Computed tomographic angiography as an aid to clinical decision making in the selective management of penetrating injuries to the neck: a reduction in the need for operative exploration

Abstract

Background: Improvements in imaging technology, particularly computed tomographic angiography (CTA), have altered the management of patients with penetrating injuries in the neck. The purpose of this retrospective study is to evaluate our 5-year experience with the management of penetrating injuries to the neck, to the further elucidate the role of CTA in clinical decision making, and to assess treatment outcome.

Methods: Clinical variables were collected and evaluated on all patients with penetrating injuries to the neck presenting to the Legacy Emanuel Hospital Trauma Service from 2000 to 2005. For comparison, the patients were divided into two groups based upon whether the patient had received a CTA before operative intervention: group 1, CTA; group 2, no CTA. A statistical analysis using the Fisher exact test and t test was performed to analyze whether the rate of neck exploration or the findings at the time of neck dissection were significantly different between the groups.

Results: Of the 120 consecutive patients with penetrating injuries to the neck, 55 were excluded from the study because the injury was superficial, the patient died before operative intervention, or they underwent emergent neck exploration to control hemorrhage. Sixty-five patients with neck injuries penetrating the platysma were identified that met the criteria for inclusion in the study. Group 1 (CTA) consisted of 24 patients and group 2 (no CTA) had 41 patients. Group 1 (CTA) had significantly fewer formal neck explorations (N = 6) compared with group 2 (no CTA) (N = 27) (p < 0.01). All six of the operations in the CTA group had clear indications for and positive findings on surgical exploration, and there were no clinically significant missed injuries. Of the 27 patients in group 2 who underwent neck exploration, only 14 had a positive finding, 4 of which were simply superficial bleeding vessels, yielding a rate of negative neck exploration of 48%, compared with 0% for group 1 (p < 0.01). The number of adjunctive studies such as esophagography, angiography, and various endoscopic procedures were similar in both groups.

Conclusion: The management of stable patients with penetrating injuries to the neck that penetrate the platysma has evolved at our institution into selective surgical intervention based on clinical examination and CTA. The use of CTA has resulted in fewer formal neck explorations and virtual elimination of negative exploratory surgery.