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journal homepage: www.JournalofSurgicalResearch.com

“No zone” approach in penetrating neck trauma

reduces unnecessary computed tomography
angiography and negative explorations

Kareem Ibraheem, MD,a Muhammad Khan, MD,a Peter Rhee, MD,b

Asad Azim, MD,a Terence O’Keeffe, MD,a Andrew Tang, MD,a
Narong Kulvatunyou, MD,a and Bellal Joseph, MDa,*
a
Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona,
Tucson, Arizona
b
Division of Acute Care Surgery, Department of Surgery, Grady Memorial Hospital, Atlanta, Georgia

article info abstract

Article history: Background: The most recent management guidelines advocate computed tomography
Received 16 March 2017 angiography (CTA) for any suspected vascular or aero-digestive injuries in all zones and
Received in revised form give zone II injuries special consideration. We hypothesized that physical examination can
4 July 2017 safely guide CTA use in a “no zone” approach.
Accepted 16 August 2017 Methods: An 8-year retrospective analysis of all adult trauma patients with penetrating
Available online 18 September 2017 neck trauma (PNT) was performed. We included all patients in whom the platysma was
violated. Patients were classified into three groups as follows: hard signs, soft signs, and
Keywords: asymptomatic. CTA use, positive CTA (contrast extravasation, dissection, or intimal flap)
Neck trauma and operative details were reported. Primary outcomes were positive CTA and therapeutic
Neck zones neck exploration (TNE) (defined by repair of major vascular or aero-digestive injuries).
CT angiography Results: A total of 337 patients with PNT met the inclusion criteria. Eighty-two patients had
Therapeutic neck exploration hard signs and all of them went to the operating room, of which 59 (72%) had TNE. One
hundred fifty-six patients had soft signs, of which CTA was performed in 121 (78%), with
positive findings in 12 (10%) patients. The remaining 35 (22%) underwent initial neck
exploration, of which 14 (40%) were therapeutic yielding a high rate of negative explora-
tion. Ninty-nine patients were asymptomatic, of which CTA was performed in 79 (80%),
with positive findings in 3 (4%), however, none of these patients required TNE. On sub
analysis based on symptoms, there was no difference in the rate of TNE between the neck
zones in patients with hard signs (P ¼ 0.23) or soft signs (P ¼ 0.51). Regardless of the zone of
injury, asymptomatic patients did not require a TNE.
Conclusions: Physical examination regardless of the zone of injury should be the primary guide
to CTA or TNE in patients with PNT. Following traditional zone-based guidelines can result in
unnecessary negative explorations in patients with soft signs and may need rethinking.
ª 2017 Elsevier Inc. All rights reserved.

Quick Shot at the 75th Annual Meeting of The American Association for the Surgery of Trauma (AAST) and Clinical Congress of Acute
Care Surgery, September 14-17, 2016, Hilton Waikoloa Village, Hawaii.
* Corresponding author. Division of Trauma, Critical Care, and Emergency Surgery, Department of Surgery, University of Arizona, 1501 N.
Campbell Ave, Room 5411, P.O. Box 245063, Tucson, AZ 85724. Tel.: þ1 520 626 5056; fax: þ1 520 626 5016.
E-mail address: bjoseph@surgery.arizona.edu (B. Joseph).
0022-4804/$ e see front matter ª 2017 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jss.2017.08.033

