Contemporary Problems in Trauma Surgery

0039-6109/91 $0.00

+ .20

Management of Penetrating Neck Injuries The Controversy Surrounding Zone II Injuries

Juan A. Asensio, MD, FAGS, * Garl P. Valenziano, MD, FAGS, t Robert E. Falcone, MD, FAGS,:!: and Julieta D. Grosh, MD, FAGS§

HISTORICAL PERSPECTIVE The first documented case of the treatment of a cervical vascular injury is attributed to the French surgeon Ambrose Pare (1510-1590), who was able to ligate the lacerated carotid artery and jugular vein of a wounded French soldier. 38 The patient's survival was complicated by the development of a profound neurologic defect consisting of aphasia and left-sided hemiplegia. In 1803, Fleming ligated the lacerated common carotid artery of a sailor, with a successful outcome. 27 In 1811, Abernathy ligated the lacerated left common and internal carotid arteries in a patient who had been gored by a bull. This patient developed a profound hemiplegia and subsequently succumbed to his injury. 86 The military setting of the first two reported cases served as a prelude to the importance of the many surgical advances that were to be made during wartime. Armed conflict has always provided the surgeon with an opportunity to advance the science of trauma surgery. Historical reviews of deaths resulting from neck wounds in various wars reveal a mortality rate ranging from 7% to 18% (Table 1).6.39.47.59 In World War II, 851 cases of neck injury were reported, with a mortality rate of 7%, which constitutes

*Director,

Surgical Critical Care and Surgical Intensive Care Units; Staff Surgeon, Trauma Surgery Service; and Assistant Professor of Surgery, Temple University Hospital, Philadelphia, Pennsylvania tAssistant Professor of Surgery, Tufts University School of Medicine; and Director, Trauma Services, Baystate Medical Center, Springfield, Massachusetts :j:Clinicai Assistant Professor of Surgery, The Ohio State University; and Chief, Trauma Surgery, Grant Medical Center, Columbus, Ohio §Associate Professor of Surgery and Former Director, Trauma Surgery, Temple University Hospital, Philadelphia, Pennsylvania

Surgical Clinics of North America-Vol. 71, No.2, April 1991

267

268

JUAN A. ASENSIO ET AL.

Table 1. Mortality Rates of Military and Civilian Neck Wounds WAR

American Civil War Spanish-American War World War I World War II Vietnam Civilian experience I

NO. OF REPORTED CASES

MORTALITY

4114 188 594 851

15 18 11 7 15 3.74-5.85

? 4193

(%)

the lowest mortality rate reported in all of America's wars.47 During the Vietnam conflict, the mortality rate for these injuries was 15%.82 The current mortality rate in the civilian arena is reported to range from 0 to 11%.* During this century, two landmark concepts revolutionized the management of penetrating neck injuries. In 1944, Bailey proposed early exploration of all cervical hematomas on the basis of his wartime experience. 5 In 1956, Fogelman and Stewart,28 in a classic study, reported a series of 100 patients from Parkland Memorial Hospital in Dallas, in which they showed a 6% mortality rate in patients undergoing early neck explorations versus a 35% mortality rate in those patients not immediately managed surgically or undergoing exploration on a delayed basis. Those authors also demonstrated an increase in the mortality rate in those patients explored after 6 hours. On the basis of their experience, they advocated early exploration of every neck injury violating the platysma. Mandatory exploration thus became the mainstay of surgical management for penetrating neck injuries. As time elapsed, the operative mortality rate was noted to decline, with a concomitant rise in the rates of negative neck explorations, which ranged from 40% to 63%. On the basis of these figures, a selective approach to the management of these injuries emerged to challenge the old dictum of mandatory exploration. The concept of selective management seeks to identify through various diagnostic criteria those patients who would benefit from early surgical intervention in order to decrease the rate of negative explorations. A heated controversy has emerged between those who favor mandatory exploration and those who support the selective approach. The mandatory exploration camp supports its viewpoint by contrasting the catastrophic consequences of missed injury with the very low morbidity of neck exploration, whereas the selective exploration camp supports its approach by demonstrating a decrease in the rate of negative neck exploration along with a higher yield of findings at the operating table in light of equally good outcomes. In this era of government supervision and cost containment, both camps provide evidence of low morbidity and mortality rates with their respective approaches. Indeed, both camps cite cost containment as the strongest plank of their platform to support their respective policies. Who is right? It is the purpose of this article to compare management *References I, 4, 7, 8, 11-13, 16, 18, 22, 23, 26, 31, 36, 37, 42-44, 46, 49-54, 56-58, 60, 61, 69, 71, 72, 74-76, 79, 80, 82, 87, 90.

269

MANAGEMENT OF PENETRATING NECK INJURIES

approaches and to review the management of penetrating zone II neck injuries from the viewpoint of both camps and as such to examine the controversy thoroughly.

ANATOMY: THE UNIQUE DESIGN OF THE NECK The anatomy of the neck is unique. In no part of the body are there so many vital structures located within such tight confines, nor is there any other area of the body that houses representative structures of so many different systems-the cardiovascular, respiratory, digestive, endocrine, and central nervous system. Neck structures are invested by two fascial layers: the superficial fascia, which encompasses the platysma, and the deep cervical fascia, which is subdivided into the investing, pretracheal, and prevertebral layers. The investing fascia encompasses the sternocleidomastoid muscle; the pretracheal fascia attaches to the thyroid and cricoid cartilages and blends with the pericardium in the thoracic cavity. The prevertebral fascia encompasses the prevertebral muscles and blends with the axillary sheath, which houses the subclavian vessels. The carotid sheath is formed by all three components of the deep cervical fascia. Such tight fascial compartmentalization of the neck structures limits external bleeding from vascular injuries, thus minimizing the chance of exsanguination. This apparently beneficial effect is countered by the effects of bleeding within these closed spaces, which frequently compromises the airway. The neck is divided into three anatomic areas69 (Fig. 1): Zone I extends from the clavicle to the cricoid cartilage. Zone II extends from the cricoid cartilage to the angle of the mandible. Zone III extends from the angle of the mandible to the base of the skull.

Knowledge of cervical anatomy, coupled with an effort to conceptualize Zone III THYROID CARTILAGE

Zone II

Zone I

Figure 1. Anatomic zones of the neck.

CRICOTHYROID MEMBRANE

• 270

JUAN A. ASENSIO ET AL.

which structures lie within each zone, allows the surgeon to institute a systematic diagnostic search of the three key anatomic components of the neck: the cardiovascular system (subclavian, carotid, and vertebral arteries; jugular and subclavian veins); the respiratory system (trachea and larynx); and the digestive system (pharynx and esophagus). Injuries in zones I and III represent difficult problems for the surgeon from the standpoint of diagnosis and surgical approach. Injuries in zone II are easier to diagnose and explore because this is the most exposed portion of the neck.

DIAGNOSIS AND EVALUATION The initial approach to the management of the patient who has sustained penetrating neck trauma should follow closely the resuscitative and diagnostic protocols outlined in the Advanced Trauma Life Support Manual (ATLS) of the American College of SurgeonsY Early attention should be turned to securing an airway, because bleeding within the tight fascial compartments of the neck will later preclude doing so, with catastrophic results. A careful history should then be obtained. Much information can and should be gathered from the emergency medical service (EMS) personnel attending the victim at the scene, but unfortunately, their valuable contribution is oftentimes ignored. Vital data that should be sought from EMS personnel are the initial vital signs, the patient's initial response to management, the mechanism of injury and wounding agent(s), the presence or absence of profuse bleeding at the scene, and the presence or absence of neurologic and respiratory impairment. The surgeon should then focus on the history, establishing the presence of pain and its location and whether the patient is experiencing difficulty in breathing, talking, or swallowing. The physical examination should be systematic, with early attention to locating the injury site(s), noting the presence of the entrance and any exit sites while attempting to elucidate the trajectory of the wounding ageilt. The injury should then be classified into one of the previously described zones. Knowledge of the anatomic structures within each zone will allow the surgeon to suspect which injuries may have occurred and to select the appropriate diagnostic tests. At the same time, the surgeon may begin to devise a preoperative plan to search for injuries at the operating table. The platysma protects the underlying structures of the neck. Thus, every effort must be made to determine whether the platysma has been violated; however, injudicious probing of the wound may be fraught with danger, as a vascular injury that has ceased to bleed may then resume as its tamponade is released-with disastrous results. Physical findings serving as reliable indicators of injuries to the vascular structures in the neck include pulsatile or expanding hematomas, the absence of pulses, the presence of bruits, and active external hemorrhage. A global neurologic defect associated with aphasia or hemiplegia likewise signals an underlying vascular injury. Oftentimes, however, a thorough neurologic examination cannot be performed, as many patients are admitted

