Is Exploration Mandatory for Zone 2 Penetrating Neck Injuries
Phil Insull
Outline
Is Exploration Mandatory for Zone II Penetrating Injuries of the Neck?
Phil Insull
Formal operative exploration for penetrating zone II neck injuries deep to platysma used to be considered mandatory
Supported by Fogelman’s 1956 paper concentrating on combat trauma, which showed significant reduction in morbidity and mortality from such injuries with this policy
Fogelman M, Stewart R. Penetrating wounds of the neck. Am J Surg. 1956 Apr;91(4):581-93
However, in the absence of hard signs, neck exploration is subject to a high rate of negative exploration
Not without its own potential risks/complications
Irish JC, Hekkenberg R, Gullane PJ, Brown DH, Rotstein LE, Neligan P, Ali J.Penetrating and blunt neck trauma: 10-year review of a Canadian experience. Can J Surg. 1997 Feb;40(1):33-8
Alternative: selective neck exploration
How to stratify patients to operative or conservative management?
Some have argued that physical examination alone may not be sensitive enough to safely stratify patients to operative or non-operative management
Clinical signs have been absent in up to 30% of positive explorations in past analysis
Apffelstaedt JP, Muller R. Results of mandatory exploration for penetrating neck trauma. World J Surg. 1994 Nov-Dec;18(6):917-9
Such high false negative examination rates suggests that imaging may be necessary if neck exploration is not routine
Many trauma centres have recently reported treating these injuries with selective exploration based on physical examination and imaging, commonly with CT or angiography
Siegrist B, Steeb G. Penetrating Neck Injuries South Med J 93(6):567-570, 2000
Routine contrast angiography for haemodynamically stable patients has been found to virtually eliminate negative exploration and is not associated with a significant risk of missed injury
Sekharan J, Dennis J. Continued Experience with physical examination alone for evaluation and management of penetrating zone two neck injuries. J Vasc Surg 2000;32:483
BUT….
CT has not found been found to add to the sensitivity of physical examination in the detection of airway or arterial injury and is less sensitive than endoscopy in the detection of oesophageal injury
Gonzalez R, Falimirski M. Penetrating zone II neck injury: does dynamic CT contribute to the diagnostic sensitivity of physical examination for surgically significant injury? A prospective blinded study. J Trauma 2003; 54:64
Penetrating zone II neck injuries deep to platysma at Auckland and Middlemore hospitals have been treated with routine neck exploration
Why should this policy be evaluated?
Current evidence based largely on overseas data and analysis
Mechanism of penetrating neck trauma in New Zealand may be different to elsewhere esp. USA
This may have a bearing on the character of resulting injuries and their management
Anecdotally:
Less GSW
Higher relative incidence of low velocity mechanisms
High incidence of self inflicted trauma
Study aims
Demonstrate the rates of negative and positive exploration in patients with and without hard signs
Explore the use of clinical signs to predict serious injury
Method
Retrospective analysis was conducted on all adult patients with Zone II penetrating neck injuries admitted to Auckland and Middlemore Hospital trauma service from 1995 to 2005
All cases were identified using the Auckland and Middlemore hospital trauma service databases
Method
Auckland District Health Board’s CRIS™ electronic document archive and Counties-Manukau District Health Board’s Concerto™ information storage systems were used to access operation and clinical notes
Statistical analysis performed using SPSS
Definitions
Neck zones were defined according to Monson’s criteria, with zone II between the cricoid and the angle of the mandible
Definitions
Hard signs of significant injury on physical examination were defined as:
Active external bleeding
Neck bruit or thrill
Dysphagia
Hoarseness
Subcutaneous emphysema
Large, expansile or pulsatile haematoma
Oropharyngeal bleeding
Sucking neck wound
Neurological deficit
Results-Demographics
63 Patients identified with zone II penetrating neck injuries deep to platysma
44 Males, 19 Female
Median age 36 (IQR25-45.5)