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114 j o u r n a l o f s u r g i c a l r e s e a r c h  j a n u a r y 2 0 1 8 ( 2 2 1 ) 1 1 3 e1 2 0
Introduction
The management of penetrating neck trauma (PNT) in the
civilian setting has changed tremendously in the last
three decades. Experience in the civilian setting of large
trauma centers, together with economic considerations
regarding unnecessary neck explorations prompted the shift
of pendulum from an era of mandatory neck exploration to an
era of more selective management.1 Trauma surgeons are
occasionally faced with the difficult decision whether to
operate or conservatively manage stable patients presenting
with PNT. The optimal management of PNT in this group of
patients has remained a source of debate among trauma
surgeons for decades, despite the evolving recent advances.
The management of PNT has been dependent on the
anatomic zone of injury.2 Figure 1 demonstrates different
anatomical zones of the neck.3 The most recent management
guidelines advocate computed tomography angiography
(CTA) for any suspected vascular or aero-digestive injuries in
all zones and give zone II injuries special consideration, where
operative intervention should be considered for symptomatic
patients.4 Current guidelines including a recent one from the
Western Trauma Association (WTA) always starts with
the zones of the neck, and the algorithm is dependent on the
zones of the neck. Penetrating injuries can transgress zone
boundaries depending upon the projectile and its angle of
penetration. A trauma surgeon might operate on external
wound in zone II and then surprisingly might encounter an
unanticipated internal vascular or aero-digestive injury in
zone III or in the mediastinum (zone I). It has been shown that
the location of the external wound does not necessarily
correlate to the location of the underlying injury.5-7 It raises
the question, should the external wound dictate our diag-
nostic and therapeutic actions?
The recent advances in technology have led to the wide-
spread and liberal use of CTA in trauma including the initial
Fig. 1 e The anatomical zones of the neck.
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management of stable patients with PNT.7 Multiple studies
have demonstrated that physical examination alone may be
as accurate as other invasive diagnostic modalities in detect-
ing significant cervical vascular8-13 or aero-digestive2,9,11,13
injuries requiring operative repair. The aim of our study was
to examine the rates on CTA use, positive CTA and therapeutic
neck exploration (TNE) among PNT patients based on their
clinical presentation, regardless of the zone of injury. We
hypothesized that physical examination can safely guide CTA
use in a “no zone” approach that takes into account the clin-
ical presentation of the patient regardless of the zone of neck
injury.
Methods
We performed an 8-year retrospective analysis (from January
2008 to December 2015) of all adult trauma patients with PNT
presented to our level I trauma center. Banner University
Medical Center Tucson is an American College of Sur-
geonsecertified level I trauma center. We included all trauma
patients with isolated penetrating neck injuries (defined by
violation of the platysma). All patients who had other body
injuries, were younger than 18 years old, had superficial neck
injuries (no platysma violation), incomplete chart informa-
tion, or presented with death on arrival were excluded from
our study. Ethical approval for this study was granted by our
institutional review board.
The following data points were collected: patient de-
mographics (age and gender), mechanism of trauma (stab
wound, gunshot, or shotgun wounds), admission vital signs
including systolic blood pressure, heart rate, Glasgow Coma
Scale score, zone of injury and associated injuries. Injury
severity score and abbreviated injury severity scores were
obtained from our trauma registry. Additional information
collected included symptoms and signs on presentation,
 ibraheem et al  no zone approach in penetrating neck trauma 115