• MANAGEMENT OF PENETRATING NECK INJURIES

271

to the trauma resuscitative area in shock and cannot cooperate with such an examination. Focal neurologic defects such as facial sensory deficits, drooping of the corner of the mouth, or deviation of the tongue indicate injury to the cranial nerves, whereas peripheral sensorimotor defects indicate brachial plexus injury. The presence of subcutaneous emphysema signals violation of the respiratory or digestive tract, whereas pain along the cricoid or thyroid cartilages or the tracheal cartilaginous rings signals injury to the respiratory tract. Once the patient has been resuscitated and stabilized and the history and physical examination are complete, the surgeon faces the first triage decision: to operate or to investigate. No disagreement exists about the immediate surgical management of those patients who are hemodynamically unstable or those who present with exsanguinating hemorrhage or expanding hematoma. Those patients who are hemodynamically stable may undergo a diagnostic evaluation. This evaluation should cover the three key anatomic components of the neck, namely the cardiovascular, respiratory, and digestive systems. The investigative armamentarium includes arteriography, laryngoscopy and bronchoscopy, esophagoscopy, and computed tomography (CT). Establishing the diagnosis of vascular and respiratory injury has been greatly facilitated by the reliability of the available diagnostic tools, whereas the diagnosis of cervical esophageal injury remains a dilemma given the unreliability of a single test. Arteriography remains the gold standard in vascular injury. It is both accurate and reliable for the exclusion of cervical vascular injury, as reported in several studies. 33, 45, 63, 77 Laryngoscopy and bronchoscopy facilitate the exclusion of laryngeal and tracheal injury; however, at times, they can be difficult to perform, particularly when a patient is awake or uncooperative. Computed tomography scanning can be a valuable adjunct to laryngoscopy and bronchoscopy. The most difficult diagnosis to establish is that of an esophageal injury, and certainly the weakest tool in the diagnostic armamentarium is esophagography. Esophageal injury can be diagnosed if a leak is demonstrated after the administration of contrast medium. However, esophagography has a sensitivity of only 70% to 80%.13,55,88 In a recent study by Weigelt and coworkers,88 the combination of esophagography and rigid esophagoscopy missed no injuries, whereas flexible endoscopy missed several injuries. The latter is not considered diagnostically reliable. Rigid esophagoscopy has notable disadvantages in that it requires a general anesthetic and always poses a risk of esophageal rupture. The indications for the various diagnostic techniques can be summarized as follows. 3, 78 Arteriography is used for injuries near vessels in zones I and III, as well as for injuries in zone II, if the patient has been entered in a selective management protocol or if a strong suspicion exists that the patient is harboring injuries to the carotid or vertebral arteries or both. Furthermore, arteriography can be utilized for the preoperative outlining of the neck vasculature and the cerebral circulation and its crossover. This study often provides helpful data for intraoperative decision making. Laryngoscopy and bronchoscopy are used if sufficient evidence of respiratory system injuries exists from the history and physical examination. This study

272

JUAN A. ASENSIO ET AL.

Table 2. Overall Mortality: A Comparison By Management Approach

Mortality Range

MANDATORY

SELECfIVE

(11 Series)

(24 Series)

5.85% 0.8-11.0%

3.75% 0-9.8%

can be supplemented by CT scanning of the larynx and trachea. Esophagography is used to rule out esophageal injury, provided the surgeon is familiar with the study's diagnostic limitations. If the results are equivocal, or if sufficient evidence exists from the history and physical examination, rigid esophagoscopy is performed.

A COMPARISON BY MANAGEMENT APPROACH

The greatest difficulty in trying to derive meaningful conclusions regarding which approach is better is posed by the lack of uniformity in the manner of reporting penetrating neck injury. The ideal study format should list the number of cases; their initial clinical presentation, including the number presenting in shock; and a thorough description of the diagnostic work-up, along with the percentages of positive and negative findings, the percentages of false-positive or false-negative findings, and the reliability and morbidity of each individual test. Other important factors are a thorough breakdown of which patients were observed, evaluated and observed, initially observed but later required surgical exploration, and surgically explored initially. The morbidity and mortality rates of each approach should then be listed, along with a thorough description of the injuries encountered, their operative or nonoperative management, and the relative incidence of each of these injuries. Unfortunately, the ideal study does not exist in the literature. In an attempt to establish some basic data to compare management approaches, the authors extensively reviewed the literature. In order to establish the mortality rate and range, 11 series advocating the mandatory approach were reviewed. 8 , 23, 28, 36, 43, 46, 52, 69, 72, 79, 87 The calculated average mortality rate for these series is 5.85%, with a range of 0.8% to 11%. * Also, 24 series advocating the selective approach were reviewed, which resulted in a calculated mortality rate of 3.74%, with a range of 0 to 9.8% (Table 2), These figures are not noticeably different. To establish the exploration rates according to the management approach, 10 series advocating the mandatory approach were reviewed. 8, 23, 28, 36,43,46,52,69,72,87 In this review, 1653 cases were collected, of which 1492 (90,2%) were explored; 161 (9.8%) were observed initially, with only 3 (1.86%) of these patients later requiring an exploration. Of the 16 series reviewed advocating the selective approach, 4, 7, 11, 22, 26, 44, SO, 53, 56, 60, 61, 74, 75, 60,90 a total of 2540 cases were collected, among which 1596 patients (62,8%) *References 4, 7, 11, 16, 18, 22, 23, 26, 37, 42, 44, 49-51, 53, 55, 56, 60, 61, 74-76, 80,90.

273

MANAGEMENT OF PENETRATING NECK INJURIES

Table 3. Exploration Rates: A Comparison By Management Approach

Total No. of cases No. of cases explored and % No. of cases observed and % No. of cases observed later requiring exploration and %

MANDATORY

SELECTIVE

(10 Series)

(16 Series)

1653 1492 (90.2%) 161 (9.8%) 3 (1.86%)

2540 1596 (62.8%) 944 (37.2%) 20 (2.11%)

were initially explored, ;nd 944 (37.2%) were observed. Of the cases initially observed, only 20 (2.11%) later required an exploration. A significant difference exists between approaches, with a 30% greater exploration rate in the mandatory group. Remarkably, the initial diagnostic accuracy of both approaches is sound in that only a small percentage of patients initially observed later required an exploration (Table 3). A clinical difference exists with regard to the operative findings in both approaches. Of the 1492 cases explored in the mandatory group, 803, or 53.82%, had positive explorations and 689, or 46.18%, had negative explorations. Of the 1596 cases from the selective approach, 1117, or 70%, had positive findings on exploration and 479, or 30%, had negative explorations (Table 4). The selective approach increases the percentage of positive findings at exploration by approximately 16% over the mandatory approach along with a similar and concomitant decrease in the negative exploration rate. Looking at the systems injured, the two groups of studies had similar rates of arterial, venous, digestive, and respiratory tract injuries (Table 5). In penetrating neck trauma, vascular injury predominates, with venous injuries appearing to be more common. Less common but as important were injuries to the digestive tract and respiratory tract, which occurred with similar frequencies. A breakdown of arterial injuries is given in Table 6. No significant differences exist with regard to the incidence of arterial injuries managed by the two approaches, the common carotid artery being the most frequently injured vessel. Remarkably, the 2% incidence of subclavian arterial injury is similar to the incidence of injuries to the internal and external carotid arteries. The incidence of venous injuries likewise was similar for the two approaches (Table 7). In summary, the locations and types of injuries managed by the two approaches were very similar. The most remarkable difference between the

Table 4. Operative Findings: A Comparison By Management Approach

Total No. of cases explored No. of positive explorations and % No. of negative explorations and %

MANDATORY

SELECTIVE

(10 Series)

(16 Series)

1492 803 (53.82%) 689 (46.18%)

1596 1117 (70%) 479 (30%)

274

JUAN A. ASENSIO ET AL.

Table 5. Systems Injured: Comparison by Management Approach MANDATORY (10 SERIES; n = 1653)

SYSTEM INJURED

213 310 163 150

Arterial Venous Digestive (pharynx and esophagus) Respiratory (larynx and trachea)

(16

SELECTIVE SERIES; n =

(12.9) (18.75) (9.86) (9.07)

303 459 191 181

2540)

(11. 9) (18.0) (7.51) (7.12)

two groups of reports is a 16% higher rate of positive explorations in the selective management approach.

