Defining Zone I of penetrating neck trauma: A surgical controversy in the light of clinical anatomy.

Journal of Trauma and Acute Care Surgery, Publish Ahead of Print DOI: 10.1097/TA.0000000000000978

Defining Zone I of Penetrating Neck Trauma. A Surgical controversy in the light of Clinical Anatomy

María Rita Rodríguez-Luna. Second Year Surgical Resident. Facultad Mexicana de Medicina. Universidad La Salle. Posgrado. Hospital Angeles Mocel.

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México DF. México. Resident and Associate Society of the American College of Surgeons

E-mail: [email protected]

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(RAS-ACS)

Joaquin E. Guarneros-Zárate. General Surgeon.

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Departamento de Anatomia. Facultad de Medicina. Universidad Nacional Autónoma de México. México DF. México

e-mail: [email protected]

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José Roberto Hérnandez-Méndez. Third Year Surgical Resident.

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Facultad Mexicana de Medicina. Universidad La Salle. Posgrado. Hospital Angeles Mocel. México DF. México

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Jorge Tueme-Izaguirre. Second Year Surgical Resident. Facultad Mexicana de Medicina. Universidad La Salle. Posgrado. Hospital Angeles Mocel. México DF. México. e-mail: [email protected]

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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Victor Noriega-Usi. Fourth Year Surgical Resident. Facultad Mexicana de Medicina. Universidad La Salle. Posgrado. Hospital Angeles Mocel. México DF. México. e-mail: [email protected]

Surgical Residency Program.


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Facultad Mexicana de Medicina. Universidad La Salle

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José Fenig-Rodríguez. General Surgeon. Program director of Hospital Angeles Mocel

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Corresponding author. María Rita Rodríguez-Luna.

Gelati 33 Consultorio 404. San Miguel Chapultepec . Delegación Miguel Hidalgo CP 11850. México DF. México

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E-mail: [email protected]

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Defining True Zone I of Penetrating Neck Trauma.

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Abstract. In 1969, Monson proposed a classification for triage purposes in penetrating neck trauma based in zones in a paper addressing carotid and vertebral injuries. Zone I below the jugular notch, even though it is not located in the neck itself, but in the superior mediastinum; Zone II from the latter point to the mandible angle and Zone III above mandible angle to the base of the skull. Ten years later, Roon published an alternate

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classification, considering a Low Zone extending from the clavicles to the cricoid cartilage, a more anatomical correct classification considering that its location at the base of the neck.

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Current publications take one of the two classifications either, despite making the mistake of defining the anatomical superior mediastinum and axilla as part of the neck region. Many authors have considered this differences as not clinically relevant, but the two

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classifications are still in use in the clinical research and decision-making process for treatment of penetrating neck injuries. What is a fact is that this anatomical region is complex on itself and surgical management of penetrating injuries to the vital elements crossing the superior thoracic aperture often requires a high anterior thoracotomy, median

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sternotomy or supraclavicular incision with claviculectomy in the search of vascular control

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for the carotid, vertebral, subclavian and axillary vessels. In the present paper, we consider to be appropriate to define the Zone I bellow the cricoid cartilage extending to the sternal

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angle encompassing a ―thoracocervicoaxiallary‖ zone. The acute-care surgeon must master this region for the treatment of penetrating injuries located in such a complex anatomical region. We present a historical review of the evolution in the surgical care of these wounds. Until now, we have no standardized classification leading to confusion among surgical students, and acute-care surgeons making it impossible for future systematic reviews and meta-analysis.

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Keywords. Penetrating neck trauma, superior thoracic aperture injury, carotid artery,

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superior mediastinum, subclavian vessels, neck surgical approach.

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Introduction Trauma to the Neck and Thoracic regions presents the highest rates of mortality in trauma patients. Mortality from Penetrating Neck Trauma (PNT) originates from exsanguinating hemorrhage and 24 hrs delay in the diagnosis of visceral injuries, the missed esophageal injuries the most lethal of all (1).

