An unusual case of a penetrating neck injury (PNI) illustrating the use of a "no zone" approach for the management of this injury and a review of the literature

Abstract

We present an unusual case of a young male with a penetrating neck injury (PNI) due to a work-related injury. A metallic foreign body traversed from entry at surgical Zone 2 to Zone 1 in the neck and resulted in a transection of the left thyrocervical trunk at the origin with the left subclavian artery. Computed Tomographic Angiography (CTA) of the aortic arch and major branch vessels demonstrated haemorrhage anterior to the left subclavian artery and left thyrocervical trunk. We describe some of the diagnostic and operative challenges which may occur in these rare and life-threatening injuries. We have also reviewed some of the recent key literature on this topic and have collated the recommendations of the review. In recent years, there has been a movement away from selective "zone-based" mandatory surgical exploration for Zone 2 injuries, as well as invasive and time-consuming investigations (such as digital subtraction angiography, contrast oesophageal swallow and bronchoscopy) for Zone 1 and 3 injuries due to the high number of negative surgical procedures and investigations. We demonstrate there is now an evidence-based algorithm which demonstrates that a "no zone" approach to the management of these patients is safe and effective. This requires an initial physical examination looking for the presence or absence of "hard", "soft" or "no" physical signs in these patients, and then deciding on subsequent management which would include immediate surgery, CTA of the aortic arch and branches (and subsequent surgical or other management) or observation only. Our aim in describing this case it to highlight that there is now good evidence-based guidance for the safe and effective management of patients with this infrequent but potentially fatal injury.

Keywords: Computed tomographic angiography; Evidence-based management; Penetrating neck injury; “No zone” evaluation.

Image 1

CXR. CXR demonstrates a 5 mm metallic foreign body projected over the left lung apex just superior to the clavicle (black arrow). No pneumothorax seen.

Image 2

Coronal CTA (a). Coronal MIP CT angiogram demonstrates the metallic foreign body (blue arrow) located immediately anterior to the left thyrocervical trunk (red arrow) with adjacent active contrast extravasation (not shown). Left vertebral artery was normal (yellow arrow).

Image 3

Coronal CTA (b). Coronal MIP CT angiogram demonstrates the metallic foreign body (yellow arrow) located immediately anterior to the thyrocervical trunk. Branches of the thyrocervical trunk (green arrowheads) and active contrast extravasation (red arrow) are shown. Injected intravenous contrast in the left subclavian vein (orange asterisks).

Image 4

Zones of neck and vessels. Key vessels: LSUB = left subclavian artery LVA = left vertebral artery TCT = thyrocervical trunk IM = internal mammary artery CCT = costocervical trunk.