OVERALL MANAGEMENT PRINCIPLES The indications for formal exploration of anterior necks wounds penetrating the platysma (Fig. 2) can be subdivided according to the organ systems represented in the neck. Vascular indications for exploration are a history of substantial blood loss, persistent and ongoing hemorrhage, and a pulsatile or expanding hematoma (Fig. 3). Respiratory indications for exploration include hemoptysis, crepitation, and dysphonia; digestive indications include hematemesis, dysphagia, and crepitation; and nervous system indications include neurologic deficits. As previously stated, the achievement of an airway early in the management of these injuries is crucial to a successful outcome. Early intubation by the oral or nasotracheal route is instituted. If these maneuvers are unsuccessful in establishing an airway, a cricothyroidotomy must be performed. The patient is oxygenated and ventilated and should be typed and cross-matched for at least four to six units of packed red blood cells. The insertion of a nasogastric tube should not be attempted in the resuscitation area, because hemorrhage from a vascular injury previously contained by tamponade may be released by the retching induced during the insertion. The patient should be resuscitated with warm crystallOid solutions according to the protocols outlined in the ATLS Manual, 17 and rapid infuser technology may be used if available. 2 A lateral film is adequate for cervical spine clearance in penetrating injury. If possible, both a lateral and an anteroposterior view of the neck should be obtained because these two views will aid in missile location and trajectory determination. Table 6. Arterial Injuries (Per Cent): A Comparison by Management Approach VESSEL INJURED

Common carotid Internal carotid External carotid Subclavian Vertebral Innominate

(10

MANDATORY SERIES; n = 1653)

89 30 37 33 18 6

(5.38) (1.81) (2.23) (2.0) (1.08) (0.36)

(16

SELECTIVE SERIES; n =

126 31 41 55 31 19

(5.0) (1.0) (1.6) (2.0) (1.0) (0.75)

2540)

275

MANAGEMENT OF PENETRATING NECK INJURIES

Table 7. Venous Injuries (Per Cent): A Comparison by Management Approach VESSEL INJURED

Jugular (internal and external) Subclavian Innominate

MANDATORY

SELECfIVE

(10 SERIES; n = 1653)

(16 SERIES; n = 2540)

257 (15.5) 29 (1.75) 24 (1.45)

399 (15.7)

51 (1.53) 9 (0.27)

On the operating table, the patient is placed supine, with the head extended and rotated to the side opposite the area to be explored. The face and neck and the supraclavicular and chest areas are included in the operating fields, should an extension of the incision high in the angle of the mandible or a thoracotomy be necessary for exposure in the management of zone I and zone III injuries. The contralateral groin or ankle areas are prepared and draped separately, should a segment of saphenous vein be needed as an autogenous graft to repair arterial injuries. ' The neck is explored through the standard incision on the anterior border of the sternocleidomastoid muscle extending from the angle of the mandible to the sternoclavicular junction. An extension of the incision toward the origin of the sternocleidomastoid muscle may be made if the injury is located in zone III, and additional exposure may be obtained by dislocation of the mandible anteriorly as described by Fisher and associates 25 and by Dossa and coworkers.21 The omohyoid muscle usually is transected to obtain greater exposure. 3 • 78 The neck incision may also be extended as a supraclavicular incision for the management of most zone I injuries, or it can be extended as a partial median sternotomy combined with an anterolateral thoracotomy to create the "book" or "trapdoor" thoracotomy used in the selective management of certain zone I injuries (Fig. 4). When bilateral neck explorations are needed, the incisions on the anterior borders of the sternocleidomastoid muscle may be connected by a transverse incision, which will allow the surgeon to elevate a flap in lJ. cephalad direction, thus exposing all structures in the midline of the neck. 3, 78 Once exposure has been obtained, the immediate goal is to stop lifethreatening hemorrhage. Digital control of the site is maintained while dissection is carried out to obtain proximal and distal control of the vessel. Once this control has been obtained, a judicious period of time should be

Figure 2. Vicious personal assaults occur frequently in the urban areas. This large slash wound violated tire platysma; tire patient underwent neck exploration.

276

JUAN A. ASENSIO ET AL.

Figure 3. Expanding cervical hematoma from gunshot wound. Uppermost arrow points to entrance site.

allotted for volume repletion with crystalloid and blood. A meticulous and systematic dissection should then be carried out with the goal of identifying all possible injuries. Finally, the surgeon should always be cognizant that injuries have been missed despite surgical intervention. MANAGEMENT OF INDIVIDUAL INJURIES Carotid Artery Injuries Carotid arterial injuries are the most difficult and certainly the most immediately life-threatening of all the injuries to the neck. Their propensity MASTOID PROCESS------~

EXTENSION INTO ORIGIN -----.,OF STERNOCLEIDOMASTOID M. HfJII!H----STANDARD NECK INCISION

STERNOCLEIDOMASTOID---..".~...

MUSCLE

CLAVICLE----r:-~~;::;:;;;;:::

STERNUM--~----~~~------~

Figure 4. Incisions for exposure of neck injuries.

MANAGEMENT OF PENETRATING NECK INJURIES

277

to bleed actively and potentially occlude the airway makes surgical intervention challenging. Their potential for causing fatal neurologic problems demands that the surgeon exercise excellent judgment in the approach to their definitive management (Fig. 5). Carotid arterial injuries are estimated to be present in 11% to 13% of all injured necks. The common carotid artery is most frequently involved (see Table 6). The most common clinical presentations are an expanding hematoma, external hemorrhage, absent or diminished pulses, or a neurologic deficit, which can range from a mild one to a fixed deficit associated with coma. Frequently, the rapidity with which these injuries bleed causes early

Figure 5. A and B, Large-caliber missile impacted at the bifurcation of the common carotid artery (arrow). In B, The missile sheared the external carotid artery. Forceps point to the ligated vessel.

278

JUAN A. ASENSIO ET AL.

airway occlusion from the extensive hemorrhage contained within the fascial planes, often necessitating the immediate achievement of an airway by intubation or a surgical cricothyroidotomy or both. This can be a difficult procedure, given the distortion of anatomic landmarks by hemorrhage. It is also fraught with danger, as the incision may release the contained hematoma, resulting in torrential bleeding that can obscure the operative site and place the patient at risk for aspiration. All patients presenting with the previously described signs should be thought of as harboring a carotid artery injury until proved otherwise. Certainly, those patients in which the missile is determined to have traversed the anteroposterior plane or to have followed transcervical trajectory are at a high risk for such injuries. Angiography is a reliable method, especially when establishing the diagnosis and planning the operative approach to injuries in zones I and III, because injuries in these zones usually require extensive surgical exposures that carry significant risk. 31, 63, 77 Angiography to diagnose carotid arterial injuries in zone II is more controversial. Several authors recommend routine angiographic evaluation for all zone II injuries, whether the patient is managed under a selective or a mandatory protocol, and state that with this approach, the yield of unsuspected injuries, especially to the vertebral vessels, will be increased. Certainly, the exclusionary validity of angiography has been well established by studies from Parkland Memorial Hospital. 63,77 McCormick and Burch45 have demonstrated that the surgeon should not rely entirely on the physical examination to diagnose carotid artery injuries; in their study, 38 of91 patients (42%) suspected of having vascular injuries on the basis of physical examination alone proved to have normal arteriograms, whereas 18 (20%) of the patients with no clinical evidence of injury had positive arteriographic findings. Hiatt and coworkers 33 evaluated the impact of routine arteriography in penetrating neck injuries. In their series of 105 patients, 88 sustained penetrating injuries from gunshots or stabbings to the neck. Of the total number oLpatients in the series, three underwent immediate exploration because of shock, and 102 underwent arteriography. Surgical explorations were performed on 18 patients because of abnormal arteriograms and in 13 because of shock or suspected hemorrhage, 10 of whom had normal arteriograms. The operative findings confirmed the angiographic interpretations in 26 of the 31 patients who were explored, whereas the angiogram underestimated the arterial injury in two patients and failed to identify associated venous injuries in three. The 72 patients with negative arteriograms were not explored and did not develop complications. In this report, 33 the authors make four observations on the basis of their experiences of more than 40 years: (1) unremarkable physical findings may accompany significant vascular or visceral injuries; (2) delays in diagnosis and therapy result in excessive morbidity and mortality rates, whereas the morbidity rate associated with explorations with negative findings is low; (3) when vascular control may be difficult to obtain, as in injuries low in the neck or near the base of the skull, preoperative arteriography is highly accurate and facilitates planning of the surgical approach; and (4) arteriography

