A tailored protocol in management of penetrating neck injuries: experience at a level 1 trauma centre


  • Ahmed M. Elshaer Department of General Surgery, Cairo University Hospitals (Kasr Alainy Hospital), Cairo, Egypt Department of Upper GI Surgery, Gloucestershire Hospitals NHS Trust, Gloucester, United Kingdom http://orcid.org/0000-0002-8178-303X
  • Hussein O. Elwan Department of General Surgery, Cairo University Hospitals (Kasr Alainy Hospital), Cairo
  • Doaa A. Mansour Department of General Surgery, Cairo University Hospitals (Kasr Alainy Hospital), Cairo




Penetrating neck injuries, Multi-detector CT-angiography, Cervical trauma, Neck zones


Background: The management of penetrating neck injuries (PNIs) evolved markedly over last year’s towards more conservative approaches. Recent improvements in imaging modalities as multi-detector CT-angiography (MDCT-A) produced a paradigmatic shift towards 'no-zone' approach. In this study, we adopted a tailored protocol to deal with such injuries with less dependency on zone classification.

Methods: This prospective study included patients with PNIs from February 2012 to January 2014. Unstable patients and patients with hard signs in zone-II were managed by immediate exploration. Patients with hard signs in zones-I and III had MDCT-A to check feasibility of endovascular intervention. However, all patients with soft signs and asymptomatic patients underwent MDCT-A regardless the zone affected to determine the need for therapeutic intervention. Complementary investigations were added in some cases with equivocal MDCT-A results.

Results: Our study included 85 patients. Majority were males (94%; n=80) with mean age 27±4. Stabs were the main causative injury (51%; n=43). 63 (74%) patients were stable; with majority (64%; n=40/63) were symptomatic (18 presented with hard signs and 22 presented with soft signs). 53 (62%) patients had MDCT-A with sensitivity, specificity of 77%, 97% respectively and significant p value <0.05. After applying this protocol, we avoided 37% (31/85) non-therapeutic neck exploration, with only 4 (7.4%) negative cases on exploration. We experienced no missed injuries in the conservative group, yet 2 (3.7%) missed nerve injuries were encountered in intervention group.

Conclusions: Zones-classification is losing popularity nowadays and shouldn't be the cornerstone of the new management protocols in PNIs. This selective tailored approach can be effectively used in management of PNIs. It avoids missed injuries and unnecessary explorations significantly.


Vishwanatha B, Sagayaraj A, Huddar SG, Kumar P, Datta RK. Penetrating neck injuries. Indian J Otolaryngol Head Neck Surg. 2007;59:221-4.

Bell RB, Osborn T, Dierks EJ, Potter BE. Basic and patient-oriented research: Management of Penetrating Neck Injuries: A New Paradigm for Civilian Trauma. J Oral Maxillofac Surg. 2007;65(4):691-705.

Saito N, Hito R, Burke PA, Sakai O. Imaging of penetrating injuries of the head and neck: current practice at a level I trauma centre in the United States. Keio J Med. 2014;63:23-33.

Siau RTK, Moore A, Ahmed T, Lee MSW, Tostevin P. Management of penetrating neck injuries at a London trauma centre. Eur Arch Otorhinolaryngol. 2013;270(7):2123-8.

Van Waes OJ, Cheriex KCAL, Van Riet PA, Nicol AJ, Vermeulen J. Management of penetrating neck injuries. Br J Surg. 2012;99:149-54.

Azuaje RE, Jacogson LE, Glover J, Gomez GA, Rodman Jr GH, Broadie TA et al. Reliability of physical examination as a predictor of vascular injury after penetrating neck trauma. Am Surg. 2003;69(9):804-7.

Nowicki JL, Stew B, Ooi E.-Penetrating neck injuries: a guide to evaluation and management. Ann R Coll Surg Engl. 2018;100(1):6-11.

Nasr A, De Oliveira JT, Mazepa MM, Lima C, De Albuquerque C, Martini GS et al. Evaluation of the use of tomography in penetrating neck trauma. Rev Col Bras Cir. 2015;42(4):215-21.

Prichayudh S, Choadrachata-anun J, Sriussadaporn S. Selective management of penetrating neck injuries using “no zone” approach. Injury. 2015;46:1720-5.

Munera F, Soto JA, Palacio D, Velez SM, Medina E. Diagnosis of arterial injuries caused by penetrating trauma to the neck: comparison of helical CT angiography and conventional angiography. Radiol. 2000;216:356-62.

