NECK INJURIES
Penetrating neck injuries
Neck injuries pose a significant mortality and morbidity due to the compact anatomical nature and
close proximity of critical structures.
Musculoskeletal structures at risk include the vertebral bodies; cervical muscles, tendons, and ligaments;
clavicles; first and second ribs; and hyoid bone.
Neural structures at risk include the spinal cord, phrenic nerve, brachial plexus, recurrent laryngeal nerve,
cranial nerves (specifically IX-XII), and stellate ganglion.
Vascular structures at risk include the carotid (common, internal, external) and vertebral arteries and the
vertebral, brachiocephalic, and jugular (internal and external) veins.
Visceral structures at risk include the thoracic duct, esophagus and pharynx, and larynx and trachea.
Glandular structures at risk include the thyroid, parathyroid, submandibular, and parotid glands.
Zones of neck injury
Serving as the line of demarcation, the sternocleidomastoid separates the neck into anterior and posterior
triangles. Most of the important vascular and visceral organs lie within the anterior triangle bounded by the
sternocleidomastoid posteriorly, the midline anteriorly, and the mandible superiorly.
Zone 1 - the base of the neck, is demarcated by the thoracic inlet inferiorly and the cricoid cartilage
superiorly.
Structures at greatest risk in this zone are the great vessels (subclavian vessels, brachiocephalic veins,
common carotid arteries, aortic arch, and jugular veins, trachea, esophagus, lung apices, cervical spine,
spinal cord, and cervical nerve roots. Signs of a significant injury in the zone I region may be hidden from
inspection of the chest or the mediastinum.
Zone 2 - encompasses the midportion of the neck and the region from the cricoid cartilage to the angle of
the mandible.
Important structures in this region include the carotid and vertebral arteries, jugular veins, pharynx, larynx,
trachea, esophagus, and cervical spine and spinal cord. Zone II injuries are likely to be the most apparent
on inspection and tend not to be occult. Additionally, most carotid artery injuries are associated with zone
II injuries.
Zone 3 - characterizes the superior aspect of the neck and is bounded by the angle of the mandible and the
base of the skull.
Diverse structures, such as the salivary and parotid glands, esophagus, trachea, vertebral bodies, carotid
arteries, jugular veins, and major nerves (including cranial nerves IX-XII), traverse this zone. Injuries in zone
III can prove difficult to access surgically.
Prehospital management
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Intubate early if necessary
Large bore access IV
C-spine immobilisation cautiously if airway needs intervention and for particular situations
o Gun shot wounds
o Reduced LOC with unknown mechanism of injury
o Significant force of injury e.g. clothesline type
o Evidence of any neurological deficit
ED evaluation
Primary survey
 Close evaluation and management of ABCDE
 Airway – 10% have airway compromise
o Look for- bubbling, expanding hematoma, hoarseness, stridor and edema
o Management
 Cautious use of neuromuscular paralysis
 Orotracheal intubation preferred
 Surgical airway difficult due to distorted anatomy
 Fibreoptic guided intubation may be useful
o
Indications for urgent intubation
 Reduced LOC
 Expanding hematoma or swelling
 Direct laryngeal or tracheal injury
 Hypoventilation
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Breathing
o Look for – subcutaneous emphysema, breath sounds and tracheal deviation, chest
examination in c/o zone 1 injury.
o Management –
 Risk for tension pneumothorax with zone 1 injury.