MANAGEMENT OF PENETRATING NECK INJURIES

279

increases the percentage of explorations with positive findings. In their selective management protocol, which included routine arteriography, the study played an integral role in the expeditious triage and accurate diagnosis in patients with penetrating injuries, and the authors state that a negative study permits a safe nonoperative approach in most cases, whereas a positive study allows the surgeon to plan the operative approach more judiciously. This enthusiasm for arteriography was not supported in the study by Rivers et al,68 in which 61 of 65 patients who sustained penetrating neck wounds underwent arteriography. In this series, 57 arteriograms were normal. Of the six arteriographic defects, three were thought to be abnormal, two were clinically insignificant, and one required surgery. No significant injuries were identified by arteriography in the absence of suggestive physical findings, and no major arterial injuries were discovered during neck surgery that were missed preoperatively. Furthermore, those investigators found that neither normal nor abnormal angiograms significantly altered the course of management, including the approach to neck exploration. They thus concluded that a thorough neck exploration with dissection of the carotid sheath in patients with positive diagnostic criteria for surgery eliminates the need for angiography in most cases and avoids the consequence of a false-negative study. Certainly one of the advantages of preoperative angiography is the establishment of a roadmap for the approach to the carotid artery. Ideally, carotid angiography with cerebral vessel studies will delineate the amount of crossover circulation. This is certainly valuable knowledge to the surgeon who is entertaining the possibility of carotid artery ligation. Although it is widely believed that good crossover circulation exists in most patients through the circle of Willis, only 20% of all individuals have a complete circle. Furthermore, the remainder of the patients harbor a developmental abnormality that may restrict the effectiveness of the vascular ring. 34. 67, 84 Four-vessel angiography with imaging of the vertebral vessels has discovered many unsuspected vertebral artery injuries, as outlined by Fry and Reed. 29, 62 Four-vessel angiography should be performed on all hemodynamically stable patients with injuries in zones I and III. Angiography for zone II injury will yield valuable information if it can be performed safely and expeditiously. Good clinical judgment should be exercised in selecting patients for angiography in zone II injuries, as operative exploration will rarely miss carotid arterial injury. The study should perhaps be reserved for hemodynamically stable patients who have sustained transcervical gunshot wounds when bilateral carotid arterial injury is suspected and for those patients whose clinical and radiographic features suggest a carotid or vertebral artery injury. In order to derive meaningful data and to shed some light on the recent trends in the management of carotid arterial injuries, 11 series dealing specifically with such injuries were reviewed. 9, 10, 15, 20, 29, 40, 41, 65, 70, 83,85 A total of 1584 cases was collected, with a total of 1607 injuries. The average calculated mortality rate from this series is 17% (Table 8). Other features we thought would yield valuable information included the mecha-

280

JUAN A. ASENSIO ET AL.

Table 8. Mortality Rates of Carotid Artery Injuries SOURCE (YEAR)

NO. OF CASES

MORTALITY RATE (%)

Cohen et al (1970)15 Bradley (1973)9 Rubio et al (1974)10 Thal et al (1974)83 Liekweg and Greenfield (1978)41 Ledgerwood et al (1980)40 Fry and Fry (1980)29 Unger et al (1980)85 Brown et al (1982)10 Richardson et al (1989)65 Demetriades et al (1989)20

85 24 72 60

15.0 33.0 23.4 8.3 10.0 16.0 10.0 21.0* 20.9 6.6 22.0 Avg. Calculated Mortality = 17%

233

36 54 722 129 45 124 Total = 1584

*Defined for only 513 cases.

nism and anatomic location of injury, as well as the number of associated arterial and venous injuries. Seven of the series reviewed included data regarding the mechanism of injury. 9,10.15,29.65.83,85 Of a total of 864 patients, 846 (98%) sustained penetrating injury (Table 9). Most of these wounds were caused by gunshots. In the series of Cohen and associates,15 reporting the military experience in Vietnam, nearly all the injuries were caused by fragments from hand grenades and other antipersonnel devices. To determine the location of injury, eight series that gave an accurate anatomic breakdown were reviewed. 9, 10, 15, 20, 40, 70, 83, 85 A total of 1091 patients having sustained 1116 injuries was collected. The common carotid artery was injured most often, and the external carotid artery the least often (Table 10), The association of carotid injuries with other arterial injuries is uncommon. The innominate artery is the vessel most frequently injured by far. The most frequent venous injury found in association with carotid arterial injury is to the jugular vein. The concept of primary repair for all arterial injuries emerged from the Korean War experience35 and became the mainstay of management for carotid arterial injuries. Primary repair was carried out in all feasible cases, Table 9. Mechanism of Carotid Arterial Injuries PENETRATING-

SOURCE (YEAR)

NO. OF CASES

GSW

SW

src

FRAC

Cohen et al (1970)15 Bradley (1973)9 Thai et al (1974)83 Fry and Fry (1980)29 Unger et al (1980)85 Brown et al (1988)10 Richardson et al (1988)65 Total

85 24 60 54 467t 129 45 864

30 17 44 41 244 81 18 475

0 7 12 12 90 30

0 0 0 0 0 16 1 17

55 0 0 0 0 0 2 57

11 162

LAC

0 1 0 0 133 0 1 135

BLUNT (MVA*) 0 0 4 1 0 2 12 18

*GSW = gunshot wound, SW = stab wound, STG shotgun wound, FRAG fragmentation devices, LAC = lacerations, MVA = motor vehicle accident. tOn the basis of 467 of the total cases.

281

MANAGEMENT OF PENETRATING NECK INJURIES

Table 10. Anatomic Location of Carotid Arterial Injuries SOURCE (YEAR)

Cohen et al (1970)15 Bradley (1973)9 Rubio et al (1974)70 Thai et al (1974)83 Ledgerwood et al (1980)40 Unger et al (1980)85 Brown et al (1982)10 Demetriades et al (1989)20 Total

NO. OF PATIENTS

85 24 72 60 33 564 129 124 1091

NO. OF INJURIES

85 26 81 60

33 564 143 124 1116

CC*

IC

66 17 61 48 23 415 103 104 837 (75%)

19 7 10 12 10 149 20 10 237 (21%)

EC

0 2 10 0 0 0 20 10 42 (4%)

*CC = common carotid, IC = internal carotid, EC = external carotid.

and ligation was reserved for those in which technically a repair could I\ot be performed. This mode of management did not take into account the preoperative neurologic status of the patient. Given the poor results in patients presenting with fixed neurologic deficits and coma who had undergone primary repair, several surgeons sought to identify a patient population preoperatively that would benefit from primary repair and to reserve ligation for those in which the neurologic outcome was expected to be poor. As such, Cohen and associates 15 suggested that patients be classified preoperatively according to their neurologic status, citing five of eight patients who died or had worsening of their neurologic status after primary repair. In this study, and in another series by Rich and coworkers from Vietnam,64 the practice of excising 1 cm of artery from each side of the grossly damaged segment was found not to guarantee good success and was no longer recommended. In 1973, Bradley9 challenged the practice of primary repair of carotid artery injuries in his report of 24 patients. Of these patients, 15 presented with neurologic defects. All underwent primary repair, and five died secondary to progressive cerebral deficits thought to have developed after primary repair. The autopsy findings in 2 revealed hemorrhagic infarction. Extrapolating data from Wiley et al,91 who first noted the conversion of anemic to hemorrhagic infarcts in 5 patients with chronic arteriosclerotic carotid occlusive disease undergoing immediate vascularization after an acute stroke, Bradley concluded that in the presence of severe neurologic defects, revascularization should not be attempted. In 1974, ThaI and colleagues,83 reporting on their experience with 60 cases, attempted to refine the preoperative classification of patients into three groups: those presenting with no preoperative neurologic symptoms, those with a mild neurologic defiCit, and those with a severe deficit. These investigators defined mild deficits as weakness of the upper or lower extremities in the absence of other neurologic injuries and severe deficits as aphasia and spastic or flaccid hemiplegia in the absence of neurologic injuries accompanied by an altered state of consciousness. ThaI and associates concluded that patients with no preoperative neurologic symptoms or those with mild deficits should undergo repair, as five of their six such patients had complete recovery. These authors recommended a more

282

JUAN A. ASENSIO ET AL.

