Publication:

A tailored protocol in management of penetrating neck injuries: experience at a level 1 trauma centre

Background The management of penetrating neck injuries (PNIs) evolved markedly over last year’s towards more conservative approaches. Recent improvements in imaging modalities as multi-detector CT-angiography (MDCT-A) produced a paradigmatic shift towards 'no-zone' approach. In this study, we adopted a tailored protocol to deal with such injuries with less dependency on zone classification.

Methods This prospective study included patients with PNIs from February 2012 to January 2014. Unstable patients and patients with hard signs in zone-II were managed by immediate exploration. Patients with hard signs in zones-I and III had MDCT-A to check feasibility of endovascular intervention. However, all patients with soft signs and asymptomatic patients underwent MDCT-A regardless the zone affected to determine the need for therapeutic intervention. Complementary investigations were added in some cases with equivocal MDCT-A results.

Results Our study included 85 patients. Majority were males (94%; n=80) with mean age 27±4. Stabs were the main causative injury (51%; n=43). 63 (74%) patients were stable; with majority (64%; n=40/63) were symptomatic (18 presented with hard signs and 22 presented with soft signs). 53 (62%) patients had MDCT-A with sensitivity, specificity of 77%, 97% respectively and significant p value <0.05. After applying this protocol, we avoided 37% (31/85) non-therapeutic neck exploration, with only 4 (7.4%) negative cases on exploration. We experienced no missed injuries in the conservative group, yet 2 (3.7%) missed nerve injuries were encountered in intervention group.

Conclusions Zones-classification is losing popularity nowadays and shouldn't be the cornerstone of the new management protocols in PNIs. This selective tailored approach can be effectively used in management of PNIs. It avoids missed injuries and unnecessary explorations significantly.