare 1510-1590

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1803, Fleming ligated lacerated common carotid artery

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2nd world war, 851 cases of neck injury were reported with a 7%

mortality, in Vietnam this rose to 15% (Thal 1988) •

1944, Bailey proposed early exploration of all cervical haematomas on the basis of wartime experience (Bailey 1944)

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1956, Fogelman and Stewart (Fogelmann & Stewart 1956) reported a series of 100 patients showing a mortality of 6% in patients undergoing early neck exploration versus 35% for those whose exploration is delayed. They advocated mandatory, early exploration of any wound penetrating the platysma.

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Subsequently the rate of negative neck explorations increased and the operative mortality fell leading to a selective approach to management challenging this older dictum (Asensio et al. 1991)

Neck anatomy The anatomy of the neck is unique as it contains many vital structures representing the most important body systems. Traditionally an anatomical scheme to look at the neck uses triangles, each triangle containing different vital structures and coated by muscle, fascia and skin. Classically the neck is divided into anterior and posterior triangles by the sternocleidomastoid muscle. The anatomical structures in the neck structures are invested by two fascial layers: 1.

The superficial fascia lies just beneath the skin and encompasses the body of platysma (a thin superficial muscle that originates over the upper part of the thorax and passes over the clavicles across the neck and blends with the superficial musculo-aponeurotic system (SMAS) of the face).

2.

The deep cervical fascia can be subdivided into investing, pretracheal and pre-vertebral layers.

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The investing fascia encompasses the sternocleidomastoid, omohyoid and trapezius muscles as it encircles the neck.

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The pre-tracheal fascia attaches to the thyroid and cricoid cartilages and blends with the pericardium in the thorax. It encloses the major neck viscera (thyroid gland, trachea & oesophagus)

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The pre-vertebral fascia encompasses the pre-vertebral muscles and blends with the axillary sheath, which houses the subclavian vessels.

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The carotid sheath is formed by all 3 components of the deep fascia.

Anatomy Neck contains structures representing different systems:  

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Cardiovascular 

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Respiratory 

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Digestive 

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Endocrine 

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Central nervous system

 

Such tight fascial compartmentalisation of the neck structures limits external  

bleeding from vascular structures (Fig. 1). This beneficial effect is countered by the dangers of bleeding within these closed spaces, which can

 

compromise the airway.

 

 

 

Figure 1: Cross sectional view of cervical fascial planes (from Gray SW, Skandalis JE, McClusky DA: Atlas of Surgical Anatomy. Baltimore, Williams & Wilkins, 1985, p15, with permission).

Penetrating neck injury is most commonly referred to in terms of zone of injury (Fig. 2), rather than triangles. This is because this allows knowledge of the possible structures involved, the need for additional specialised

 

investigations, surgery and prognosis.

 

 

Figure 2: Anatomic zones of the neck (from Feliciano, Moore & Mattox:  

Trauma 3rd edition. Appleton & Lange 1996, p330, with permission).

 

Anatomic zones of injury  

Zone

Boundaries

I

Structures at risk   Proximal Common Carotid, Vertebral and Subclavian Arteries

Clavicles inferiorly to the inferior aspect of the Major vessels of the Superior Mediastinum, Cricoid cartilage Apices of the lungs Oesophagus, Trachea and Thoracic Duct Carotid and Vertebral Arteries and Internal Jugular Vein

II Cricoid cartilage inferiorly up to the angle of the mandible

Larynx, Trachea & Oesophagus Vagus nerve, Recurrent

(Note - Some authors use the inferior border of the mandible as the upper boundary of zone 2) (Demetriades et al. 1997) Mechanisms of injury  

Classification of neck injury can be accomplished in different ways. The anatomical site of injury and the related structures are vital, however the

 

history, mechanism and pattern of injury also give us important information and clinicians should get as much history as possible from the pre-hospital carers / ambulance personnel.