imaging studies performed and their findings. Injuries and
repairs to the vascular and aero-digestive structures were
identified by examining the charts and operative reports.
The three anatomical zones of the neck were defined ac-
cording to Monson et al.14,15 Patients who sustained injuries in
more than one zone of the neck were grouped as multiple
zones. Patients were classified into three groups as follows;
hard signs, soft signs, and asymptomatic. This classification
was based on their signs and symptoms upon presentation.
Hard signs were defined as shock, active bleeding, expanding/
pulsatile hematoma, focal neurologic deficit, airway compro-
mise, massive subcutaneous emphysema, air bubbling
through wound, and severe hematemesis.4,16 All other pa-
tients were considered to have soft signs of neck injury that
included stable hematomas, minor hemoptysis, hoarseness,
dysphagia, and mild subcutaneous emphysema. The asymp-
tomatic group included all patients with no signs of neck
injury other than the stab or gunshot wounds and who
completely had no symptoms related to the neck injury.
Our primary outcomes were positive CTA (contrast
extravasation, dissection, or intimal flap) and TNE (full-neck
exploration including carotid sheath plus repair of major
vascular or aero-digestive injuries). Negative neck exploration
was defined as full-neck exploration, including carotid sheath
without repair of any major vascular or aero-digestive in-
juries. Taking the patient to the operating room (OR) for only
wound exploration, irrigation, hemostasis or closure was not
considered as a neck exploration. Secondary outcomes were
complications, missed injury rates, hospital and intensive
care unit length of stay, and mortality. The level I trauma
center in this study is the only trauma center in the metro-
politan region and have a working relationship with the
community that all trauma patients presenting to an outside
hospital after the initial encounter at the trauma center are
either transferred back or the trauma center is made aware
through communication.
Data are reported as mean standard deviation for contin-
uous descriptive variables, as median (range) for ordinal
descriptive variables and as proportions for categorical vari-
ables. ManneWhitney U and Student’s t-test was used for
continuous variables. The chi-square test was used for cate-
population are shown in Table 1. Overall mortality rate was
4.5% (n ¼ 15). The following were the main causes of mortality;
massive hemorrhage from major carotid arteries (n ¼ 5),
postoperative stroke and anoxic brain injury (n ¼ 5), cardiac
arrest from severe respiratory distress (n ¼ 3), and sepsis from
severe dog bites (n ¼ 2). Figure 2 demonstrates management of
neck injuries based on initial physical examination.
Patients with hard signs
A total of 82 patients presented with hard signs of vascular or
aero-digestive injuries. These hard signs were as follows:
shock (n ¼ 24), active bleeding (n ¼ 44), expanding hematoma
(n ¼ 9), respiratory distress (n ¼ 9), air bubbling through the
wound (n ¼ 8), and massive subcutaneous emphysema (n ¼ 2).
The injured structures in patients with hard signs are
described in Table 2.
All 82 patients with hard signs went to the OR for neck
exploration. On presentation, 58 (72%) patients were unstable
and underwent neck exploration immediately, of whom 45
(76.3%) had a TNE. Indications for urgent exploration were
severe shock, massive hemorrhage, severe airway compro-
mise leading to cardiac arrest, air-bubbling and visible lar-
yngotracheal injuries through the wound. The decision
whether to take the patient directly to the operating room or
to the imaging suite for CTA was totally dependent on the
attending surgeon. A total of 23 patients (28%) had CTA first, of
whom 11 (47%) had positive CTA findings. All stable patients
with hard signs eventually went to the OR, of whom 14 (61%)
Table 1 e Descriptive statistics of our study population.
Characteristics N ¼ 337
Age, y, median [IQR] 30 [26-40]
Sex (male), % (n) 81.3% (274)
Stab wounds, % (n) 69.1% (233)
Gunshot wounds, % (n) 21.1% (71)
Shotgun wounds, % (n) 9.8% (33)

gorical variables. P < 0.05 was considered statistically signifi- Self-inflicted injuries, % (n) 17.8% (60)
cant. All statistical analyses were performed using Statistical ISS, median [IQR] 2 [1-5]
Package for Social Sciences (SPSS, Version 20; SPSS Inc, Chi- Admission SBP, mean  SD 130.5  21.1
cago, IL). Admission HR, mean  SD 89.8  15
GCS, median [IQR] 15 [13-15]
Zone of injury
Results
I 16.6% (56)

During our 8-year study period, 337 patients with PNT pre- II 60.2% (203)

sented to our level I trauma center. The majority were male III 18.7% (63)
(81.3%), and the median age was 30 [26-40]. A total of 233 pa- Multiple zones 4.5% (15)
tients (62.1%) sustained a stab wound, 71 (21.1%) had a gun- Hard signs, % (n) 24.3% (82)
shot wound and 33 (9.8%) had a shotgun injury. A total of 203 Soft signs, % (n) 46.3% (156)
patients (62.2%) had their injuries in zone II, which was the
Asymptomatic, % (n) 29.4% (99)
most commonly injured zone. This was followed by zone I (40
Mortality, % (n) 4.5% (15)
patients, 18%) and zone III (43 patients, 19%). Fifteen patients
(4.5%) sustained injuries in multiple zones of the neck. De- SD ¼ standard deviation; ISS ¼ injury severity score; IQR ¼ inter-
quartile range; SBP ¼ systolic blood pressure; GCS ¼ Glasgow Coma
mographics, mechanism of injury, injury severity score,
Scale.
admission vital signs, and zones of injury of our study

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116 j o u r n a l o f s u r g i c a l r e s e a r c h  j a n u a r y 2 0 1 8 ( 2 2 1 ) 1 1 3 e1 2 0

Fig. 2 e Management of neck injuries based on physical exam. (Color version of figure is available online.)

