Selective management of penetrating neck

injuries using ‘‘no zone’’ approach

• The neck is an extremely complex anatomical region
where several vital structures.

• Although zones of neck injury can provide a useful

guideline in the management of PNIs, there are some
disadvantages.
• Selective management has been the standard
management protocol in PNI since this approach has
significantly reduced unnecessary neck exploration

• The purpose of this study is to evaluate outcomes of

selective management in PNIs using the ‘‘no zone’’
approach
A retrospective study was performed in patients treated
for PNIs at King Chulalongkorn Memorial Hospital
(KCMH) from January 2003 to December 2013.

The patients with hard signs of neck injury underwent

emergency neck exploration.
The asymptomatic patients and the patients with soft
signs (other symptoms) were considered to be
candidates for selective management.

Data collection included demographic data,

emergency department parameters, details of neck
injury, and outcomes in terms of mortality, negative
exploration rate, and missed injury rate
Figure 1. Management of Penetrating Neck Injuries And The
Details Of The Signs Of Neck Injury
Table 1. Demographic Data And Emergency Department
(ED) Parameters.
Table 2. The Zones of neck injury
Fig. 2. A 35 Year-old Male With A Stab Wound To The Left
Neck Zone II Underwent Neck Exploration Due To Active
Haemorrhage.

Asterisk (*) Indicates The

Orientation Of The Patient Head To
The Right. The Bleeding From The
Left Vertebral Artery Through The
Transverse Processes Of The
Spine Was Controlled By An
Application Of Bone Wax (White
Arrow). The Hypopharyngeal Injury
Was Also Identified And Repaired
With Polydioxanone 3–0 Suturing
(Black Arrow).
 Fig. 3. An Angiography Was Performed As An Adjunct
Treatment Of The Left Vertebral Artery Injury In The Patient In
Fig. 2.

A. A false aneurysm of the

left vertebral artery was
identified (black arrow).
B. B. Coil embolization of the
left vertebral artery was
performed (white arrow).
The patient recovered
uneventfully without
neurological deficit
Table 3. Outcomes of penetrating neck injury patients
 The management of PNIs has shifted from
mandatory neck exploration to selective
management.

Early experiences of selective management

of PNIs have come from the use of ‘‘zone-
based’’ algorithms
Nevertheless, there are problems associated
with the zone-based approach.

Furthermore, patients with multiple or

transcervical injuries occasionally cannot be
grouped into one zone, as seen in 6% of
patients in the present study.
It is clear that immediate neck exploration is
warranted in unstable patients with ‘‘hard
signs’’ of neck injury after optimal airway has
been obtained

The negative exploration rates of the PNI

patients with hard signs ranges from 10 to
27%, which are higher compared to the
present study
• In stable but symptomatic patients (the soft sign
group), the selective use of investigation to
diagnose internal organ injuries seems to be a
better approach

• As newer imaging modalities emerge, CTA has

become widely used as an initial screening tool in
stable PNI patients
• Surgically, the zones of neck injury help surgeons
prepare and select the appropriate incisions

• Moreover, difficult vascular control should be

anticipated in zone III injuries, thus angiography
and endovascular treatment could be useful
 Firstly, the present study is a retrospective
descriptive study performed in a low volume
centre with a high incidence of stab wounds to test
our management algorithm

Secondly, the use of selective investigations in the

soft sign group was not uniform during the study
period since there was no clear protocol and the
routine use of CTA was started in 2006
 the selective management of PNIs using
‘‘no zone’’ approach is a safe and simple
strategy

The unstable patients with hard signs should

undergo immediate neck exploration

Stable symptomatic (soft signs) patients can

be selectively investigated
 Asymptomatic patients can be simply
observed with very low risk of missed
injuries.

Further prospective studies are required

to compare the outcomes between ‘‘no
zone’’ and ‘‘zone-based’’ approaches,
and to identify the role of endovascular
treatment in PNIs.
 24

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