judicious approach for patients presenting with severe neurologic deficits and proposed assessment of carotid flow before deciding on further management. In these patients, operative arteriography is helpful if it shows that flow is uninterrupted in these vessels, in which case, the surgeon probably should proceed to repair. If distal patency does not exist, repair with restoration of flow would carry a great risk of converting an anemic infarct to a hemorrhagic one, and therefore, ThaI and associates recommended that these patients undergo ligation. These investigators found no correlation between the presence of shock at presentation and negative neurologic outcome and suggested a selective rather than a mandatory use of shunts in these patients. Liekweg and Greenfield,41 in a thorough review of the literature consisting of 233 cases, concluded that if a patient has a neurologic deficit less severe than coma, repair will be associated with a good outcome 85% of the time, whereas ligation will have a favorable outcome in 50% of the cases. These authors recommended that primary vascular repair be attempted in patients with all grades of neurologic deficit short of coma. In comatose patients, neither repair nor ligation appeared to influence the invariably poor prognosis. On the basis of these data, Liekweg and Greenfield recommended that ligation of the carotid artery be reserved for the comatose patient with no prograde flow and for cases in which repair is impossible for technical reasons. In 1980, a second report from Parkland Memorial Hospital, written by Fry and Fry,29 supported the published conclusions by Liekweg and Greenfield and proposed that, in patients in whom ligation of the carotid artery becomes necessary because of technical inability to carry out repair, ligation be followed by an extracranial-intracranial bypass. These authors reported a series of seven patients who underwent bypass, six of whom returned to or maintained normal neurologic status, with the rest being neurologically stable. Furthermore, Fry and Fry recommended the routine use of four-vessel multiplane arteriography in all injuries to the neck, as this study led to the discovery of 17 associated vertebral artery injuries. Ledgerwood and coworkers 40 in 1980 recommended that primary arterial repair be carried out in all patients who were not comatose and provided direct evidence of its safety in five patients who presented in a coma or with a stroke, all of whom underwent primary repair of the injured vessel. Postmortem examination in these cases revealed that these patients' deaths were caused by diffuse cerebral edema and not by hemorrhagic infarction, as previously believed, thus disproving the contention that primary revascularization converts an anemic into a hemorrhagic infarct. Unger et al,85 in an extensive review of the English-language literature from 1952 through 1979, analyzed 722 cases. Of the 186 patients presenting with severe neurologic deficit, 34% improved if they underwent primary arterial repair, in contrast to only 14% of those who had a carotid artery ligated or were not treated surgically. Shock or coma independently were significantly ominous findings, but there was no evidence to support coma as a contraindication to restoring arterial continuity. At the same time, these investigators pointed out the dismal follow-up rate for these patients: only 40 cases in the entire body of the literature had satisfactory follow-up data.

283

MANAGEMENT OF PENETRATING NECK INJURIES

These views are also supported in a 1982 article by Brown et ai, 10 who recommended that all patients who present with central neurologic deficits short of coma undergo revascularization. In this study, nine patients presenting in coma underwent revascularization, with significant clinical improvement in six, whereas three died. This study also is interesting in that for the first time, a citation is made of the possible role of barbiturates in decreasing cerebral edema in these patients. Finally, Richardson et al 65 confirm good outcomes for primary repair of carotid arterial injuries and identify a population of patients whose neurologic status is difficult to determine because of the presence of shock or confusion or who have equivocal signs of neurologic injury. In their study, 13 patients presented in the previously described fashion, and all underwent repair of their injuries, with a good neurologic outcome in 12. One death resulted from exsanguination not related to the carotid arterial injury. These authors' views on liberal exploration of neck injuries were unchanged; however, they recommended that a rapid preoperative angiogram be obtained, which can alert the surgeon to occult injuries to the vertebral or subclavian arteries and thus decrease the incidence of missed vascular injuries. They presented five cases with findings of five additional injuries, including one case of bilateral carotid artery injury, to support their recommendation. They also proposed that angiography be performed expeditiously and state that it is critical that the patients be accompanied by a surgeon who monitors the procedure. This surgeon should have sufficient experience and enough authority to terminate the angiographic procedure if necessary. In order to examine whether the trend toward primary arterial repair is supported in the literature, seven series dating from 1970 through 19889 , 10, 15,29,40,65,70 were reviewed. A total of 433 patients having sustained 456 injuries was collected, of which 392 (86%) underwent primary repair and 64 (14%) underwent ligation (Table ll). On the basis of this extensive review, the following guidelines for the management of carotid arterial injury are offered: 1. Thorough preoperative neurologic examination; 2. Preoperative classification of the patient into the following categories: (a) Normal neurologic examination: no deficit present; (b) mild neurologic deficit, Table 11. Operative Management of Carotid Arterial Injuries

AUTHOR

NO. OF CASES UNDER OPERATIVE REPAIR

NO. OF INJURIES

REPAIRED

Cohen, 1970 Bradley, 1973 Rubio, 1974 Ledgerwood, 1980 Fry, 1980 Brown, 1982 Richardson, 1988 Total

85 22 72 36 54 125 39 433

85 22 81 36 54 139 39 456

78 20 69 31 42 U5 37 392 (86%)

7 2 12 5 12 24 2 64 (14%)

284

JUAN A. ASENSIO ET AL.

defined as weakness of an upper or lower extremity in the absence of other neurologic injuries; (c) severe neurological deficit, defined as aphasia or spastic or flaccid hemiplegia; and (d) coma and indeterminate neurologic status secondary to the presence of shock. In these cases, correction of hypotension and a reassessment of the neurologic status are carried out; 3. Selective performance of four-vessel multiplane angiography in patients who are hemodynamically stable and present with transcervical gunshot wounds and in those whose clinical and radiographic evidence suggests a carotid or vertebral artery injury (e.g., the trajectory mapped by the preoperative lateral and anteroposterior cervical spine films). This recommendation presumes that angiography does not pose a risk or cause an undue delay of operative intervention; 4. Wide surgical exposure of all injuries; 5. Primary repair for all injuries with selective exceptions to be made for those patients presenting in profound coma with bilaterally fixed and dilated pupils; 6. Shunts to be utilized at the discretion of the surgeon managing the injury; and 7. The use of the external carotid-internal carotid bypass in a very few cases according to the judgment of the surgeon and the consulting neurosurgeon. 30

Esophageal Injuries One of the most important reasons for mandatory exploration of the neck is to rule out an esophageal injury (Fig. 6). As discussed earlier, these injuries are notoriously difficult to diagnose preoperatively. The symptoms include dysphagia, hematemesis, and odynophagia. Signs include subcutaneous air or crepitus, retropharyngeal air and edema, hematoma, and a deviated trachea. However, patients usually have no preoperative signs and symptoms to signal the presence of this injury. Four series dating from 1977 to 1990 dealing specifically with the management of esophageal injuries were reviewed. 14. 19, 81, 89 From these series, a total of 173 patients was collected who had sustained 122 cervical esophageal injuries (Table 12). Of all esophageal injuries, 70% were confined to the cervical esophagus. Most such injuries are caused by penetrating

Figure 6. Left neck exploration. Vessel loop shown retracting the common carotid artery laterally. Jugular vein also seen. Forceps point to the esophagus.

Table 12. Management of Esophageal Injuries

SOURCE (YEAR)

Defore et al (1977)1. Symbas et al (1980)84 Cheadle and Richardson (1982)14 Winter and Weigelt (1990)8. Total

NO. OF PATIENTS

NO. WITH CERVICAL ESOPHAGEAL INJURIES

REPAIR AND DRAINAGE

DRAINAGE ALONE

MISSED INJURIES

FISTULAS

60 48 19 46 173

45 24 7 46 122

42 24* 7 45 U8

3 0 0 1 4

3 0 0 0 3

5 4 2 4 15

DEATHS

(%)

5 (U) 3 (12.5) 4 (57) 0(0) 12 (10.0 Avg. Mort.)t

*Cervical esophagostomy. tAverage mortality calculated on the basis of the total number of deaths in the series reviewed divided by the total number of patients in the series reviewed.

~

00

'"

286

JUAN A. ASENSIO ET AL.

Figure 7. Esophageal laceration from gunshot wound (arrow). Nasogastric tube clearly visible. Pa~ient underwent primary repair with a two-layer closure and drainage.

trauma: gunshots or stabbings. The average calculated mortality rate for cervical esophageal wounds is 10.0%. The difficulty in establishing the diagnosis of esophageal injuries has been pointed out by Weigelt and coworkers88 in a recent study in which 118 patients with penetrating neck wounds were investigated by barium swallow (112 patients), flexible endoscopy (106 patients), and rigid esophagoscopy (116 patients). A total of 93 patients underwent all three studies. The studies identified 10 esophageal injuries. On the basis of their findings, Weigelt and coworkers estimated the sensitivity of physical examination, contrast esophagography, and rigid esophagoscopy at 80%, 89%, and 89%, respectively. They noted that all patients with esophageal injuries had at least one positive test preoperatively and that the combination of esophagography with rigid esophagoscopy identified all 10 injuries. On the basis of these data, those authors suggested that patients with penetrating neck trauma and minimal clinical findings be evaluated initially with esophagography. If the results are equivocal, rigid esophagoscopy should be performed. Flexible endoscopy proved to be an unreliable investigative tool. The most common operative management of esophageal injuries consists of primary repair and drainage (Fig. 7), which was used in 118 of the 122 cases collected from the literature. Drainage alone was used in four cases, three of which were missed injuries and one case for which it was the selected method of management. Esophageal repairs have a propensity to leak and fail, which is the most important cause of esophageal fistulas. In this review, 15 of 118 patients developed esophageal fistulas, for an incidence of 12.7%. Remarkably, all 15 patients recovered fully after wide drainage and institution of hyperalimentation. Winter and Weigelt89 reported 4 cases of cervical esophageal fistulas that developed in 46 cases of penetrating trauma to the esophagus. This study identified risk factors such as shock and the performance of tracheostomy in the emergency department as being significantly associated with