had a TNE. CTA findings correlated with the intraoperative
findings in the majority of cases. In three patients, CTA
findings guided the use of intraoperative esophagogas-
troduodenoscopy and bronchoscopy, where one patient had
esophageal injury and two patients had laryngotracheal in-
juries. However, in another three patients, CTA failed to detect
external jugular and anterior jugular venous injuries that were
detected later during the neck exploration. In patients with
negative CTA (n ¼ 12), significant disruptions of the sterno-
cleidomastoid and strap muscles were identified along with
injuries to multiple unnamed vessels.
Neck injuries were categorized as follows: 10/82 (12%) zone
I; 58/82 (71%) zone II, and 10/82 (12%) zone III. A total of 4/82
patients (5%) with hard signs had injuries in more than one
zone of the neck. Rates of CTA use, positive CTA, and TNE
across the neck zones in patients with hard signs are illus-
trated in Table 3. There was no difference in the rates of TNE
(P ¼ 0.23) between any of the neck zones.
Patients with soft signs
A total of 156 patients presented with soft signs. CTA was
performed in 121 patients (78%), with positive findings in 12
(10%). Patients with soft signs presented with stable hema-
toma (n ¼ 81), mild bleeding (n ¼ 73), hemoptysis (n ¼ 7),
hoarseness (n ¼ 5), dysphagia (n ¼ 2), and mild subcutaneous
emphysema (n ¼ 10). The vascular and aero-digestive injuries
found during TNE in patients with soft signs are described in
Table 2. A total of 14 patients had TNE with stable hematoma
(n ¼ 8) and mild bleeding (n ¼ 8) as the most common pre-
senting complaints. One patient presented with hemoptysis
and was found to have hypopharyngeal injury.
Neck injuries were categorized as follows: 27/156 (17%)
zone I; 83/156 (53%) zone II, and 36/156 (23%) zone III. A total of
10/156 (6.4%) patients with soft signs had injuries in more than
one zone of the neck rates of CTA use, positive CTA, and TNE
across the neck zones in patients with soft signs are illus-
trated in Table 4. Patients with zone II neck injuries were more
likely to undergo exploration (P ¼ 0.013); however, there was
no difference in rates of TNE (P ¼ 0.55) between all zones. The
rates of other modalities in patient with soft signs were
esophagogastroduodenoscopy (n ¼ 3), bronchoscopy (n ¼ 3),
and contrast swallow (n ¼ 2).
Asymptomatic patients
A total of 99 patients (29.4%) were asymptomatic and had no
signs of vascular or aero-digestive injuries. This group
included 22 patients (zone I), 57 patients (zone II), and 19 pa-
tients (zone III). Only one patient had injuries in more than
one zone of the neck. None of the asymptomatic patients had
TNE. CTA was performed in 80% of the asymptomatic patients
and only three were positive. None of these three patients had
clinically significant injuries and they did not require any
surgical intervention. Two patients had small vertebral artery
aneurysms and one patient had small intimal tear of internal

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 ibraheem et al  no zone approach in penetrating neck trauma 117

Table 2 e Incidence of injuries among the three groups based on clinical presentation.
Variable Overall (n ¼ 337) Hard signs (n ¼ 82) Soft signs (n ¼ 156) Asymptomatic (n ¼ 99) P-value
Vascular injuries
CCA 9 (2.7%) 9 (11%) 0 0 <0.001
ICA 11 (3.3%) 7 (8.5%) 4 (2.6%) 0 0.005
ECA 5 (1.5%) 4 (4.9%) 1 (0.6%) 0 0.013
Vertebral artery 11 (3.3%) 7 (8.5%) 2 (1.3%) 2 (2%) 0.008
IJV 16 (4.7%) 11 (13.4%) 4 (2.6%) 1 (1%) <0.001
EJV 24 (7.1%) 16 (19.5%) 8 (5.1%) 0 <0.001
AJV 15 (4.5%) 9 (1%) 6 (3.8%) 0 0.002
Aero-digestive injuries
Larynx 9 (2.7%) 7 (8.5%) 2 (1.3%) 0 0.001
Trachea 12 (3.6%) 10 (12.2%) 2 (1.3%) 0 <0.001
Hypopharynx 7 (2.1%) 6 (7.3%) 1 (0.6%) 0 0.001
Esophagus 3 (0.9 %) 2 (2.4%) 1 (0.6%) 0 0.194

CCC ¼ common carotid artery; ICA ¼ internal carotid artery; ECA ¼ external carotid artery; IJV ¼ internal jugular vein; EJV ¼ external jugular
vein; AJV ¼ anterior jugular vein.