51% Europeans
19% Maori
11% Pacific Islanders
8% Chinese
11% Other
Results-Intent
46% Self-inflicted
40% Assault
14% Unintentional
Results-Mechanism
75% Cutting tool (knife, machete etc)
17% Other sharp object (broken bottle/glass etc)
8% Explosion/GSW
Results
No patients underwent preoperative CT
One patient underwent preoperative angiography for a zone III component of their injury
Results
All patients sustained a degree of muscular and venous injury
One patient died of significant abdominal injuries
No patients died as a direct result of their neck injury
No missed injuries were identified during the period of hospital admission
Results
28% of patients had documentation of other injuries requiring surgical input
7 patients had hand or wrist injury requiring operative tendon or vascular repair
5 patients required laparotomy for abdominal injury
5 patients sustained soft tissue injury requiring washout, debridement and suturing distant to their neck injury
1 patient also had significant chest injuries with haemothorax
Results
Univariate Analysis
Rate of positive neck exploration was 25% (95% CI 0.16-0.37)
87% (95% CI 0.61-0.98) for those with hard signs
2% (95% CI 0.00-0.12) for those without hard signs
P<0.01 FET
Univariate Analysis
No significant specific ethnic or sex differences in the rates of positive exploration
Multi-Variate Analysis
Multi-variable logistic regression analysis
Constructed a model for the prediction of positive operative neck exploration
Variables included in experimental models:
Age
Gender
Ethnicity
Intent
Instrument
Presence of hard signs
Presence of other injuries
Multi-Variate Analysis
Presence of hard signs on physical examination was found to be a significant predictive variable in the resulting model (P<0.01)
No other variables were found to be significant predictors of positive neck exploration in the resulting regression model (P>0.05)
Bayesian Analysis
To provide parameters of reliability in the clinical diagnosis of significant injury requiring OT exploration, from zone II penetrating neck injury with the finding of hard signs on physical examination
Based on the series of 63 patients
Bayesian Analysis
Discussion
Nason et al 2001 108 patients
33% rate of positive exploration
95% stabbings compared with 40% in our series
Nason RW, Assuras GN, Gray PR, Lipschitz J, Burns CM.Penetrating neck injuries: analysis of experience from a Canadian trauma centre. Can J Surg. 2001 Apr;44(2):122-6
Discussion
Sekharan et al 2000 reported a case series where patients were managed on the basis of physical examination alone
145 patients
0.7% rate of missed injury (one patient)
The one patient with false negative analysis suffered no complications as a result of the delay
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 Sep;32(3):483-9
If patients in the Auckland region were managed solely on the basis of physical examination over the study period then one deep cervical foreign body would have been missed
Discussion
Irish et al 1997 demonstrated that mandatory neck exploration is subject to a high rate of negative procedures, no reduction in mortality and lengthened hospital stays
Our investigation did not focus on length of stay (LOS) as an endpoint of interest, as comparison with the LOS of patients not undergoing neck exploration was impossible in the setting of mandatory neck exploration
Irish JC, Hekkenberg R, Gullane PJ, Brown DH, Rotstein LE, Neligan P, Ali J.Penetrating and blunt neck trauma: 10-year review of a Canadian experience. Can J Surg. 1997 Feb;40(1):33-8
Limitations
Retrospective case series design
Analysis of electronic records and manual data entry
Lack of information available in operation notes regarding the exact operative procedure (ie. comprehensiveness)
Caution must be applied when interpreting the results of this investigation, regarding the safety of neck exploration
Difficult to generalise the results to other services as a result of the above
Conclusions
In the Auckland setting, physical examination would appear to be a safe and reliable method for the stratification of patients for either operative or conservative management
Proposed Algorithm
Acknowledgements
Rangi Dansey
Rhondda Paice
Mr Civil
Mr Ng
Mr Adams
|
Ministry
of Health
