1. • Patients that sustained penetrating neck trauma
• 12/2008-03/2011
• prospectively analyzed
• Location of the external wound(s) documented
• Internal injuries were then correlated with the
external wounds
• An internal injury was defined as “unexpected”
if it was located outside the borders of the neck
zone corresponding to the external wound.
• Soft signs included venous oozing,
nonexpanding hematomas, minor hemoptysis,
dysphonia, and subcutaneous emphysema.
• Hard signs included active hemorrhage, pulsatile
hematoma, bruit or thrill, shock unresponsive to
fluid resuscitation, massive hemoptysis or
hematemesis, and bubbling at the injury.
Background
The Utility of the Anatomic Neck “Zones” of the Neck in the
Assessment of Penetrating Neck Injury
Garren Low, MS1, Kenji Inaba, MD2, Konstantinos Chouliaras, MD2, Bernardino Branco, MD2, Lydia Lam, MD2,
Elizabeth Benjamin, MD2, Jay Menaker, MD2, Demetrios Demetriades, MD, PhD2
1Keck School of Medicine of USC, 2LAC+USC Medical Center, Division of Trauma Surgery and Surgical Critical Care, Los Angeles, CA, USA
Objective
Results
References
Traditionally, the anatomic
zones of the neck have
guided the diagnosis and
treatment of penetrating
neck trauma. Unfortunately,
this resulted in a high rate of
negative exploration.
The objective of this project is to characterize the
association between external wounds and the
corresponding internal injuries after penetrating
neck trauma in order to identify the clinical utility
of the anatomic zones of the neck.
Inaba K, Branco BC, Menaker J, et al. Evaluation of multidetector computed
tomography for penetrating neck injury: a prospective multicenter study. J
Trauma Acute Care Surg. 2012 Mar;72(3):576-83.
Inaba K, Munera F, McKenney M, et al. Prospective evaluation of screening multislice
helical computed tomographic angiography in the initial evaluation of
penetrating neck injuries. J Trauma. 2006;61:144–149.
Demetriades D, Theodorou D, Cornwell E, et al. Evaluation of penetrating injuries of
the neck: prospective study of 223 patients. World J Surg 1997; 21:41.
Demetriades D, Salim A, Brown C, et al. The neck with complex anatomic features
and dense concentration of numerous vital structures. Curr Probl Surg. 2007
Jan;44(1):6-10.
Materials and Methods
• The traditional approach to penetrating neck
trauma utilizes the zones of the neck as the
primary basis for management.
• Zone II injuries are explored
• Zone I and III injuries investigated by a
combination of catheter-based
angiography, bronchoscopy,
esophagoscopy, and contrast swallow
evaluation.
• Surgical accessibility of the underlying
structures and the presumption that the
external & internal wounds correlates.
• 27% patients with a documented internal injury
were found to have an injury in an unexpected
location. This brings into question the entire
foundation of the traditional zone approach.
• Although this is the first study that evaluates
the relationship between the external wound
location and the internal injuries, collecting a
sufficient number of patients remains difficult.
Due to the complexity of neck anatomy, a
greater sample size would be needed to provide
more power.
• This would also show a larger spread of
unexpected injuries.
In the 32 patients with hard signs, 27 (84%) had an internal
injury. The mechanism of injury (MOI) was gunshot wound
(GSW) in 15 (47%) patients & stab wound (SW) in 16 (50%).
Twenty (74%) patients had an internal injury in an expected
location. The remaining seven (26%) patients had
unexpected injuries.
Zone 1
Zone 2
Zone 3
Penetrating Neck
Injury
Hard Signs
(n=32)
OR
Soft Signs
(n=114)
CT Angio
No Signs (n=189) Observation
Discussion
2
1
1
1
2
0
2
4
6
8
10
12
14
16
Vascular Aerodigestive Vascular Aerodigestive Vascular Aerodigestive Vascular Aerodigestive Vascular Aerodigestive
Zone I Zone II Zone III Multiple Zones No External Neck Wound
Injuries resulting in Hard Signs
Expected Unexpected
In the 114 patients that had soft signs, only 10 (8%) had an
internal injury. The MOI for this group was GSW in 54 (47%)
& SW in 58 (51%). Seven (70%) of the 10 patients had
expected injuries. The remaining three (30%) patients had
unexpected injuries.
1
0
1
2
3
4
Vascular Aerodigestive Vascular Aerodigestive Vascular Aerodigestive Vascular Aerodigestive Vascular Aerodigestive
Zone I Zone II Zone III Multiple Zones No External Neck
Injuries Resulting in Soft Signs
Expected Unexpected