jugular vein. No missed injuries or delayed complications
were reported in these patients. Rates of CTA use, positive
CTA, and TNE across the neck zones in asymptomatic patients
are illustrated in Table 5. No other modalities were used in
asymptomatic patients. Figure 3 demonstrates the proposed
“No Zone” algorithm for the management of penetrating neck
trauma based on physical examination.
Discussion
Results of our analysis show the significance of physical ex-
amination in the clinical decision-making regarding the
management of neck injuries, irrespective of anatomical
zones of the neck. Our study demonstrates that regardless of
the anatomical zones or hemodynamic stability, all patients
with hard signs after neck injury underwent neck exploration
with a high rate of therapeutic interventions. As far as pa-
tients with soft signs who underwent neck exploration, only a
third of them were therapeutic. None of the asymptomatic
patients underwent neck exploration. On sub analysis based
on symptoms, there was no difference in the rate of TNE be-
tween the neck zones in patients with hard signs or soft signs.
Historically, the algorithms for treating penetrating neck
injury were developed because injuries in the upper neck and
lower neck were more difficult to manage, and the diagnostic
studies to evaluate these injuries were invasive or cumber-
some. Thus the search for the most efficient way of identifying
injury and the optimal use of resources were the key variables
in managing these injuries. Currently, the evolution of CTA
has changed much of our practice and it is time for us to
rethink our approach.
Based on our data, we have proposed a new algorithm for
the evaluation and management of penetrating neck injuries
Figure 1. This new algorithm does not start with the zone of
the external wound, as it does not seem to matter based on
our data. Our data showed that asymptomatic patients did not
benefit from CTA, surgery or other interventions. Thirty
percent of the patients in this study were asymptomatic and
78% of these patients underwent a CTA, which turned out to
be unnecessary because it only identified three minor vascular
injuries which were inconsequential and clinically insignifi-
cant. This approach would emphasize the need for meticulous
physical examinations and trusting the clinical judgment of
the trauma surgeon.
For patients with soft signs, which were the largest group
(46%) in this study, the new proposed algorithm recommends
CTA before taking them for neck exploration. Using the clin-
ical presentation would better help our decision on how to use
our resources. For the patients with presentation that is un-
reliable, good clinical judgment is required, and a period of
observation in stable patients would be suggested.

Table 4 e Rates of CTA use, positive CTA and TNE in

Table 3 e Rates of CTA use, positive CTA and TNE in patients with soft signs.
patients with hard signs.
Zones of Number of CTA OR TNE
Zones of Number CTA TNE% injury patients (n) % (n)
injury of (n) Overall Positive
patients Overall Positive
Zone I 27 22 1 6 66 (4)
Zone I 10 4 2 100 (10) Zone II 83 65 7 28 25 (7)
Zone II 58 12 4 70.7 (41) Zone III 36 34 4 6 50 (3)
Zone III 10 5 5 50 (5) Multiple 10 0 0 0 0
Multiple zones 4 2 0 75 (3) zones

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118 j o u r n a l o f s u r g i c a l r e s e a r c h  j a n u a r y 2 0 1 8 ( 2 2 1 ) 1 1 3 e1 2 0

many trauma centers for hemodynamically stable patients.

Table 5 e Rates of CTA use, positive CTA and TNE in
asymptomatic patients. The liberal use of CTA recommended by zone-guided algo-
rithms will, however, also result in high rates of unnecessary
Zones of Number of CTA TNE%
CTA and negative neck explorations. It has also resulted in
injury patients (n)
Overall Positive positive CTA studies that were clinically insignificant and did
Zone I 22 21 0 0
not require any surgical intervention.
Of course there are wounds that require surgical attention
Zone II 57 41 1 0
even if formal neck explorations are not required. For this type
Zone III 19 16 2 0
of wounds, it is recommended that the wounds be repaired in
Multiple 1 0 0 0
the OR if it is better for the patient. However, our algorithm is
zones
most useful for those with smaller external wounds such as
small stab wounds, gunshot wounds, and shotgun wounds
In our study, patients with zone II injuries presenting with that do not need much external wound care.
soft signs (n ¼ 82), only 14 patients had TNE. Following the The practice of mandatory neck exploration has been
WTA guidelines and algorithm, it recommends that symp- challenged and discouraged because of the high unacceptable
tomatic patients undergo neck exploration.4 Following this rates of negative neck explorations. The routine use of full
approach, our data showed that it would have resulted in 68 four-vessel cerebral angiography in patients with PNT has also
negative neck explorations. been challenged because it is invasive and results in high
The evolution and advances of modern CTA have allowed number of negative examinations.17 Following the same
for its widespread implementation as the standard of care in concept, zone-based algorithms should be reconsidered after

Fig. 3 e “No zone” algorithm in penetrating neck trauma.