 

  

 

Epidemiology •

The typical victim sustaining a penetrating neck wound is male in his late 20’s (Miller & Duplechain 1991)Male: Female =5:1 (Markey, Jr.,

 

Hines, & Nance 1975) •

Although one might expect that the number of firearm injuries to have increased over the last 30 years, both firearm and stab wounds have increased at a comparable rate (Markey, Jr., Hines, & Nance 1975;Noyes, McSwain, Jr., & Markowitz 1986;Saletta et al. 1976)

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The most common site of injury is the anterior triangle of the neck

Initial management An “ABC” approach to all trauma patients has now become standard thanks to the teaching of Advanced Trauma Life Support (ATLS). As part of this teaching, the assessment and immediate management of life threatening problems go hand in hand in a stepwise progression. The presence of a bleeding neck wound shouldn’t detract from an airway injury, respiratory distress, stridor and altered level of consciousness mandating emergency airway management. (Walls, Wolfe, & Rosen 1993) The importance of this process cannot be emphasised too much; approximately 10% of patients with penetrating neck injuries present with airway compromise. (Pate 1989) 2540% have a vascular injury (10% carotid artery), 10% have a respiratory tract injury. Expeditious pre-hospital transfer without intervention in the urban environment, gives the patient with life threatening soft tissue neck injury the best chance of survival. Airway and respiratory care are paramount and early endotracheal intubation should be considered if patients present with symptoms of respiratory obstruction: •

Restlessness

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Stridor

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Air hunger

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Hoarseness

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Tracheal tug

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Retraction of supraclavicular, intercostals or epigastric areas

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Cyanosis

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Inability to swallow and drooling

Prophylactic intubation is preferred in as controlled a fashion as possible rather than emergency intubation, cricothyroidotomy or tracheostomy. Patients should be assessed and initially treated in a Trendelenburg position in order to minimise the chances of air embolism. Direct pressure is used to control external haemorrhage. Vascular access

should be attained, ideally on the contra-lateral side to the injury and blood is taken for cross-match of 6 units of packed red blood cells. If bleeding cannot be controlled by direct pressure, balloon-tamponade may be attempted (Gilroy et al. 1992), however blind / non-selective clamping of vessels should be avoided to prevent further injury to structures. The insertion of a nasogastric tube at this early stage should be avoided to keep patient agitation to a minimum and to prevent bleeding which had previously been controlled. Demetriades (Demetriades, Asensio, Velmahos, & Thal 1996) suggests an algorhythmn for evaluation of penetrating neck injuries (Figure 3)

 

 

 

Figure 3: Algorithm for neck injury evaluation (with permission) There are other schemes based on findings in zones of the neck, (Klyachkin et al. 1997;Velmahos et al. 1994). The basic aim is to have a fast and effective method of assessment, so that injuries are not missed and over treatment avoided. A chart to aid the examination and recording of this type of injury has been proposed by Demetriades et al (Figure 4). Some authors feel that examination alone is sufficient in the assessment of Zone 2 neck injuries whilst others feel that it is reliable in all Zones (Demetriades et al.

 

1995;Demetriades, Theodorou, Cornwell, Berne, Asensio, Belzberg, Velmahos, Weaver, & Yellin 1997;Jarvik et al. 1995;Kendall, Anglin, & Demetriades 1998;Velmahos, Souter, Degiannis, Mokoena, & Saadia 1994). We feel that this chart allows a methodical examination of the structures involved in penetrating neck injury and serves as a template for notes and research. Its universal adoption would allow better communication (Atta & Walker 1998). Emergency Treatment

 

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ABC approach

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Direct pressure to control bleeding

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Immediate transfer to hospital

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Thorough clinical examination

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Operate or investigate

 

 

 

 

Figure 4: From Demetriades D, Asensio JA, Velmahos G et al; Surgical Clinics of North America 76:664, 1996 (with permission)

 

Investigations

 

Adve rtise

Investigations available Plain lateral cervical spine XRay

Indications All patients

CT

Stable patients with foreign body, laryngotracheal or oesophageal injury suspected

Angiography

Injury to all Zones I-III in haemodynamically stable pts*

Colour flow Doppler 4 QUOTE "(Demetriades, Theodorou, Cornwell, III, Weaver, Yellin, Velmahos, & Berne 1995;Demetriades, Theodorou, Cornwell, Berne, Asensio, Belzberg, Velmahos, Weaver, & Yellin 1997;Ginzburg et al. 1996;Peter Corr, ATO Abdool Carrim, & John Robbs 1999)"

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