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Circulation
o Examination
 Palpate all pulses, auscultate for bruits (continuous = AV fistula, systolic =
obstruction)
 Sudden tachypnea, tachycardia and machinery murmur – air embolism
o
Management
 Direct pressure dressing for hemorrhage, avoid clamps
 Lines in opposite limb to side of injury
 Avoid lines in neck
 If suspected air embolism – left lateral decubitus and Trendelenburg
position, if significant risk – consider for emergent thoracotomy
Secondary survey
 Check LIMITS before starting secondary survey
o Check lines – ETT, NGT, IVC, IDC
o Investigations – bloods sent, ABG, ECG, Xray chest
o Monitoring – ongoing O2, etCO2, ECG, NBP, neuro, BSL, temp
o IV therapy ongoing, predict need for blood and arrange for crossmatch
o Teams – inform vascular/ENT surgical teams as appropriate
o Stabilise ABCDE
 Neck – reassess
 Neurologic –
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o Examine and record CNS function, spinal cord function, brachial plexus injury
o Look for cervical sympathetic chain injury – Horner’s
o Vagus/ Recurrent laryngeal nerve injury – hoarseness of voice
o Spinal accessory nerve – trapezius function
o Hypoglossal nerve – tongue protrusion
o Phrenic nerve elevated hemidiaphragm
Vascular
o Manage circulation
Investigations
o Bedside – BSL, ECG, ABG
o Laboratory – FBC, EUC, group and hold, Coagulation studies
o Radiologic –
 Mobile CXR to r/o pneumothorax
 Consider CT neck with contrast angiography to evaluate vascular injury if stable
Management
 Supportive care, monitoring and resuscitation
 Depending on clinical status and active bleeding manage in resuscitation bay initially
with full cardiovascular monitoring
 Support ABCDE as charted above
 Assess and treat any deficits
 Specific management
Zone 1 injuries
Primary survey
Stabilise ABCDE
Check limits
Resuscitate as needed
Refractory shock
Hemodynamically stable
and signs/symptoms
Exploration
Aortic arch/ great vessel aortography
Tracheobronchoscopy
Esophagogram/ Esophagoscopy
Negative
Positive
Observation
Exploration
Zone 2 injuries
Assess and resuscitate
ABCDE as needed
Check LIMITS
Assess safety for investiagtions
Stab wound
Gunshot wound
Significant signs/symptoms
High velocity injury
Stab wound
Gunshot wound
No hard findings of vascular injury
No signs/ symptoms
Stab wound
Gunshot wound
transcervical injury
hemodynamically stable
Exploration
Expectant management
Aortic arch/great vessel aortography
Tracheobronchography
Esophagography
Selective management
Zone 3
Assess and Resuscitate
Manage ABCDE
Check LIMITS
Refractory shock
Hemodynamically stable
+/- Signs/symptoms
Exploration
Oropharyngeal exam
Laryngoscopy
Neck vessel angiography
CT angiography
Cervical Spine fractures
Approximately 5-10% of unconscious patients who present to the ED as the result of a motor vehicle
accident or fall have a major injury to the cervical spine. Most cervical spine fractures occur
predominantly at 2 levels. One third of injuries occur at the level of C2, and one half of injuries occur
at the level of C6 or C7. Most fatal cervical spine injuries occur in upper cervical levels, either at
craniocervical junction C1 or C2.
View the cervical spine as 3 distinct columns: anterior, middle, and posterior.
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The anterior column is composed of the anterior longitudinal ligament and the anterior two
thirds of the vertebral bodies, the annulus fibrosus and the intervertebral disks.
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The middle column is composed of the posterior longitudinal ligament and the posterior one
third of the vertebral bodies, the annulus and intervertebral disks.
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The posterior column contains all of the bony elements formed by the pedicles, transverse
processes, articulating facets, laminae, and spinous processes.
Pathophysiology
Cervical spine injuries are best classified according to several mechanisms of injury. These include
flexion, flexion-rotation, extension, extension-rotation, vertical compression, lateral flexion, and
imprecisely understood mechanisms that may result in odontoid fractures and atlanto-occipital
dislocation.
Flexion injury
Common cervical spine injuries associated with flexion mechanism include:
A. Simple Wedge compression fracture without
posterior disruption
B. Flexion teardrop fracture: occurs when there is
flexion with vertical axial compression causing
fracture of anteroinferior aspect of vertebral body.
For a flexion teardrop to occur, there needs to be significant posterior ligamentous disruption with
significant anterior disruption as well, so these fractures are considered unstable.
C. Anterior subluxation with flexion mechanism –
stable in extension potentially unstable in flexion
D. Bilateral facet dislocation with a flexion
mechanism is extremely unstable and can have an
associated disk herniation that impinges on the
spinal cord during reduction.
Bilateral facet joint dislocation is an extremely unstable condition with high risk for spinal
cord injuries.
E. Clay shoveler fracture due to flexion injury –
usually stable injury. Most commonly involving C7T1 junction so needs full visualization
Flexion-rotation injury
A. Unilateral facet dislocation – anterior
displacement <50% of body diameter. AP view –
disruption of spinous process line. Stable fracture.
Rotary atlantoaxial dislocation
This injury is a specific type of unilateral facet dislocation.
Radiographically, the odontoid view shows asymmetry of the lateral masses of C1 with respect to the
dens along with unilateral magnification of a lateral mass of C1 (wink sign). However, since the
atlantoaxial joint permits flexion, extension, rotation, and lateral bending, radiographic asymmetry is
produced when the head is tilted laterally or rotated or if a slightly oblique odontoid view is obtained
despite perfect head positioning. To confirm true dislocation, basilar skull structures (jugular
foramina) should appear symmetric in the presence of the findings described above.
