Transcervical Neck Injury & Vertebral Artery Injury Supparerk Prichayudh, M.D. Fellow Ryder Trauma Center, JMH

Anatomy Anatomy of the neck is unique  contains many vital structures Great vessels Aerodigestive tract Endocrine Central Nervous System

Neck fascia 1. Superficial fascia  platysma muscle 2. Deep cervical fascia Investing  covers SCM Pretracheal  blends with pericardium Prevertebral  blends with axillary sheath Carotid sheath is formed by all 3 components of the deep cervical fascia.

Zone of neck injury (anterior) 1. Zone I Clavicle  cricoid cartilage Thoracic outlet vessels, brachial plexus, trachea, esophagus 2. Zone II Cricoid cartilage  angle of mandible CCA, IJV, larynx, pharynx 3. Zone III Angle of mandible  base of skull ICA, ECA, IJV, pharynx

Zone III Zone II Zone I Zone I – inferior trachea and esophagus vessels of the root of the neck: the brachiocephalic trunk, the subclavian arteries, the common carotid arteries, the thyrocervical trunk and the corresponding veins, thoracic duct, thyroid gland, spinal cord. Zone II – the larynx, hypopharynx common carotid arteries the internal and external carotid arteries the internal jugular veins and cranial nerves 10, 11, and 12, the spinal cord. Zone III – the pharynx carotid arteries the vertebral arteries Zone I

Initial management: ATLS Primary survey & resuscitation Airway with C spine protection first priority Orotracheal intubation Cricothyroidotomy Breathing Circulation Bleeding control Fluid resuscitation Disability/ Neurological status Exposure/ prevent hypothermia

Orotracheal intubation & Digital pressure

Surgical cricothyroidotomy

Foley catheter balloon tamponade in a zone 2 neck injury Foley catheter balloon tamponade in a zone 2 neck injury. The catheter is knotted on itself (black arrow) to prevent flow of blood through the lumen, and the wound is sutured around it (white arrow). Navsaria P,et al. Foley Catheter Balloon Tamponade for Life-threatening Hemorrhage in Penetrating Neck Trauma. World J Surg 2006:30;1265-8

Adjunct to primary survey Insertion of nasogastric tube before airway establishment should be avoided  may precipitate bleeding.

Secondary survey Obtain history, mechanism of injury PE Site of injury, wound tract (X-ray with marker) Vascular structures (bleeding, BP, hematoma, pulses, bruit) Aerodigestive tract (hemoptysis, air bubbling, subcutaneous emphysema, hoarseness, pain on swallowing, hematemesis ) Nervous system (GCS, pupil, CN, brachial plexus)

Signs of penetrating neck injury Hard Signs Soft Signs Active bleeding Expanding pulsatile hematoma Massive subcutaneous emphysema or air bubbling from wound Dysphagia Voice change Hemoptysis Widening mediastinum

Definitive care Unstable patients with hard signs  Emergency operation. Stable patients Wound does not penetrate platysma muscle. Discharge or observe Wound penetrates platysma muscle. Selective management in stable patients Careful PE Appropriate diagnostic tests Reserve operation for patients with significant injury

Algorithm Mansour et al 1991 retrospective study in 188 patients  63% non operative treatment, 1.5% mortality rate.

Algorithm for evaluation of penetrating neck wounds Hard signs Yes No Soft signs OR Yes No CT/CTA Bronchoscope Esophagoscope Observe Injury present or suspected Yes No

Transcervical Neck Injury Mandatory exploration VS. Selective management

Hirshberg et al, 1994 Retrospective study of 41 transcervical GSW patients. 34 patients (83%) sustained 52 major injuries. Most common  vascular 22 injuries and upper airway 13 injuries Positive neck exploration 30 of 36 patients (83%) Transcervical injuries are excellent markers of associated visceral injury.  Mandatory exploration.

Demetriades, Asensio, et al, 1996 Prospective study of 33 patients underwent selective management. Transcervical GSWs are more likely to involve vital structure. (73% VS. 31%) Only 7 patients (21%) had a therapeutic operation. Advice selective management (careful examination combined with appropriate diagnostic tests).  80% can be managed nonoperatively.

CT scan in penetrating neck injury Combine with PE! Munera et al, 2000  CT had sensitivity 90%, specificity 100% and PPV 100%. Woo, et al 2005  CTA Wound tract could be visualized.  assist in further diagnostic study selection May demonstrate injury.

Tracks did not involve vital structures.

Extravasation of contrast

CTA showed Rt CCA injury

Operative treatment: General principle Position  Supine, towel roll under patient’s shoulders. Prepare skin from neck to knee. Standard neck exploration  incision along anterior border of SCM muscle, with head turned to the opposite side.

