NECK

TRAUMA
APOLONIO L. LASALA, MD
Professor
Department of Surgery
Faculty of Medicine and Surgery
University of Santo Tomas
 Background
• Few emergencies pose as great a challenge
as neck trauma
• Neck is a relatively small conduit where
multitude of organ systems are involved
– Respiratory/airway (eg. trachea)
– Gastrointestinal (eg. esophagus)
– Neurological (eg. cervical nerve roots,
cervical spine, brachial plexus, etc.)
– Vascular (eg. Carotid arteries, jugular
veins, great vessels, etc.)
– Musculoskeletal structures
 Background
• Single penetrating wound may be harmful
or lethal
• Therefore, a clear understanding of the
anatomic relationships within the neck and
the mechanisms of injury is critical to
devising a rational diagnostic and
therapeutic strategy
Anatomy of the Neck
Anatomy of the Neck
 Anatomic Structures at
Risk
• Neck protected by the spine posteriorly,
the head superiorly, and the chest
inferiorly
• Therefore, anterior and lateral regions
are most exposed to injury, esp. trachea
and larynx
• Spinal cord lies posteriorly, cushioned
by the vertebral bodies, muscles, and
ligaments, therefore, more prone for
blunt than penetrating injury
• Esophagus and the major blood vessels
are between the airway and spine
Anatomic Structures at
Risk
• Musculoskeletal: • Neural structures:
– cervical spine – spinal cord
– cervical muscles – phrenic nerve
– tendons, and – brachial plexus
ligaments
– clavicles – recurrent
laryngeal nerve
– first and second
ribs – cranial nerves
– hyoid bone (specifically IX-
XII)
– stellate
ganglion.
Anatomic Structures at
Risk
• Vascular structures • Visceral structures:
– carotid – thoracic duct
(common, – esophagus
internal, – pharynx
external)
– larynx
– vertebral
– trachea
arteries
– brachiocephalic
– jugular (internal
and external)
veins
Anatomic Structures at
Risk
• Glandular structures:
– thyroid glands
– parathyroid glands
– submandibular glands
– parotid glands
Anatomic Landmarks
Anatomic Zones of the
Neck
 Anatomic Zones of the
Neck
• Zone I
• Structures: Great vessels, trachea,
esophagus
• Involvement may have high mortality
rate upto 12%
• Osseous shield makes surgical
exploration of the root of the neck
difficult
• R side  median sternotomy
• L side  L anterior thora-
 Anatomic Zones of the
Neck
• Zone II
• Structures: internal & external carotid
arteries, jugular veins, pharynx, larynx,
esophagus, RLN, spinal cord, trachea,
thyroid and parathyoids
• Most frequently involved (60 to 75%)
 Anatomic Zones of the
Neck
• Zone III
• Structures: carotid and vertebral
arteries, jugular veins, cranial nerves
• Protected by skeletal structures and
is difficult to explore
• Recognizing injuries to the cranial
nerves exiting the base of the skull in
zone III is important because these
injuries may be indicative of injuries
• to the great vessels due to
• their close proximity
 Neck trauma: Zone I
• Between clavicle
/cricoid cartilage
• Thoracic outlet –
hemothorax
• Stable patients
– CXR
– angiography
– esophagography/
endoscopy
– bronchoscopy
• Unstable patients
– immediate
exploration
 Neck trauma: Zone II
• Between cricoid
/mandibular angle
• neck proper -
easiest evaluation
• wound exploration
– platysmal
penetration
• stable
asymptomatic
patients
– Observed
– Cervical spine x-ray
• symptomatic
patients
– explored
 Neck trauma: Zone III
• Above angle of
mandible
• require
carotid/vertebral
angiograms
• neurologic injuries
 Mechanisms of Injury
• Penetrating
• >95% results from stab and GSW
• GSW sustain more injury than stab wounds
for it damages even outside the tract
• After GSW to the neck, surgery is indicated
in 75% of cases
• About 50% of stab wound to the neck would
require surgery
Mechanisms of Injury
• Penetrating
• internal jugular vein 9% most
common sites of vascular
• carotid artery 7% injuries
• pharynx 5-15%
• esophagus
• larynx 4-12%
• trachea
• major nerve injury 3-8%
Whiplash injury
 WHIPLASH INJURY
• Neck sprain or neck strain
• An injury to the soft tissues of the neck
• Often the result of rear-end car crashes
 WHIPLASH INJURY
• Symptoms of Whiplash
• Neck stiffness
• Injuries to the muscles and ligaments (myofascial
injuries)
• Headache and dizziness (symptoms of a
concussion)
• Difficulty swallowing and chewing and hoarseness
• Abnormal sensation such as burning or prickling
• Shoulder and back pain
 WHIPLASH INJURY
• Diagnosis of Whiplash
• Physical exam to evaluate patient’s condition