This injury is considered unstable because of its location.
Extension Injury
Common injuries associated with an extension mechanism include hangman fracture, extension
teardrop fracture, fracture of the posterior arch of C1 (posterior neural arch fracture of C1) and
posterior atlantoaxial dislocation.
A. Hangman fracture
A. Hangman fracture (traumatic spondylolisthesis
of C2) – considered unstable but seldom associated
with deficit due to greatest diameter of spinal
canal.
Hangman fractures derive their name from being typical after hanging. Commonly now seen with
MVA and involves bilateral fractures through the pedicles of C2 due to hyperextension.
Radiographically, a fracture line should be evident through the pedicles of C2 along with obvious
disruption of spinolaminar line. Although considered unstable, by itself it is rarely associated with
deficit due to largest area of spinal canal at this level. When associated with unilateral or bilateral
facet dislocation at the level of C2, this type of hangaman fracture becomes highly unstable with high
rate of complications requiring immediate referral and cervical traction.
Extension teardrop fracture
Similar in appearance to anterior teardrop with displaced anteroinferior bony fragment, this fracture
is stable in flexion but highly unstable in extension requiring traction with tongs.
Fracture common with diving accidents and may cause central cord syndrome, due to buckling of the
ligamenta flava into spinal canal.
Fracture of the posterior arch of C1:
A.Fracture of posterior arch of C1 due to extension
– stable
B.Jefferson fracture – vertical axial compression.
Fracture of all aspects of C1 ring.
Vertical (axial) compression injury
Jefferson fracture (burst fracture of the ring of C1)
This fracture is caused by a compressive downward force that is transmitted evenly through the
occipital condyles to the superior articular surfaces of the lateral masses of C1. The process displaces
the masses laterally and causes fractures of the anterior and posterior arches, along with possible
disruption of the transverse ligament.
Radiographically the fracture is characterized by bilateral lateral displacement of the articular masses
of C1. The odontoid view shows unilateral or bilateral displacement of the lateral masses of C1 with
respect to the articular pillars of C2; thus differentiating it from the simple fracture of posterior neural
arch of C1. The lateral projection reveals striking amount of prevertebral soft tissue edema.
Displacement <6.9mm – transverse ligament intact; if displacement >6.9mm – complete disruption is
likely.
Burst fracture of vertebral body
Burst fracture of vertebral body due to vertical
compression is stable mechanically. Requires
CT/MRI to document amount of middle column
retropulsion into cord.
Fractures with >25% loss of height, retropulsion and neurological deicit treated with tractions, others
considered stable.
Multiple or complex injuries
Common injuries associated with multiple or complex mechanisms include odontoid fracture, fracture
of the transverse process of C2 (lateral flexion), atlanto-occipital dislocation (flexion or extension with
a shearing component), and occipital condyle fracture (vertical compression with lateral bending).
Upper cervical spine (occiput to C2) injuries
Injuries at the upper cervical level are considered unstable because of their location. Nevertheless,
since the diameter of the spinal canal is greatest at the level of C2, spinal cord injury from
compression is the exception rather than the rule.
Atlas (C1) fractures
Four types of atlas fractures (I, II, III, IV) result from impaction of the occipital condyles on the atlas,
causing single or multiple fractures around the ring.
The first 2 types of atlas fracture are stable and include isolated fractures of the anterior and
posterior arch of C1 (posterior arch fracture is described under Extension injury). Anterior arch
fractures usually are avulsion fractures from the anterior portion of the ring and have a low morbidity
rate and little clinical significance. The third type of atlas fracture is a fracture through the lateral
mass of C1. Radiographically, asymmetric displacement of the mass from the rest of the vertebra is
seen in the odontoid view. This fracture also has a low morbidity rate and little clinical significance.
The fourth type of atlas fracture is the burst fracture of the ring of C1 and also is known as a Jefferson
fracture (discussed under Vertical (axial) compression injury above). This is the most significant type
of atlas fracture from a clinical standpoint because it is associated with neurologic impairment.