287

MANAGEMENT OF PENETRATING NECK INJURIES

fistula formation. The question of whether single-layer closures are adequate for esophageal wounds remains unanswered; from their data, Winter and Weigelt could not show a disadvantage to such closure. They recommended that all patients having cervical esophageal wounds repaired undergo postoperative esophagography, as 50% of the esophageal fistulas in this study were asymptomatic and discovered only on routine postoperative contrast study. Vertebral Artery Injuries Vertebral artery injuries are uncommon, accounting for approximately 1% of all neck vascular injuries (see Table 6). The average calculated mortality rate for these patients is 11.0%. Three series32, 48, 62 spanning 1980 to 1988 were reviewed and 79 patients collected. Clinical findings to suggest arterial injury were usually absent. In a study by Reid and Weigelt,62 74% of the patients had no suggestion of an underlying vertebral artery injury. Any clinical findings usually are secondary to associated injuries, including isolated peripheral neurologic deficits and manifestations of associated spinal cord injury. Nearly all of these patients sustained injury by penetrating trauma: 58 of the 79 patients were injured by gunshots, 15 by stabbings, 1 by a shotgun wound, and 2 by laceration. Only 3 patients had sustained blunt injury. Of the 79 injuries, 68 were diagnosed on the basis of four-vessel multiplane angiography, which also tended to detect associated vascular injury. Two series reported a 13% and 18.6%32,62 incidence of associated vascular injury. Fistulas between the vertebral artery and veins occurred in 9 of the 79 patients, for a calculated incidence of 11.3%. Other associated injuries included pharyngoesophageal injuries, with an 11% and 21. 7% incidence in two of these series. 32, 62 Other notable injuries included those to the peripheral nervous system and the spinal cord; 15 patients had associated neurologic and spinal cord injuries, for a calculated incidence of 19%. Surgery was the most common form of management (Table 13). Two camps advocating different management styles for these patients exist. The Parkland group32,48 is a strong advocate of the surgical approach, which they used in 52 of their 56 patients, whereas the group from King's County Hospital in New York32 is a strong advocate of embolization and managed 5 of their 23 patients by embolization alone. However, only 15 of Table 13. Management of Vertebral Artery Injuries

SOURCE (YEAR)

Meier et al (1981)48 Golueke et al (1987)32 Reid et al (1988)6" Total

SURG NO. OF SURGERY + PATIENTS ANGIOGRAPHY LIGATION EMBQ* EMBO OBSERVED

13 23 43 79

12 21 35 68

11 2 41 54

1 5 0 6

0 1 1 2

1 15 1 17

DEATHS(%)

0(0) 4 (17.4) 5 (12) 9 (11.0 Avg. Mort.)t

*Embo = embolization. t Average mortality calculated on the basis of the total number of deaths in the series reviewed divided by the total number of patients in the series reviewed.

288

JUAN A. ASENSIO ET AL.

their 23 cases were observed. At this time, it appears that surgical management prevails; however, embolization can be a valuable alternative in the management of selected cases of vertebral artery injury, either alone or in combination with surgery. Tracheal Injuries Injuries to the respiratory tract usually cause tenderness over the trachea, cricoid, and thyroid cartilages. They can also produce hoarseness, hemoptysis, crepitation, and dysphonia as well as acute airway obstruction, necessitating immediate management of the airway surgically (Fig. 8). Their diagnosis can be established reliably by the combination of laryngoscopy and bronchoscopy. Injuries to the respiratory tract should be repaired primarily and protected with a tracheostomy one ring below the injury. Patients who need preoperative cricothyroidotomy for airway access should have this converted to a standard tracheostomy during neck exploration. Immediate intraoperative consultation with an otolaryngologist should be obtallled when dealing with injuries to the larynx and vocal cords. In general, primary repair with absorbable sutures to approximate the mucosa and nonabsorbable monofilament sutures to approximate the cartilaginous structures will suffice. Jugular Venous Injuries The clinical presentation of jugular venous injuries is similar to that of the arterial injuries in the neck. The jugular veins are the most frequently injured vascular structures in the neck (see Table 7). These injuries usually are not detected preoperatively, and no study in the literature advocates the use of preoperative venography for their identification. There seems to be a complacency with regard to the management of jugular venous injuries. This is evident in the camp advocating the selective approach to the management of penetrating neck injuries. It almost seems that most of these authors are willing to accept nondetection of injuries to the jugular vein and consider them trivial. However, Meyer and colleagues52

Figure 8. Multiple stabbings to zone II of the neck. Midline wounds have a high propensity for injuring the trachea and larynx, as in this case. This patient presented with crepitation and subcutaneous emphysema. Arrow points to the stab wound that lacerated the trachea.

MANAGEMENT OF PENETRATING NECK INJURIES

289

point to the occurrence of active external hemorrhage or hematoma formation with airway compression as findings common in the acute setting after an injury to the internal jugular vein and thus point out the necessity of considering injuries to the internal jugular veins as important. The management of these injuries consists of primary repair by lateral venorrhaphy or ligation if repair is not feasible. Most venous repairs narrow the lumen of the vein. Although this can be considered a predisposing factor for thrombosis and, possibly, pulmonary embolization, these complications probably are rare. In our extensive review of the literature, we found no cases of these complications. Complex Combined Injuries Tracheoesophageal injuries certainly create one of the most difficult management problems. Feliciano et aJ24 have artfully described their management in a series of 23 patients having combined tracheoesophageal injuries from penetrating wounds. Physical examination, endoscopy, bariu~ swallow, or a combination of these techniques confirmed the diagnosis preoperatively in 19 patients. A variety of operative techniques were used, with 20 of the 23 cases having some type of primary repair of the trachea and esophagus such as a side repair or end-to-end anastomosis, with or without a tracheostomy. In this series, significant complications occurred in 74% of the patients and included eight cases of pneumonia, eight esophageal leaks, six tracheoesophageal fistulas, five mediastinal abscesses, four wound infections, and two carotid artery blowouts. The authors describe various surgical techniques to decrease the incidence of these complications and recommend debridement and primary repair of all injuries as feasible with an interposed sternocleidomastoid or strap muscle flap between the suture lines, avoiding tracheostomy whenever possible. If an extensive esophageal injury is present, a cutaneous esophagostomy should be created. The authors also recommend that drainage be instituted with closed systems and directed anteriorly, so that the drains do not cross the carotid artery. If a concomitant ipsilateral carotid artery injury has been repaired, drainage can be established through the side of the neck opposite the injury. For transcervical missile injuries or very large neck lacerations, bilateral neck explorations usually are in order (Figs. 9 and 10). Standard incisions may be connected by a transverse incision approximately 2 to 3 cm above the suprasternal notch and a flap elevated. Because these patients usually undergo extensive dissections and frequently have tremendous edema, a protective tracheostomy should be considered to prevent the disastrous consequences of inadvertent extubation and airway loss, as replacement of an endotracheal tube by either the oral or the nasotracheal route would be difficult under these circumstances. 3 The association of transpharyngeal gunshot wounds (Fig. 11) with the development of cervical osteomyelitis has been described by Schafer and coworkers. 73 They cite contamination with pharyngeal flora, inappropriate antibiotic therapy, and inadequate osseous, diskal, and ligamentous debridement along with insufficient spinal immobilization during healing as possible contributing factors. These authors described five cases and outline a

290

JUAN A. ASENSIO ET AL.

Figure 9. Large neck laceration involving both sides of the neck, due to personal assault.

protocol consisting of triple endoscopy to identify the pharyngeal injury, anteroposterior and lateral views of the cervical spine to localize the injury, administration of penicillin and gentamicin intravenously, exploration of the neck and repair of pharyngeal wounds, debridement of the cervical spine, and external immobilization of the spine for 6 weeks in order to prevent this dreadful complication.

MANDATORY VERSUS SELECTIVE APPROACH: THE CONTROVERSY

Much of the controversy over the selective versus the mandatory approach centers on the management of zone II injuries: little if any, controversy exists with regard to the management of zone I and zone III injuries. The concept of selective management evolved as a result of large reported numbers of negative neck explorations coupled with a number of injuries reportedly missed at the time of surgical exploration. Perhaps the most important justification offered for the selective approach is cost containment; however, recent reports by Weigelt et alBB

Figure 10. Injuries such as this require bilateral neck exploration.