Gonzalez RP, Turk B, Falimirski M, Turk B. Penetrating zone II neck injury: Does dynamic computed tomographic scan contribute to the diagnostic sensitivity of physical examination for surgically significant injury? A prospective blinded study. J Trauma. 2003;54(1):61-5.

Gracias VH, Reilly PM, Philpott J, Klein WP, Lee SY, Singer M et al. Computed tomography in the evaluation of penetrating neck trauma: A preliminary study. Arch Surg. 2001;136(11):1231-5.

Burgess CA, Dale OT, Almeyda R, Corbridge RJ. An evidence-based review of the assessment and management of penetrating neck trauma. Clinical Otolaryngol. 2002;37:44-52.

Roon AJ, Christensen N. Evaluation and treatment of penetrating cervical injuries. J Trauma. 1979;19:391-7.

Kortbeek JB, Al Turki SA, Ali J, Antoine JA, Bouillon B, Brasel K et al. Advanced Trauma Life Support, 8th Edition, The Evidence for Change. J Trauma-Injury Infect Critical Care. 2008;64(6):1638-50.

Demetriades D, Theodorou D, Cornwell EE, Berne TV, Asensio J, Belzberg H et al. Evaluation of penetrating injuries of the neck: prospective study of 223 patients. World J Surg. 1997;21:41-8.

Pakarinen TK, Leppäniemi A, Sihvo E, Hiltunen KM, Salo J. Management of cervical stab wounds in low volume trauma centres: systematic physical examination and low threshold for adjunctive studies, or surgical exploration. J Injury. 2006;37(5):440-7.

Nason RW, Assuras GN, Gray PR, Burns CM. Penetrating neck injuries: analysis of experience from a Canadian trauma centre. Can J Surg. 2001;44(2):122-6.

Apffelstaedt JP, Muller R. Results of mandatory exploration for penetrating neck trauma. World J Surg. 1994;18:917-9.

Bishara RA, Pasch AR, Douglas DD, Schuler JJ, Lim LT, Flanigan DP. The necessity of mandatory exploration of penetrating zone II neck injuries. Surgery. 1986;100(4):655-60.

Isaza-Restrepo A., Quintero-Contreras JA, Escobar-Diaz GJ, Ruiz-Sternberg ÁM. Value of clinical examination in the assessment of penetrating neck injuries: a retrospective study of diagnostic accuracy test. BMC Emerg Med. 2020;20.

Teixeira F, Menegozzo CA, Netto SD, Poggeti RS, Collet e Silva Fd, Birolini D et al. Safety in selective surgical exploration in penetrating neck trauma. World J Emerg Surg. 2016;11:32.

Shiroff AM, Gale SC, Martin ND, Marchalik D, Petrov D, Ahmed HM et al. Penetrating neck trauma: a review of management strategies and discussion of the 'No Zone' approach. Am Surg. 2013;79(1):23-9.

Low GM, Inaba K, Chouliaras K, Branco B, Lam L, Benjamin E et al. The use of the anatomic 'zones' of the neck in the assessment of penetrating neck injury. Am Surg. 2014;80:970-74.

Steenburg SD, Sliker CW, Shanmuganathan K, Siegel EL. Imaging evaluation of penetrating neck injuries. Radiographics. 2010;30:869-86.

Inaba K, Branco BC, Menaker J, Scalea TM, Crane S, DuBose JJ et al. Evaluation of multidetector computed tomography for penetrating neck injury: a prospective multicenter study. J Trauma Acute Care Surg. 2012;72:576-84.

Thoma M, Navsaria PH, Edu S, Nicol AJ. Analysis of 203 patients with penetrating neck injuries. World J Surg. 2008;32(12):2716-23.

Kocamer Şimşek B, Dağlı G, Uysal E, Çalıker N, Gökçe ON et al. Characteristics of the injuries of Syrian refugees sustained during the civil war. Ulus Travma Acil Cerrahi Derg. 2017;23(3):199-206.

MacFarlane C, and Ann CR. Penetrating neck injury: A review. Trauma. 2002;4:79-90.

Hirshberg A, Wall MJ, Johnston RH, Burch JM, Mattox KL. Transcervical gunshot injuries. Am J Surg. 1997;167:309-12.

Sperry JL, Moore EE, Coimbra R, Croce M, Davis JW, Karmy-Jones R et al. Western Trauma association critical decisions in trauma: penetrating neck trauma. J Trauma Acute Care Surg. 2013;75(6):936-40.

Bryant AS, Cerfolio RJ. Esophageal trauma. Thorac Surg Clin. 2007;17:63-72.






Original Research Articles