title: Penetrating neck trauma: a review of management strategies and discussion of the 'No Zone' approach.
abstract: The evaluation and management of hemodynamically stable patients with penetrating neck injury has evolved considerably over the previous four decades. Algorithms developed in the 1970s focused on anatomic neck "zones" to distinguish triage pathways resulting from the operative  constraints associated with very high or very low penetrations. During that era, mandatory endoscopy and angiography for Zone I and III penetrations, or mandatory neck exploration for Zone II injuries, became popularized, the so-called "selective approach." Currently, modern sensitive  imaging technology, including computed tomographic angiography (CTA), is widely available. Imaging triage can now accomplish what operative or selective evaluation could not: a safe and noninvasive evaluation of critical neck structures to identify or exclude injury based on trajectory, the  key to penetrating injury management. In this review, we discuss the use of CTA in modern screening algorithms introducing a "No Zone" paradigm: an evidence-based method eliminating "neck zone" differentiation during triage and management. We conclude that a comprehensive  physical examination, combined with CTA, is adequate for triage to effectively identify or exclude vascular and aerodigestive injury after penetrating neck trauma. Zone-based algorithms lead to an increased reliance on invasive diagnostic modalities (endoscopy and angiography) with their associated  risks and to a higher incidence of nontherapeutic neck exploration. Therefore, surgeons evaluating hemodynamically stable patients with penetrating neck injuries should consider departing from antiquated, invasive algorithms in favor of evidence-based screening strategies that use physical  examination and CTA.
authors: Department of Surgery, Division of Acute Care Surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey 08901, USA.
authors: Adam M
authors: AM
authors: Shiroff
authors: Stephen C
authors: SC
authors: Gale
authors: Niels D
authors: ND
authors: Martin
authors: Daniel
authors: D
authors: Marchalik
authors: Dmitriy
authors: D
authors: Petrov
authors: Hesham M
authors: HM
authors: Ahmed
authors: Michael F
authors: MF
authors: Rotondo
authors: Vicente H
authors: VH
authors: Gracias
mesh_terms: D000465:Algorithms; D000792:Angiography / Q000379:methods; D003661:Decision Support Techniques; D006801:Humans; D018810:Magnetic Resonance Angiography; D061330:Multidetector Computed Tomography; D019838:Neck Injuries / Q000175:diagnosis* / Q000601:surgery; D010808:Physical Examination; D014218:Triage / Q000379:methods; D018615:Ultrasonography, Doppler, Color; D014950:Wounds, Penetrating / Q000175:diagnosis* / Q000601:surgery