MANAGEMENT OF PENETRATING NECK INJURIES

291

and Noyes et al 55 do not necessarily support the concept that selective management is more economical than the mandatory approach. In the series of Weigelt and coworkers,BB the cost of selective management, including arteriography, esophagography, and a I-day hospitalization, was reported to be $2670. If rigid esophagoscopy was added, the cost increased to $3350, and if a neck exploration was still required, the charge increased to $4790. The hospital cost for mandatory exploration and other diagnostic tests was $2849 for a negative cervical exploration. Thus, an aggressive selective approach is not less expensive than mandatory exploration. In the series of Noyes and colleagues, 55 a negative cervical exploration was reported to carry a cost of $3185, while four-vessel arteriography with panendoscopy was reported to cost $3492. Thus, the selective approach produces minimal savings. In 1981, Merion et also reported data on 65 cases of penetrating neck trauma, 27 of which had no injuries detected. They cited an average cost of $877 covering procedures such as four-vessel angiography, contrast swallow, and cervical spine and soft tissue films, with a cost of $1930 for those patients who underwent surgical exploration. These authors stated that substantial savings could be achieved ($1053 per patient) if patients were managed selectively. In a close review of this article, however, we find that the average duration of hospitalization for patients who did not have surgery was 5.5 days, yet no mention is made ofthe daily professional fee for a surgeon's visit, which would of course increase the charge. Therefore, the financial analysis of this study seems to be invalid. Several questions come to mind. First, are patients who are being reported in the selective management series truly being observed, or are they being explored by invasive nonsurgical means such as interventional radiography and endoscopy? Second, are the risks of the nonsurgical means of exploration being considered in the reporting of morbidity and mortality in the selective management series? If they are not, why not? In none of the series advocating selective management we found in the literature was mention made of complications arising from nonsurgical means of exploration (arteriography, laryngoscopy, bronchoscopy, or esophagoscopy, rigid or flexible).

Figure 11. Transpharyngeal gunshot wounds present a high risk for the development of cervical spine osteomyelitis. Arrow points to entrance site. This patient also sustained a fractured mandible.

292

JUAN A. ASENSIO ET AL.

A much more accurate way of describing these approaches to the management of penetrating zone II neck injuries would be to divide the patient populations into the surgically explored and nonsurgically explored! invasively studied and then compare the risk of surgical exploration with that of nonsurgical exploration, simultaneously taking into consideration the morbidity and deaths caused by these invasive procedures while at the same time analyzing the percentage of injuries detected and missed by both approaches. This comparison should be done in a prospective fashion. Only then can this issue be resolved scientifically. So far, only one study in the literature54 advocated true observation in the asymptomatic patient without the expense of mandatory nonsurgical invasive testing. No mention is made in this study of any complications observed in these patients or of the results of long-term follow-up. Other important questions raised by Tha182 that remain unanswered include: how much diagnostic work-up is necessary to rule out injuries short of operation? and what is the actual complication rate and what are the late sequelae in those patients who are not operated on but are lost to follow-up? With such questions unanswered, the controversy is not likely to be resolved any time soon.

CONCLUSIONS On the basis of these data, we cannot recommend one approach as superior to the other. The optimal approach to the management of a penetrating zone II neck injury is yet to be defined and the controversy to be resolved. We can conclude that a selective approach is safe in the asymptomatic and hemodynamically stable patient, provided that accurate diagnostic means are immediately available to exclude injuries needing immediate surgical management. We also conclude that the mandatory approach is a safe, reliable, and time-tested method of dealing with these injuries. Moreover, we conclude that the rate-limiting factors appear to be the reliability and accuracy of preoperative detection of cervical esophageal injuries; their diagnosis can be difficult to establish preoperatively by radiologic means alone and may necessitate the performance of rigid esophagoscopy with its inherent risk of perforation. At the same time, esophageal injuries may easily be missed during surgical exploration. On the basis of our current review of the literature, we propose that a separate classification for these patients be created (surgically explored versus non surgically explored!invasively studied versus totally observed). This classification would allow a prospective study of these populations and the comparison of risks for surgical explorations and the invasive procedures used to diagnose these injuries in the non surgically explored group. The institution of this classification scheme would entail developing a system for long-term follow-up in those patients who have only been observed, so that the actual complication rate in patients not operated on can be elucidated. As neither approach can be stated to be superior to the other, the surgeon has to tailor the approach on the basis of personal as well as institutional experience and the demographics of the patient population served.

MANAGEMENT OF PENETRATING NECK INJURIES

293

REFERENCES 1. Almskog BA, Angeras U, Hall-Angeras M, et al: Penetrating wounds of the neck: Experience from a Swedish hospital. Acta Chir Scand 151:419, 1985 2. Asensio JA: Exsanguination. Trauma Q 6(2):1, 1989 3. Asensio JA, Buckman RF, Grosh J, et al: The management of penetrating neck trauma: The controversey. In Frederickson JM, Goebel MA (eds): Insights in Otolaryngology, vol 3(6). St. Louis, CV Mosby, 1988, pp 1-8 4. Ayuyao AM, Kaledzi YL, Parsa MH, et al: Penetrating neck wounds: Mandatory versus selective exploration. Ann Surg 202:563, 1985 5. Bailey H: Surgery of Modern Warfare, ed 3, vol 2. Baltimore, Williams & Wilkins, 1944, p 674 6. Beebe GW, DeBakey ME: Battle Casualties: Incidence, Mortality and Logistic Considerations. Springfield, Illinois, Charles C Thomas, 1952 7. Belinkie SA, Russell JC, Da Silva J, et al: Management of penetrating neck injuries. J Trauma 23:235, 1983 8. Bishara RA, Pasch AR, Douglas DD, et al: The necessity of mandatory exploration of penetrating zone II neck injuries. Surgery 100:655, 1986 • 9. Bradley EL III: Management of penetrating carotid injuries: An alternative approach. J Trauma 13:248, 1973 10. Brown MF, Graham JM, Feliciano DV, et al: Carotid injuries. Am J Surg 144:748, 1982 11. Cabasares HV: Selective surgical management of penetrating neck trauma: 15 year experience in a community hospital. Am Surg 48:355, 1982 12. Campbell FC, Robbs JV: Penetrating injuries of the neck: A prospective study of 108 patients. Br J Surg 67:582, 1980 13. Carducci B, Lowe RA, Dalsey W: Penetrating neck trauma: Consensus and controversies. Ann Emerg Med 15:208, 1986 14. Cheadle W, Richardson JD: Options in management of trallma to the esophagus. Surg Gynecol Obstet 155:380, 1982 15. Cohen A, Brief D, Mathewson C: Carotid artery injuries. Am J Surg 120:210, 1970 16. Cohen ES, Breaux CW, Johnson PN, et al: Penetrating neck injuries: Experience with selective exploration. South Med J 80:26, 1987 17. Committee on Trauma, American College of Surgeons: Advanced Trauma Life Support Instructors Manual. Chicago, American College of Surgeons, 1989 18. Cruz ADL, Chandler JR: Management of penetrating wounds of the neck. Surg Gynecol Obstet 137:458, 1973 19. Defore WW Jr, Mattox KL, Hansen HA, et al: Surgical management of penetrating injuries of the esophagtIs. Am J Surg 134:734, 1977 20. Demetriades D, Skalkides J, Sofianos C, et al: Carotid artery injuries: Experience with 124 cases. J Trauma 29:91, 1989 21. Dossa C, Shepard AD, Wolford DG, et al: Distal internal carotid exposure: A Simplified technique for temporary mandibular subluxation. J Vasc Surg 12:319, 1990 22. Dunbar LL, Adkins RB, Waterhouse G: Penetrating injuries to the neck: Selective management. Am Surg 50:198, 1984 23. Elerding SC, Manart FD, Moore EE: A reappraisal of penetrating neck injury management. J Trauma 20:695, 1980 24. Feliciano DV, Bitondo CG, Mattox KL, et al: Combined tracheoesophageal injuries. Am J Surg 150:710, 1985 25. Fisher DF, Claggett JP, Parker JI, et al: Mandibular subluxation for high carotid exposure. J Vasc Surg 1:727, 1984 26. Flax RL, Fletcher HS, Joseph WL: Management of penetrating injuries of the neck. Am Surg 39:148, 1973 27. Fleming D: Case of rupture of the carotid artery and wounds of several of its branches, successfully treated by tying the common trunk of the carotid itself. Med Chir J Rev 3:2, 1817 28. Fogelman MJ, Stewart RD: Penetrating wounds of the neck. Am J Surg 91:581, 1956 29. Fry RE, Fry WJ: Extracranial carotid artery injuries. Surgery 88:581, 1980

294

JUAN A. ASENSIO ET AL.