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Currently, PNT is classified into three zones depending on the location of the external injury on the surface of the neck. This classification seeks to standardize diagnostic and

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treatment principles, based on the potential internal injuries and the difficulty to obtain the necessary surgical exposure to resolve it. It helps the attending surgeon with a practical perspective, to decide between initial nonoperative management and assessment by

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imaging studies, or direct surgical exploration in patients without hard evidence of vascular or aerodigestive tract injury (2). Although the concept of zone-related management of PNT is a well-accepted principle among acute-care surgeons, a controversy still exists deep in the anatomical basis of the Zone I limits, and although this fact is common knowledge,

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there has been no attempt to correct it. As we shall see in the current paper, although

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superficially looks like a trivial controversy, the lack of this unified concept determines relevant academic, diagnostic and therapeutic dilemmas.

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Zones II and III share the angle of the mandible as its common boundary. However, when we try to address the actual Zone I actual limits, of which the superior limit is shared with Zone II, the trauma literature tears in two main answers. On the one hand, we could find the boundaries of the Zone I placing it on the horizontal planes that cross through the jugular notch and cricoid cartilage, and on the other hand, we could find its superior limit placing it below the jugular notch. The Zone I could lie above or below the superior aperture, depending on which author we believe is right defining its limits. 5


The importance of defining a unified boundary of Zone I is far beyond any single surgeon opinion: PNT management has radically changed over the last 50 years and is still evolving due to multiple clinical studies, advances in medical imaging, interventional radiology, and superior surgical techniques. However, how can we improve our comprehension in PNT management, if we cannot

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achieve to define the universally accepted Zone I boundaries? How can we compare the multiple clinical trials results if the operative definitions differ from each other? How can

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we explain to undergraduates and surgical residents that the ZoneI in PNT is not even in the neck? To approach our goal, we need to understand the origin of such controversy.

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Historical Background

Trauma to the Neck and Thoracic regions presents the highest rates of mortality in trauma patients. Mortality from PNT originates from exsanguinating hemorrhage and 24 hours

(1).

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delay in the diagnosis of visceral injuries being the esophageal injuries the most lethal of all

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Surgeons have learned surgical fundaments of trauma management from military experience probably since the dawn of human history (3), but also, we know that it is

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difficult to draw conclusions for civil trauma management from studies with military settings. Since World War I when most patients were managed expectantly, mortality was reported approximately 11% the principal causes were exsanguination and airway obstruction (4). Dr. Fogelman in 1956 proposed early neck exploration for penetrating neck injuries lowering mortality rates to 6%. This concept leads to an early surgical therapy and neck exploration for suspected vascular injuries. Based on these experiences mandatory

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surgical exploration for neck injuries with platysma penetration was accepted as a surgical dogma for several years to come, regardless of the high rate of negative explorations (5). Monson et al. in 1969 published a paper addressing the carotid and vertebral trauma (6); they utilized an arbitrary division of the neck based on the ease of surgical exposure to control the carotid arteries, especially the left one arising from the aortic arch. Its origin is

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located in the superior mediastinum, so they referred this area as Zone I, being defined bellow the jugular notch. Zone II was described between the latter and the angle of the

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mandible and Zone III up to the base of the skull. This was illustrated in one of the most utilized figures in trauma literature (Figure 1). The impact of this division in surgical practice was such that trauma surgeons easily adopted it as the classification of PNT until

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today, despite a fundamental anatomical error: Zone I of the ―Neck‖ actually lies inside the Thorax, not in the neck itself. A classification originally used for carotid trauma was used to classify the vast array of penetrating injuries to the neck, use for which it was not designed in the first place.

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Ten years later Roon and Christensen (7) presents at the thirty-eight Annual Session of the

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American Association for the Surgery of Trauma in 1978, their classical work in Neck Trauma, redefining the way as neck-penetrating injuries can be classified. They divided the

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neck as Superior, Middle, and Lower Regions (avoiding the use of the term Zones): The latter two sharing their boundary with the one used for Zones II and III in the Monson´s Classification. However, in contrast to the classifications used for the past ten years, they found the horizontal plane that crosses through the cricoid cartilage as a much sound boundary for the Lower and Middle regions as opposed to the jugular notch that divided the former zones II and I (Figure 2).

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Evolution in Neck Trauma Management In the years to come, the different studies dealing with penetrating cervical injuries adopted the Zones classification, some taking the superior limit of the zone I in the jugular notch and clavicles, and others at the level of the cricoid cartilage, focusing in the treatment of carotid, vertebral and pretracheal compartment injury. Nevertheless, the studies of the

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axillosubclavian injuries usually do not use this classification (8), although being part of the

adequately the PNT (9).