• Neurological exam
• X-ray cervical spine to rule out cervical injuries
• CT scan to assess condition of the
• cervical spine’s soft tissues

• MRI
 WHIPLASH INJURY
• Treatment
• Soft cervical collar to be worn 2 to 3 wks
• Heat therapy to relieve muscle tension and pain
• Pain medications (Analgesics and NSAIDS)
• Muscle relaxants
• Range of motion of exercises and physical
therapy
• Cervical traction
 Mechanisms of Injury
• Blunt
• Usually from motor vehicle accident
• Other causes:
– sports-related injuries
– strangulation
– blows from the fists or feet
 Mechanisms of Injury
• BLUNT • PENETRATING
• direct blows • stab
• fall – knife/icepick
• frontal impact – sharps
• “whiplash” • gunshot wounds
• “clothesline” – small caliber
• “head banging” – rifle/shotgun
• chiropractic
• soccer
 Signs/Symptoms of Neck
Injury
Shock Dyspnea Hemoptysis Focal /
Lateralized
deficit
Active Stridor Dysphagia
Bleeding

Expanding Hoarseness/ Hematemesis

hematoma dysphonia

Subcutaneous Subcutaneous
emphysema emphysema

Vascular
Vascular Airway
Airway Esophagus
Esophagus Neurologic
Neurologic
 Work-ups and Diagnostic
Modalities
• Mainly based on the zone
affected:
 CBC, blood typing
 Chest X-ray
 Cervical spine X-ray (AP-lateral-
open mouth views)
 Angiography
 Esophagography/endoscopy
 Bronchoscopy
 Carotid/vertebral angiograms
 CT scan
Chest X-ray
Cervical Spine X-ray

• Lateral views must be able to

visualize all cervical vertebrae (C1 to
C7) because majority involves C5-C6
Cervical Spine X-ray

• Open mouth/odontoid views will be

able to visualize the AP view of C1-
C2
• AP view can only visualize C3-C7
because of the mandible
 Carotid Angiography
• relatively invasive
• can be done to
stable patients
• if CT scan is not
available
• less expensive but
also has lower
sensitivity and
specificity
compared to CT
angiography
 CT angiography
• relatively invasive
• can only be done to
stable patients
• renal function test
must be normal
• may delay the
diagnosis and of
treatment
• sensitivity 97.7%
• specificity 100%
• PPV 100%
• NPV 99.3%
• accuracy 99.3%
History of Management
• 1552  Ambrose Pare ligated both
common carotid
• arteries and the jugular vein
of a soldier w/
• a traumatic neck injury 
patient survived
• but developed aphasia and
hemiplegia
• 1803  Fleming ligated a lacerated
common carotid
• artery and reported a
successful outcome
• after 5-month follow-up
History of Management
• As continual advances in anesthesia and
new technologies developed, therapy has
evolved

Nonoperative Routine neck

management exploration

No treatment Selective neck

exploration
Management Algorithm
Management Algorithm
 Indications for Neck
Exploration
• Shock
• Expanding hematoma
• Active bleeding
• Subcutneous emphysema
• Hoarseness
• Stridor
• Obvious esophageal and/or tracheal injuries
 Management
•ABCs of Trauma
•A - airway
• B -breathing
•C - circulation
•D- disability and neuorologic
status
• E- exposure and over-all
evaluation
 Management
• Stabilization
• Critically injured patient
– Rapidly assessing vital functions and
the area of injury
– Performing stabilizing interventions
– Initiating a diagnostic workup
– Definitive care
• No immediate life threat
– Violates the platysma ( explore at OR )

• * If hemodynamic stability cannot be

achieved, prompt transfer to the
operating room is in order
 Management
• Medical
• Resuscitative efforts with emphasis
on the ABCs
• Clear airway
• Establish optimal airway (ie, through
ET intubation) and possibly start
mechanical ventilation
• Control of bleeding with direct
pressure
• Large-bore IV catheters for fluid
resuscitation
• Cervical spine precaution until injury
 Management
• Surgical
• Immediate surgical exploration if indicated
• Surgical management depending on the
injured structure
 Neck trauma
• A 28 year old male, hold-up
victim is admitted to the ER because of
a punctured wound to the neck.
• VS: BP: 130/90 PR: 98/min RR:
22/min ; a 3mm punctured wound is
noted over the left anterior triangle of
the neck,beside the thyroid cartilage.
While taking his history, the patient
starts to panic and complains of
severe dyspnea.
 Neck trauma
• A 42 yr old female is thrown against
the front seat of a car during a high speed
vehicular accident. She is unconscious, BP:
60 palpatory, pulse is faint and thready; both
clavicles are fractured; there are no breath
sounds over the left hemithorax