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 ibraheem et al  no zone approach in penetrating neck trauma
taking into account the no zone approach, where patients are
stratified based on their clinical signs and symptoms. The no
zone approach is a promising utility to reduce the rates of
unfavorable outcomes such as unnecessary CTA and negative
neck explorations as well as simplifying the approach. Few
studies adopted this approach; however, the evidence in
literature is still lacking and evolving.5-7,18
Once vascular or aero-digestive injury is suspected, some
zone-based guidelines recommend the liberal use of CTA in
zones I and III, while recommending neck exploration in pa-
tients with zone II injuries.4 Our data show that suspicion
alone does not warrant the liberal use of CTA and neck
exploration in asymptomatic patients with PNT.
Supporting the notion that asymptomatic patients do not
need CTA is the fact that Demetriades et al.9 showed that the
absence of signs suspicious of esophageal injury (painful
swallowing, subcutaneous emphysema, or hematemesis) can
reliably exclude esophageal injury. None of the 174 awake,
asymptomatic patients in their study had esophageal injuries.
Studies have also shown that small esophageal or tracheal
injuries can be safely managed conservatively.19 The fear of
missing small but critical aero-digestive injuries by relying on
clinical presentation is not justified in literature.
After comparing our results to the results if WTA algorithm
had been followed, we emphasize the fact that all asymp-
tomatic patients should be managed with clinical observation
only and do not require CTA. All asymptomatic patients
should be treated as one entity without any special consid-
erations to zone II. As for patients with soft signs, a small
modification is to be considered in WTA algorithm. Patients
with soft signs in zone II should be offered CTA first and
should not be taken directly to the OR. This means that all
patients with soft signs, regardless of the zone of injury,
should undergo CTA, and only patients with positive CTA
might be considered for surgical neck exploration. In patients
without hard signs (soft signs and asymptomatic), following
WTA algorithm (zone based) will lead to a total of 82 trips to
the OR and 120 CTA versus 12 trips to the OR and 156 CTA
following our proposed algorithm.
In our study, the rate of negative neck exploration in pa-
tients with PNT presenting with hard signs was 28%. These
results were higher from other studies that reported negative
exploration rates ranging from 10%-27% in that group of pa-
tients.6,7,12 Schroll et al.16 showed that the use of CTA in
selected patients presenting with hard signs can reduce the
number of these negative explorations. However, this study
focused only on zone II neck injuries. Ibraheem et al.20 sug-
gested that extending the implementation of CTA to zone I
and III might reduce more numbers of unnecessary neck ex-
plorations especially in zones I and III in which there is diffi-
culty in accessing the injured structures.
The findings of our results should be interpreted within the
context of our study’s limitations. Our study has a number of
limitations, including its retrospective nature and the fact that
it was conducted at a single institution. Also, the attending
surgeon determined whether to perform CTA or observation
in the hemodynamically stable patient, which is an inherent
limitation of a retrospective study. However, we believe that
our study is one of the largest series in PNT, which is infre-
quently encountered by trauma surgeons. This study is also
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119
another important piece of evidence to the literature that
supports the need for approaching PNT patients in a “no zone”
approach that considers the symptoms and signs of the pa-
tient not the zone of injury. Future research should focus on
multi-institutional retro- or prospective studies with a large
number of patients to accurately investigate the applicability
of implementing the “no zone” approach and compare it to the
zone-based algorithms.
Conclusion
Physical examination, not the zone of injury, should be the
primary guide to CTA use in patients with PNT. Following a
“no zone” approach can reduce unnecessary CTA and nega-
tive neck explorations in stables patients presenting with PNT.
Asymptomatic patients do not require CTA and should be
managed with observation, regardless of the zone of injury.
The proposed algorithm needs to be validated by other studies
at other institutions.
Acknowledgment
Authors’ contribution: B.J., K.I., M.K., T.K., A.A., and P.R.
designed this study. B.J., K.I., A.T., T.K., A.A., and P.R. searched
the literature. B.J., K.I., N.K., A.T., and M.K. collected the data.
B.J., K.I., N.K., M.K., and A.A. analyzed the data. All other au-
thors participated in data interpretation and manuscript
preparation.
Disclosure
There are no identifiable conflicts of interests to report. The
authors have no financial or proprietary interest in the subject
matter or materials discussed in the manuscript.
references
1. Thoma M, Navsaria PH, Edu S, Nicol AJ. Analysis of 203
patients with penetrating neck injuries. World J Surg.
2008;32:2716e2723.
2. Tisherman SA, Bokhari F, Collier B, et al. Clinical practice
guideline: penetrating zone II neck trauma. J Trauma.
2008;64:1392e1405.
3. Stawicki SP. Trends in nonoperative management of
traumatic injuriesea synopsis. Int J Crit Illn Inj Sci. 2017;7:38.
4. Sperry JL, Moore EE, Coimbra R, et al. Western Trauma
Association critical decisions in trauma: penetrating neck
trauma. J Trauma Acute Care Surg. 2013;75:936e940.
5. Low GM, Inaba K, Chouliaras K, et al. The use of the anatomic
’zones’ of the neck in the assessment of penetrating neck
injury. Am Surg. 2014;80:970e974.
6. Prichayudh S, Choadrachata-anun J, Sriussadaporn S, et al.
Selective management of penetrating neck injuries using “no
zone” approach. Injury. 2015;46:1720e1725.
7. Inaba K, Branco BC, Menaker J, et al. Evaluation of
multidetector computed tomography for penetrating neck
injury: a prospective multicenter study. J Trauma Acute Care
Surg. 2012;72:576e583. discussion 583-574; quiz 803-574.
120 j o u r n a l o f s u r g i c a l r e s e a r c h  j a n u a r y 2 0 1 8 ( 2 2 1 ) 1 1 3 e1 2 0