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large group of cervical lesions. This self-exclusion makes it harder to characterize

During the 1980´s decade, many authors addressed the need for surgical exploration in penetrating injuries some of them proposing a selective surgical approach (10), others

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pointing the need of mandatory neck exploration. Despite the controversy what couldn´t be denied the majority of this papers reported negative surgical exploration as high as 40 to 63% with the latter. Eventually, a more selective approach was adopted and work up studies such as barium esophagography, esophagoscopy, and neck arteriography reported to

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be sufficiently precise for predicting negative operative findings (11). The scientific papers

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addressing this new modality in neck trauma management relied on the Neck Zone Approach. As we advance in the second decade of the 21st century, the scientific literature

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regarding the treatment of PNT still differs in the definition of the Zone I boundaries, or even not use it at all (12). In 2013, the Western Trauma Association Algorithm for penetrating neck injuries (13) described this discrepancy as insignificant, according to the belief of many experts in trauma surgery, and holds the original classification described by Monson. Guides from the Eastern Association for the Surgery of Trauma (14) utilizes mainly the classification of Roon. Major textbooks of surgery and trauma differ from each other in the Zone I boundaries (2,15). 8


One undisputable fact is that the location of the external wound is not a reliable predictor of the injury vector. For instance, Low Et al. reported the lack of correlation between the external and the internal injuries supporting the use of Multidetector Computed Tomographic Angiography (CTA) (16). Overall, studies using CTA to evaluate PNT demonstrate it to be a highly sensitive and specific study with positive predictive values of

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75 to 100 percent and negative predictive values of 98 to 100 percent (17). These facts have lead to the evaluation of the hemodynamically stable patient with PNT with a single or ―No

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Zone‖ approach during triage and management. This novel modality in trauma research states that comprehensive physical examination, combined with CTA, is adequate for triage to identify or exclude vascular and aerodigestive injury after PNT regardless of the site of

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external injury in the neck and surely we will see an increasing number of reports related to it (18). However, despite the likely disappearance of the use of zoning in the triage of penetrating trauma, it is still important to try to unify the definition of the Zone I due to its

(19).

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intricated anatomical characteristics, requiring complex surgical management when injured

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Clinical Anatomy

Related to exsanguinating hemorrhage sources in the neck, two significant vascular

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territories can be compromised in PNT: Carotid and Subclavian (20). The carotid and internal jugular vein in the neck run behind the Sternocleidomastoid (SCM) muscle and into the carotid triangle, bounded by the superior belly of the omohyoid, the posterior belly of the digastric and anterior border of the SCM muscles in the anterior triangle of the neck (21). On the other hand, one of the most challenging vascular lesions a surgeon can confront with lies in the posterior triangle of the neck: The subclavian vessels (22). The subclavian arteries arise beside the carotid arteries: The left one has its origin in the aortic 9


arch, behind the manubrium sterni, and the right one in the brachiocephalic trunk, behind the superior border of the right sternoclavicular joint. From there, both find their way out from the superior thoracic aperture crossing the first rib on the floor of the omoclavicular triangle: the area bound between the clavicle, the posterolateral border of the SCM, and omohyoid muscle, below the horizontal plane of the cricoid cartilage (23). Their path enters

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the cervicoaxillar inlet behind the clavicle and subclavian muscle to reach the axilla behind the pectoralis major muscle. The subclavian vein runs parallel to the artery, both separated

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by the scalenus anterior muscle inserting at the scalene tubercle, found in the superior surface of first rib (24). The natural extension of the subclavian vessels behind and bellow the clavicles are the axillary vessels, running past the lateral border of the first rib. At this

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point, we must emphasize that when a surgeon accomplishes a partial resection of the clavicle to expose the subclavian-axillary vessels at the lateral border of the first rib, he is entering the axillary space. In other words, the superior component of the axilla is known as the cervicoaxillary inlet, bounded anteriorly by the posterior border of the clavicle, and

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anteriorly by the lateral border of the first rib. A particular vessel arises from the first

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portion of the subclavian vessels but runs in a parallel fashion with the curse of the carotid arteries: The vertebral arteries (25). These vessels are deepened in the posterior triangle of

