The Use of the Anatomic ‘Zones’ of the Neck in the Assessment of Penetrating Neck Injury

Abstract

The traditional classification of neck injuries uses an anatomic description of Zones I through III. The objective of this article was to characterize the association between external wounds and the corresponding internal injuries after penetrating neck trauma to identify the clinical use of the anatomic zones of the neck. Patients who sustained penetrating neck trauma from December 2008 to March 2011 were analyzed. All patients underwent structured clinical examination documenting the external zone where the wound(s) were located. All internal injuries were then correlated with the external wounds. An internal injury was defined as “unexpected” if it was located outside the borders of the neck zone corresponding to the external wound. In total, 146 patients sustaining a penetrating neck injury were analyzed; 126 (86%) male. The mechanism of injury was stab wounds in 74 (51%) and gunshot wounds in 69 (47%). Mean age was 31 years (range, nine to 62 years). Thirty-seven (25%) patients sustained had a total of 50 internal injuries. There was a high incidence of noncorrelation between the location of the external injury and the internal structures that were damaged in patients with hard signs of vascular or aerodigestive injury. The use of the anatomic zones and their role in the workup of penetrating neck injury are questionable.

Penetrating Neck Trauma in a 4-Year-Old Child

“…Injuries within zone II should generally be approached via a vertical incision paralleling the sternocleidomastoid muscle, or alternatively via an incision along Langer's lines in a natural skin crease. The site of external injury may not always correlate with the damaged internal structures [20].…”

ACR Appropriateness Criteria ® Penetrating Neck Injury

“…Injury to any zone of the neck has the potential to damage multiple densely positioned vital structures because of the associated complex anatomy [4]. Traditionally, penetrating injuries to zone II were immediately taken for surgical exploration, whereas injuries to zones I and III were evaluated by conventional angiography and other modalities, including CT angiography (CTA) [3,[5][6][7]. However, some current literature supports the use of a "no-zone" approach to the evaluation of penetrating neck injuries [6,7].…”

“…Traditionally, penetrating injuries to zone II were immediately taken for surgical exploration, whereas injuries to zones I and III were evaluated by conventional angiography and other modalities, including CT angiography (CTA) [3,[5][6][7]. However, some current literature supports the use of a "no-zone" approach to the evaluation of penetrating neck injuries [6,7]. Multiple algorithmic approaches are used in evaluation and treatment of these patients [1,2,8,9].…”

“…Imaging of the brain in addition to the head and neck vasculature may be used to determine optimal surgical, endovascular, or medical therapy. Soft signs of vascular and aerodigestive injury include nonpulsatile or nonexpanding hematoma, venous oozing, dysphagia, dysphonia, and subcutaneous emphysema [6,7]. These commonly result in further evaluation, typically with imaging.…”

Effectiveness of No-Zone Approach for Management of Isolated Penetrating Neck Injuries Among Hemodynamically Stable Patients. A Longitudinal Retrospective Study.

“…The classic management protocol for PNIs was the mandatory neck exploration to avoid missed injuries (7,8). It utilized the zone-based approach to guide investigations and management with very low rates of missed injuries and high rates of successful conservative management (9,10).…”