8. Azuaje RE, Jacobson LE, Glover J, et al. Reliability of physical
examination as a predictor of vascular injury after
penetrating neck trauma. Am Surg. 2003;69:804e807.
9. Demetriades D, Theodorou D, Cornwell E, et al. Evaluation of
penetrating injuries of the neck: prospective study of 223
patients. World J Surg. 1997;21:41e47. discussion 47-48.
10. Ferguson E, Dennis JW, Vu JH, Frykberg ER. Redefining the role
of arterial imaging in the management of penetrating zone 3
neck injuries. Vascular. 2005;13:158e163.
11. Gonzalez RP, Falimirski M, Holevar MR, Turk B. penetrating
zone II neck injury: does dynamic computed tomographic
scan contribute to the diagnostic sensitivity of physical
examination for surgically significant injury? A prospective
blinded study. J Trauma. 2003;54:61e64. discussion 64-65.
12. Sekharan J, Dennis JW, Veldenz HC, Miranda F, Frykberg ER.
Continued experience with physical examination alone for
evaluation and management of penetrating zone 2 neck
injuries: results of 145 cases. J Vasc Surg. 2000;32:483e489.
13. Insull P, Adams D, Segar A, Ng A, Civil I. Is exploration
mandatory in penetrating zone II neck injuries? ANZ J Surg.
2007;77:261e264.
14. Monson DO, Saletta JD, Freeark RJ. Carotid vertebral trauma. J
Trauma. 1969;9:987e999.
15. Roon AJ, Christensen N. Evaluation and treatment of
penetrating cervical injuries. J Trauma. 1979;19:391e397.
16. Schroll R, Fontenot T, Lipcsey M, et al. Role of computed
tomography angiography in the management of zone II
penetrating neck trauma in patients with clinical hard signs. J
Trauma Acute Care Surg. 2015;79:943e950. discussion 950.
17. Núñez Jr DB, Torres-León M, Múnera F. Vascular injuries of
the neck and thoracic inlet: helical CTeangiographic
correlation 1. Radiographics. 2004;24:1087e1098.
18. Shiroff AM, Gale SC, Martin ND, et al. Penetrating neck
trauma: a review of management strategies and discussion of
the ’No Zone’ approach. Am Surg. 2013;79:23e29.
19. Demetriades D, Velmahos GG, Asensio JA. Cervical
pharyngoesophageal and laryngotracheal injuries. World J
Surg. 2001;25:1044e1048.
20. Ibraheem K, Joseph B. Role of computed tomography
angiography in the management of zone II penetrating neck
trauma in patients with clinical hard signs. J Trauma Acute
Care Surg. 2016;81:400.

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