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the neck and enter at the level of the sixth cervical vertebra the conduct formed from the superposition of the foramina transversaria located on its transverse process, situated deep in the pretracheal cervical fascia (26). The Actual Zone I of Neck Trauma Only now we can define a unique region: bounded above by the horizontal plane passing through the cricoid cartilage and the sixth cervical vertebra, below with the plane crossing horizontally through the sternal angle, encompassing the superior mediastinum inside the 10


thoracic cavity, encompassing the cervicoaxillary inlet external to it. Within this area, we have vital vascular structures contained in the superior mediastinum, superior thoracic aperture, the root of the neck and cervicoaxillary inlet, which can be harmed by a single penetrating injury. Just as the thoracoabdominal region, between the 6th and 10th ribs, where thoracic and abdominal organs project to the surface of the torso and can be injured

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simultaneously, this thoracocervicoaxillary counterpart must be mastered by acute-care surgeons, as a vascular and aerodigestive injury in it can be life-threating and surgically

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challenging (27).

The surgeon in need for vascular control in the carotid territory usually has to approach the neck through an incision parallel to the anterior border of the SCM muscle. If the injury

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locates at the base of the neck, this incision can be extended to the thorax with a median sternotomy, to gain vascular control at the level of the aortic arch in the superior mediastinum (28). In contrast, in the subclavian-axillary vessels territory injury, must expose the base of the neck and the cervicoaxillary inlet, dividing the clavicle to reach it. A

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left anterolateral thoracotomy must be done to gain vascular control at the aortic arch for

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the left subclavian vessels, and through median sternotomy for the right counterpart, two different surgical approaches, converging towards the superior mediastinum (29). Figure 3

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shows an example of the surgical approach to the origin of the left carotid and subclavian vessels, suggested by Demetriades et al. (30), Utilizing a median sternotomy and claviculectomy for such porpoise. No acute care surgeon can deny the clinical significance of such complex anatomy at the superior thoracic aperture (31). No wonder the selective operative approach in trauma below the cricoid cartilage has gained acceptance over the past two decades (32). To describe the superior mediastinum and the axillary inlet as a part of the neck is 11


academically incorrect, but its visceral content (Vascular and Aerodigestive tracts, among others) presents in a continuous manner through the superior thoracic aperture, extending through this three different regions (33). When injured, must be surgically addressed exposing the thorax and the neck and the axilla (34). Conclusion

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Two different definitions of the ―Zone I‖ in neck trauma exist in the surgical literature since 1978, by Monson (6), Roon and Christensen (7). The triage process of PNT has evolved

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since then, despite the obvious differences in such definitions and the exclusion of the cervicoaxillary trauma from the carotid and vertebral injuries. We propose to conceptualize the Zone I of the PNT triage classification extending bellow the cricoid cartilage to the

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sternal angle. In this way, it encompasses the superior mediastinum, the superior thoracic aperture, and the cervicoaxillary inlet. The vascular structures running from the aortic arch, passing through the root of the neck and entering the axilla behind the clavicles are contiguous vessels that can be potentially injured from a single penetrating insult in the

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thoracocervicoaxillary region. The importance of clarifying this zone lies in standard

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criteria unification for future clinical research, systematic revisions, and meta-analysis to come. The acceptance of the same operational definition of the PNT Zone I will allow

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better clinical trials, better scientific communication affecting better clinical outcomes in the work of trauma surgeons

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Figure Legends

Figure 1. Original PNT Classification by Monson et al. (From Monson DOMD, Saletta JDMD, Freeark RJMD. CAROTID VERTEBRAL TRAUMA. .J. Trauma-Injury Infect.

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Crit. Care.; 1969;9:987–999. With permission)

Figure 2. Original PNT Classification by Roon et al. (From Roon AJ, Christensen N.

1979;19:391–397. With permission)

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Evaluation and Treatment of Penetrating Cervical Injuries. .The Journal of Trauma.;

Figure 3. Median sternotomy and claviculectomy. Notice the surgical exposure obtained for

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the Toracocervicoaxillary region for penetrating injuries. (Modified from Demetriades D, Chahwan S, Gomez H, Peng R, Velmahos G, Murray J, Asensio J, Bongard F. Penetrating injuries to the subclavian and axillary vessels. J Am Coll Surg. 1999;188(3):290–5. With

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Permission)

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FIGURE 1

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FIGURE 2

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FIGURE 3

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