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

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

5. 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.

7. 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

9. 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

10. 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

11. Orotracheal intubation & Digital pressure

15. Surgical cricothyroidotomy

16. 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

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

18. 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)

20. 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

21. 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

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

23. 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

24. Transcervical Neck Injury
Mandatory exploration
VS.
Selective management

25. 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.

26. 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.

27. 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.

28. Tracks did not involve vital structures.

29. Extravasation of contrast

30. CTA showed Rt CCA injury

31. 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.

32. 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.

36. Facial vein = gate keeper of the neck

38. 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

39. 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

41. 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.

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

43. 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

44. V1 V2 V4 V3

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

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

47. 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:

48. Rt VA occlusion with pseudoaneurysm  embolization with coil

49. CTA shows Lt VA occlusion

50. 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

51. 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 Jan;66(1):132-43; discussion

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

53. 33 y/o female, MVC, GCS 15

57. Rt ICA thrombosis

58. MRA  Lt side weakness on the table

59. Angiogram  Rt MCA stroke

60. Embolectomy, stenting Rt ICA  Improved motor function

62. 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.

64. 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.

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

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

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

68. 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

69. 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.