Atlantoaxial subluxation
When flexion occurs without a lateral or rotatory component at the upper cervical level, it can cause
an anterior dislocation at the atlantoaxial joint if the transverse ligament is disrupted. Because this
joint is near the skull, shearing forces also play a part in the mechanism causing this injury, as the skull
grinds the C1-C2 complex in flexion. Since the transverse ligament is the main stabilizing force of the
atlantoaxial joint, this injury is unstable. Neurologic injury may occur from cord compression between
the odontoid and posterior arch of C1.
Radiographically, this injury is suspected if the predental space is more than 3.5 mm (5 mm in
children); axial CT is used to confirm the diagnosis. These injuries may require fusion of C1 and C2 for
definitive management.
Atlanto-occipital dislocation
When severe flexion or extension exists at the upper cervical level, atlanto-occipital dislocation may
occur. Atlanto-occipital dislocation involves complete disruption of all ligamentous relationships
between the occiput and the atlas. Death usually occurs immediately from stretching of the
brainstem, which causes respiratory arrest.
Radiographically, disassociation between the base of the occiput and the arch of C1 is seen. Cervical
traction is absolutely contraindicated, since further stretching of the brainstem can occur.
Odontoid process fractures
The 3 types of odontoid process fractures are classified based on the anatomic level at which the
fracture occurs.
Type 1 – avulsion of tip of dens at
insertion of alar ligament
Type 2 – base of the dens and most
common
Type 3 – fracture line extends in
body of axis
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Type I odontoid fracture is an avulsion of the tip of the dens at the insertion site of the alar
ligament. Although a type I fracture is mechanically stable, it often is seen in association with
atlanto-occipital dislocation and must be ruled out because of this potentially lifethreatening complication.
Type II fractures occur at the base of the dens and are the most common odontoid fractures.
This type is associated with a high prevalence of nonunion due to the limited vascular supply
and small area of cancellous bone.
Type III odontoid fracture occurs when the fracture line extends into the body of the axis.
Nonunion is not a major problem with these injuries because of a good blood supply and the
greater amount of cancellous bone.
With types II and III fractures, the fractured segment may be displaced anteriorly, laterally, or
posteriorly. Since posterior displacement of segment is more common, the prevalence of spinal cord
injury is as high as 10% with these fractures.
Occipital condyle fracture
Occipital condyle fractures are caused by a combination of vertical compression and lateral bending.
Avulsion of the condylar process or a comminuted compression fracture may occur secondary to this
mechanism. These fractures are associated with significant head trauma and usually are accompanied
by cranial nerve deficits.
Radiographically, they are difficult to delineate, and axial CT may be required to identify them.
These mechanically stable injuries require only orthotic immobilization for management, and most
heal uneventfully. These fractures are significant because of the injuries that usually accompany
them.
Mechanical Instability
Column disruption may lead to mechanical instability of the cervical spine. The degree of instability
depends on several factors that may translate into neurologic disability, secondary to spinal cord
compression.
Trafton has ranked specific cervical injuries based on their degree of mechanical instability. 1 The list
below ranks cervical spine injuries in order of instability (most to least unstable):
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Rupture of the transverse ligament of the atlas
Fracture of the dens (odontoid fracture)
Burst fracture with posterior ligamentous disruption (flexion teardrop fracture)
Bilateral facet dislocation
Burst fracture without posterior ligamentous disruption
Hyperextension fracture dislocation
Hangman fracture
Extension teardrop (stable in flexion)
Jefferson fracture (burst fracture of the ring of C1)
Unilateral facet dislocation
Anterior subluxation
Simple wedge compression fracture without posterior disruption
Pillar fracture
Fracture of the posterior arch of C1
Spinous process fracture (clay shoveler fracture)
Imaging Studies
Radiographic evaluation is indicated in the following:
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Patients who exhibit neurologic deficits consistent with a cord lesion
Patients with an altered sensorium from head injury or intoxication
Patients who complain about neck pain or tenderness
Patients who do not complain about neck pain or tenderness but have significant distracting
injuries
To be clinically cleared using the CCR(Canadian C-spine Rule), a patient must be alert (GCS 15), not
intoxicated, and not have a distracting injury (eg, long bone fracture, large laceration). The patient can
be clinically cleared providing the following:
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The patient is not high risk (age >65 y or dangerous mechanism or paresthesias in
extremities).
A low risk factor that allows safe assessment of range of motion exists. This includes simple
rear end motor vehicle collision, seated position in the ED, ambulation at any time
posttrauma, delayed onset of neck pain, and the absence of midline cervical spine
tenderness.
The patient is able to actively rotate their neck 45 degrees left and right.