Incision for Neck Exploration: Zone 2 /3 injuries: “hockey stick incision.” Open in layers Retract the SCM laterally. Methylene blue to aid in visualizing leaks. Mandibulotomy or mandibular subluxation for zone 3.

Facial vein = gate keeper of the neck

Incisions for Neck Exploration: Zone I – left anterior thoracotomy vs. left posterolateral thoracotomy for left zone I. midline sternotomy with extension to the right supraclavicular region for right I

Operative treatment: transcervical injury Symptomatic side of the neck should be explored first. If both sides require exploration. Bilateral neck incision Transverse (collar) incision Gives convenient access to anterior aspect of upper airway

Conclusions: transcervical injury ABCs are crucial!! Selective management can also be done in stable transcervical injury patients. Carefully repeat examination Appropriate diagnostic study Reserve operation in unstable patients or patients with established injuries.

Vertebral artery injury Incidence in penetrating trauma 1.0 – 7.4% Blunt trauma – rare

Anatomy Vertebral artery (VA) is the first branch of subclavian artery (SCA). 4 parts V1: SCA  C6 transverse process foramen (most accessible) V2: C6  C2 (Interosseous portion) V3: C2  Foramen magnum V4: Foramen magnum  Basilar artery

V1 V2 V4 V3

Clinical manifestations Hard signs  50% Expanding hematoma, cervical bruit, pulsatile hemorrhage Soft signs  30% Hx of bleeding, proximity wound, neurological abnormality Asymptomatic  20%

Diagnosis Clinical Color-flow duplex  limited role CTA, MRA  Noninvasive, screening tools Contrast angiography Gold standard has therapeutic options (stent, embolization)

38-year-old man with both blunt carotid artery and blunt vertebral artery injuries resulting from motor vehicle collision Sliker, C. W. et al. Am. J. Roentgenol. 2008;190:790-799

Rt VA occlusion with pseudoaneurysm  embolization with coil

CTA shows Lt VA occlusion

Treatment Majority of VA injuries do not require treatment. Majority of VA injuries requiring treatment are treated with angiographic embolization. Blunt VAI  antithrombotic treatment Indications for operation Active hemorrhage Failed angiographic treatment

Stein DM, et al 2009 147 patients identified with Blunt cerebrovascular injuries (BCVI) detected by routine CT scan. The incidence 1.2%, Mortality 13%. Treatments endovascular therapy (22%), antiplatelet medications (36%), anticoagulation (10%), and combination therapy (18%) 30% received no therapy, primarily due to contraindications from concomitant injuries. Blunt cerebrovascular injuries: does treatment always matter? Stein DM, Boswell S, Sliker CW, Lui FY, Scalea TM. J Trauma. 2009 Jan;66(1):132-43; discussion 143-4.

Stroke rate 12% (18 patients  8 before admission, 10 after). Treatment group = 3.9% Untreated group = 25.8% (p = 0.0003) Stroke-related mortality was 50%.

33 y/o female, MVC, GCS 15

Rt ICA thrombosis

MRA  Lt side weakness on the table

Angiogram  Rt MCA stroke

Embolectomy, stenting Rt ICA  Improved motor function

Surgical treatment: V1 Position patient’s head away from the injury. Incision Standard neck exploration  allow incision extension Transverse supraclavicular approach Retract Carotid sheath medially , SCM laterally Anterior scalene m. (with phrenic n.) laterally +Cut omohyoid m., clavicular head of SCM VA is found posterior to Vertebral vein.

Surgical treatment:V2 Same exposure as V1 Sweep longus coli m. of transverse processes. Remove anterior rim of vertebral foramen by using bone rongeurs. VA may be repaired or ligated. VV plexus bleeding  packing with hemostatic agent. Do not blindly clip VA  cervical nerve root behind VA may be injured.

Asensio, et al. Management of penetrating neck injury: the controversy surrounding zone II injuries. Surg Clin North Am 1991:71;267-296.

Surgical treatment: V3, V4 V3: posterior auricular approach. V4: suboccipital craniectomy

Asensio, et al. Management of penetrating neck injury: the controversy surrounding zone II injuries. Surg Clin North Am 1991:71;267-296.

Conclusion: VA injury Rare Diagnosis  PE and CTA/angiography Majority of VA injuries do not require operative treatment. Reserve operation for patients with Active hemorrhage Failed angiographic treatment

Case discussion 40 year-old male rode bicycle and fell down.  sustained penetrating neck trauma from wood stick. No LOC Could breathe spontaneously, but with secretion sound and small amount of blood from his mouth. Hemodynamically stable.