30. Gewertz BL, Samson DS, Ditmore OM: Management of penetrating injuries of the internal carotid arteries at the base of the skull utilizing extracranial intracranial bypass. J Trauma 20:365, 1980 31. Golueke PJ, Goldstein AS, Sclafani SJA, et al: Routine versus selective exploration of penetrating neck injuries: A randomized prospective study. J Trauma 24:1010, 1984 32. Golueke P, Sclafani SJA, Phillips T, et al: Vertebral artery injury: Diagnosis and management. J Trauma 27:856, 1987 33. Hiatt JR, Busuttil RW, Wilson SE: Impact of routine arteriography on management of penetrating neck injuries. J Vasc Surg 1:860, 1984 34. Hodes pJ, Campoy F, Riggs HE, et al: Cerebral angiography: Fundamentals in anatomy and physiology. Am J Roentgenol 70:61, 1953 35. Hughes CW: Arterial repair during the Korean War. Ann Surg 147:555, 1958 36. Jones RF, Terrell JC, Salyer KE: Penetrating wounds of the neck: An analysis of 274 cases. Trauma 7:228, 1967 37. Jurkovich GJ, Zingarelli W, Wallace J, et al: Penetrating neck trauma: Diagnostic studies in the asymptomatic patient. J Trauma 25:819, 1985 38. Key G (ed): The Apologie and Treatise of Ambroise Pare Containing the Voyages made into Divers Places with Many Writings upon Surgery. London, Falcon Education Books, 1957 39. La Garde LA: Gunshot injuries. New York, W. Wood, 1916, p 204 40. Ledgerwood AM, Mullins RJ, Lucas CE: Primary repair vs ligation for carotid artery injuries. Arch Surg 115:488, 1980 41. Liekweg WG Jr, Greenfield LJ: Management of penetrating carotid arterial injury. Ann Surg 188:587, 1978 42. Lundy LJ, MandaI AK, Lou SMA, et al: Experience in selective operations in the management of penetrating wounds of the neck. Surg Gynecol Obstet 147:845, 1978 43. Markey JC Jr, Hines JL, Nance FC: Penetrating neck wounds: A review of 218 cases. Am Surg 4:77, 1975 44. Massac E, Siram SM, Lefall LD: Penetrating neck wounds. Am J Surg 145:263, 1983 45. McCormick TM, Burch BH: Routine angiographic evaluation of neck and extremity injuries. J Trauma 19:384, 1979 46. McInnis WD, Cruz AB, Aust JB: Penetrating injuries to the neck: Pitfalls in management. Am J Surg 130:417, 1975 47. Medical Department of the United States Army in the World War, vol 2. Washington, DC, US Government Printing Office, 1927, p 68 48. Meier DE, Brink BE, Fry WJ: Vertebral artery trauma. Arch Surg 116:236, 1981 49. Meinke AH, Bivins BA, Sachatello CR: Selective management of gunshot wounds to the neck. Am J Surg 138:314, 1979 50. Merion RM, Harness JK, Ramsburgh SR, et al: Selective management of penetrating neck trauma. Arch Surg 116:691, 1981 51. Metzdorfl' MT, Lowe DK: Operation or observation for penetrating neck wounds: A retrospective analysis. Am J Surg 147:646, 1984 52. Meyer JP, Barrett JA, Schuler JJ, et al: Mandatory vs selective exploration for penetrating neck trauma: A prospective assessment. Arch Surg 122:592, 1987 53. Narrod JA, Moore EE: Selective management of penetrating neck injuries. Arch Surg 119:574, 1984 54. Narrod JA, Moore EE: Initial management of penetrating neck wounds: A selective approach. J Emerg Med 2:17, 1984 55. Noyes LD, McSwain NE, Markowitz IP: Panendoscopy with arteriography versus mandatory exploration of penetrating wounds of the neck. Ann Surg 204:21, 1986 56. Obeid FN, Haddad GS, Horst HM, et al: A critical reappraisal of a mandatory exploration policy for penetrating wounds of the neck. Surg Gynecol Obstet 160:517, 1985 57. Ordog GJ: Penetrating neck trauma. J Trauma 27:543, 1987 58. Ordog GJ, Albin D, Wasserberger J, et al: 110 Bullet wounds to the neck. J Trauma 25:238, 1985 59. Otis GA: Medical and surgical history of the War of Rebellion, part 3, vol 2: Surgical history. Washington, DC, US Government Printing Office, 1883, p 69

MANAGEMENT OF PENETRATING NECK INJURIES

295

60. Pate JW, Casini M: Penetrating wound of the neck: Explore or not? Am Surg 46:38, 1980 61. Prakaschandra MR, Bhati MFK, Gaudino J, et al: Penetrating injuries of the neck: Criteria for exploration. J Trauma 23:47, 1983 62. Reid JDS, Weigelt JA: Forty-three cases of vertebral artery trauma. J Trauma 28:1007, 1988 63. Reid JD, Weigelt JA, ThaI ER, et al: Assessment of proximity of a wound to major vascular structures as an indication for arteriography. Arch Surg 123:942, 1988 64. Rich NM, Marian WC, Hughes CW: Surgical and patholOgical evaluation of vascular injuries in Viet-Nam. J Trauma 9:987, 1969 65. Richardson JD, Simpson C, Miller FB: Management of carotid artery trauma. Surgery 104:673, 1988 66. Richardson JD, Martin LF, Barzatla AP, et al: Unifying concepts in treatment of esophageal leaks. Am J Surg 149:157, 1985 67. Riggs HE, Rupp C: Variation in form of Willis. Arch Neurol 8:8, 1963 68. Rivers SP, Patel Y, Delany HM, et al: Limited role of arteriography in penetrating neck trauma. J Vasc Surg 8:112, 1988 69. Roon AJ,. Christiansen N: Evaluation and treatment of penetrating surgical injuries. J Trauma 19:391, 1979 70. Rubio PA, Reul GJ Jr, Beall AC Jr, et al: Acute carotid artery injury: 25 years' experience. J Trauma 14:967, 1974 71. Saletta JD, Folk FA, Freeark RJ: Trauma to the neck region. Surg Clin North Am 53:73, 1973 72. Saletta JD, Lowe RJ, Leonardo fL, et al: Penetrating trauma of the neck. J Trauma 16:579, 1976 73. Schafer SD, Bucholz RW, Jones RE, et al: The management of transpharyngeal gunshot wounds to the cervical spine. Surg Gynecol Obstet 152:27, 1981 74. Sheely CH II, Mattox KL, Reul GJ Jr, et al: Current concepts in the management of penetrating neck trauma. J Trauma 15:895, 1975 75. Shirkey AL, Beall AC Jr, DeBakey ME: Surgical management of penetrating wounds of the neck. Arch Surg 86:97, 1963 76. Shuck JM, Gregory J, Edwards WS: Selective management of penetrating neck wounds. Ann Emerg Med 12:159, 1983 77. Snyder WH, Thal ER, Bridges RA, et al: The validity of normal arteriography in penetrating neck trauma. Arch Surg 113:424, 1978 78. Standiford S, Asensio JA: Current controversies in the management of penetrating neck trauma. Trauma Q 6(1):17, 1989 79. Stone IH, Callahan GS: Soft tissue injuries of the neck. Surg Gynecol Obstet 117:754, 1963 80. Stroud WH, Yarbrough DR III: Penetrating neck wounds. Am J Surg 140:323, 1980 81. Symbas PN, Hatcher CR Jr, Viasis SE: Esophageal gunshot injuries. Ann Surg 191:703, 1980 82. ThaI ER: Injury to the neck. In Mattox KL, Moore EE, Feliciano DV (eds): Trauma. Norwalk, Appleton & Lange, 1988, p 301 83. ThaI ER, Snyder WH, Hays RA, et al: Management of carotid artery injuries. Surgery 76:955, 1974 84. Thomas GI, Anderson KN, Hain RF, et al: The significance of anomalous vertebral-basilar artery communications in operations on the heart and great vessels. Surgery 46:747, 1959 85. Unger SW, Tucker WS Jr, Mrdeza MA, et al: Carotid arterial trauma. Surgery 87:477, 1980 86. Watson WL, Silverstone SM: Ligature of the common carotid artery in cancer of the head and neck. Ann Surg 109:1, 1939 87. Weaver AW, Sankaran S, Fromm SH, et al: The management of penetrating wounds of the neck. Surg Gynecol Obstet 149:49, 1971 88. Weigelt JA, Thal ER, Snyder WH, et al: Diagnosis of penetrating cervical esophageal injuries. Am J Surg 154:619, 1987 89. Winter RP, Weigelt JA: Cervical esophageal trauma: Incidence and cause of esophageal fistulas. Arch Surg 125:849, 1990

296

JUAN A. ASENSIO ET AL.

90. Wood J, Fabian TC, Mangianate EC: Penetrating neck injuries: Recommendations for selective management. J Trauma 29:602, 1989 91. Wylie EJ, Hein MF, Adams JE: Intracranial hemorrhage following surgical revascularization for treatment of acute strokes. J Neurosurg 21:212, 1964

Address reprint requests to Juan A. Asensio, MD, FACS Department of Surgery Temple University Hospital Broad and Ontario Streets Philadelphia, Pennsylvania 19140

Management of penetrating neck injuries. The controversy surrounding zone II injuries.

Penetrating neck injuries present a difficult challenge in management, given the unique anatomy of the neck. Controversy surrounds the approach to zon...
2MB Sizes 0 Downloads 0 Views