The NEXUS criteria state that a patient with suspected c-spine injury can be cleared providing the
following:
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No posterior midline cervical spine tenderness is present.
No evidence of intoxication is present.
The patient has a normal level of alertness.
No focal neurologic deficit is present.
The patient does not have a painful distracting injury.
Both studies have been prospectively validated as being sufficiently sensitive to rule out clinically
significant c-spine pathology. The CCR were shown to be more sensitive than the NEXUS criteria
(99.4% sensitive vs 90.7%), and the rates of radiography were lower with the CCR (55.9% vs 66.6%). 7
Debate still exists as to which criteria are more useful and easier to apply.
Cervical X-ray interpretation
A standard trauma series is composed of 5 views: cross-table lateral, swimmer's, oblique, odontoid,
and anteroposterior.
Cross-table lateral view
Approximately 85-90% of cervical spine injuries are evident in lateral view, making it the most useful
view from a clinical standpoint.
A technically acceptable lateral view shows all 7 vertebral bodies and the cervicothoracic junction.
First line – anterior contour line – connects
anterior margins of all vertebrae
Second line – posterior contour line – connects
posterior margins of all vertebrae
Third line – spinolaminar contour line – connecting
bases of spinous process.
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Each of these lines should form a lordotic curve.
Suspect bony or ligamentous injury, if disruption is seen in contour lines.
Young children may have benign pseudosubluxation in the upper cervical spine.
Check individual vertebrae thoroughly for obvious fracture or changes in bone density.
Look for soft tissue changes in the predental and prevertebral spaces.
Predental space – between anterior aspect of odontoid and the posterior aspect of anterior
arch of C1 → <3mm in adult and <5mm in child →transverse ligament rupture if ↑
Prevertebral space – between anterios border of vertebra to posterior wall of pharynx.
o At level of C2, <7mm
o At the level of C3 and C4, <5mm or <half of width of corresponding vertebra
o At the level of C6 – widened due to esophagus and cricopharyngeus - <22mm in
adults and <14mm in children
Check for fanning of the spinous processes – suggestive of posterior ligamentous disruption.
Check for abrupt change in angulation of >11˚ → possible ligamentous injury
Complications of spinal fractures:
Spinal shock
 Severe spinal cord injury may cause a concussive injury of the spinal cord termed spinal
shock syndrome
 SS manifests as distal areflexia of a transient nature, lasting from few hours to weeks.
 Flaccid quadriplegia with return of segmental reflexes in 24hrs occur with resolution
 Eventually, total resolution can be expected
Neurogenic shock
 Spinal shock that causes vasomotor instability because of loss of sympathetic tone
 Hypotension with paradoxical bradycardia
 Flushed, dry and warm skin may be present
 Ileus, urinary retention and poikilothermia
 Loss of anal sphincter tone with fecal incontinence and priapism suggest spinal shock
 Return of bulbocavernous reflex heralds resolution of spinal shock
Complete or incomplete cord syndromes
 Spinal shock mimics complete cord transection and prognostication should be withheld until
its resolution
 Incomplete cord syndromes are described and include anterior spinal cord syndrome, central
spinal cord syndrome, Brown-Séquard syndrome and less commonly cord syndromes at high
cervical levels
 Patient with complete lesion after resolution of spinal shock usually have permanent
paraplegia
Anterior spinal cord syndrome
 Complete motor paralysis and loss of temperature and pain perception distal to the lesion
 Sparing of posterior column function – light touch, vibration and proprioceptive inputs
 Syndrome caused by compression of the anterior spinal artery → anterior cord ischemia or
direct compression of cord
Central spinal cord compression
 Caused by damage to the corticospinal tract
 Weakness, greater in the upper extremities than the lower extremities and mor pronounced
in distal aspect of extremity
 Usually associated with hyperextension injury in patients
 Buckling of ligamentum flavum into spinal cord due to severe extension
Brown-Séquard syndrome
 Involves injury to one side of the spinal cord
 Paralysis, loss of vibration sense, loss of proprioceptive input ipsilaterally with contralateral
loss of pain and temperature perception due to involvement of posterior columns and
spinothalamic tracts on the same side
 Associated with hemisection of the cord from penetrating trauma or lateral mass fracture of
cervical vertebra
High cervical spinal cord syndrome
 Damage to the spinal tract of the trigeminal nerve in the high cervical region
 Characteristic onion-skin pattern of anesthesia in the face
Horner syndrome
 Ptosis, miosis and anhydrosis
 Results from damage to cervical sympathetic chain