The hidden value of MRI: modifying treatment decisions in C-spine injuries.

BACKGROUND DATA: Computed Tomography (CT) is the gold standard for cervical spine (c-spine) evaluation. Magnetic resonance imaging (MRI) emerges due to its increasing availability and the lack of radiation exposure. However, MRI is costly and time-consuming, questioning its role in the emergency department (ED). This study investigates the added the value of an additional MRI for patients presenting with a c-spine injury in the ED. METHODS: We conducted a retrospective monocenter cohort study that included all patients with neck trauma presenting in the ED, who received imaging based on the NEXUS criteria. Spine surgeons performed a full-case review to classify each case into "c-spine injured" and "c-spine uninjured". Injuries were classified according to the AO Spine classification. We assessed patients with a c-spine injury detected by CT, who received a subsequent MRI. In this subset, injuries were classified separately in both imaging modalities. We monitored the treatment changes after the additional MRI to evaluate characteristics of this cohort and the impact of the AO Spine Neurology/Modifier modifiers. RESULTS: We identified 4496 subjects, 2321 were eligible for inclusion and 186 were diagnosed with c-spine injuries in the retrospective case review. Fifty-six patients with a c-spine injury initially identified through CT received an additional MRI. The additional MRI significantly extended (geometric mean ratio 1.32, p < 0.001) the duration of the patients' stay in the ED. Of this cohort, 25% had a change in treatment strategy and among the patients with neurological symptoms (AON ≥ 1), 45.8% experienced a change in treatment. Patients that were N-positive, had a 12.4 (95% CI 2.7-90.7, p < 0.01) times higher odds of a treatment change after an additional MRI than neurologically intact patients. CONCLUSION AND RELEVANCE: Our study suggests that patients with a c-spine injury and neurological symptoms benefit from an additional MRI. In neurologically intact patients, an additional MRI retains value only when carefully evaluated on a case-by-case basis.

Diagnostic approach to penetrating neck trauma: What you need to know.

ABSTRACT: Diagnostic evaluation of penetrating neck trauma has evolved considerably over the last several decades. The contemporary approach to these injuries is based primarily on clinical signs of injury and multidetector computed tomographic angiography. The neck is evaluated as a unit, rather than relying on the surface anatomy zones in which external injuries are seen to guide the workup of internal injuries. This "no-zone" approach safely spares many patients from negative explorations and unnecessary invasive tests. The purpose of this review is to describe an evidence-based approach to the diagnostic evaluation of penetrating neck trauma, including indications for adjunctive testing beyond physical examination and multidetector computed tomographic angiography. LEVEL OF EVIDENCE: Literature Synthesis and Expert Opinion; Level V.

Prognostic Significance of Multifactorial Analysis in Complex Cervical Aero-Digestive Trauma Cases.

Background and Objectives: In the context of complex aerodigestive cervical traumas, the prognosis and outcome heavily depend on risk factors, particularly injuries to the larynx, trachea, major digestive tissues, cervical vertebrae, and vascular structures. With the increasing prevalence of trauma as a public health concern, there is a pressing need for epidemiological research and the implementation of preventative measures. The purpose of this research is to establish the profile of the predictable impact factors that determine the prognosis of patients with complex cervical trauma. Methods and Methods: The study group consisted of 106 patients with complex cervical trauma pathology developed by various mechanisms such as car accidents, home-related accidents, aggression, gunshot wounds, and self-inflicted attempts, resulting in hospitalization in the E.N.T. Clinic at "St. Spiridon" Iași Hospital, from 2012 to 2016; medical records were the source of the collected data. Results: Hemodynamic instability upon admission associated with age, muscle and laryngeal injuries, and anemia were identified as negative prognostic factors. Additionally, the utilization of imaging-based paraclinical investigations for diagnosing traumatic lesions emerged as a positive prognostic factor in managing this pathology. The management of penetrating cervical trauma remains a subject of debate, with some advocating for surgical exploration beyond the platysma layer in all cases, while others argue for a more selective conservative approach due to a high rate of negative explorations. Conclusions: The statistical evaluation of epidemiological, clinical, lesion, paraclinical, and therapeutic parameters is needed to establish predictable risk factors in the prognosis of complex aerodigestive cervical trauma.

Penetrating Head and Neck Trauma: A Narrative Review of Evidence-Based Evaluation and Treatment Protocols.

Penetrating injury to the head and neck accounts for a minority of trauma but significant morbidity in the US civilian population. The 3-zone anatomical framework has historically guided evaluation and management; however, the most current evidence-based protocols favor a no-zone, systems-based approach. In stable patients, a thorough physical examination and noninvasive imaging should be prioritized, with surgical exploration of the head and neck reserved for certain circumstances. Diagnostic and management decisions should be tailored to the mechanism of injury, history, physical examination, experience of personnel, availability of equipment, and clinical judgment.

A Rare Self-Inflicted Stabbing to the Neck Injuring the Distal Trachea and Proximal Esophagus.

Penetrating neck trauma poses a significant risk to multiple vital structures, which if not treated immediately may lead to devastating consequences. Our patient presented after sustaining self-inflicted stab wounds to the neck. He was taken to the operating room for a left neck exploration and median sternotomy, revealing a distal tracheal injury. Following repair of the tracheal injury, an intraoperative esophagogastroduodenoscopy demonstrated a full-thickness esophageal injury 15 cm proximal to the tracheal injury. Both injuries were the result of separate stab entries originating from the same external midline wound. To our knowledge, this case report is unique in bringing this circumstance to the literature, demonstrating the importance of full intraoperative examination to assess for concomitant wounds in stab injuries after the initial pathology has been found and the initial stab trajectory understood.

Airway Obstruction with Blunt Neck Trauma from an Accidental High Tackle in Rugby.

ABSTRACT: Blunt neck trauma is an uncommon condition in sports yet life-threatening if left untreated; hence, early diagnosis and management is necessary once suspected. We report a collegiate rugby player tackled around the neck during intersquad scrimmage. He broke his cricoid and thyroid cartilage, resulting in cervical subcutaneous emphysema and pneumomediastinum and eventually, airway obstruction. Thus, he underwent cricothyroidotomy and emergency tracheotomy. After 20 d, the emphysema disappeared. However, dilation failure of the vocal cord remained, thereby requiring laryngeal reconstruction. In conclusion, blunt neck trauma can cause airway obstruction in various sports.

Review article: Non-penetrating neck artery dissection in young adults: Not to be missed!

Young adults who present to the ED with neck pain following non-penetrating, seemingly trivial trauma to the neck, are at risk of neck artery dissection and subsequent stroke. Sport-related neck injury is the chief cause. Physical examination may often be unremarkable, and although there may be reluctance to expose young patients to radiation, radiological imaging is central to making a diagnosis of arterial wall disruption. A comprehensive literature search was performed in relation to neck artery dissection, and the evidence was scrutinised. We discuss the typical mechanism of injury, symptoms, anatomical considerations and clinical aids in diagnosis of neck artery dissection. Although the incidence is low, neck artery dissection has a mortality of 7%. As such, it is important for front-line physicians to have a high suspicion of the diagnosis and a low threshold to organise radiological examinations, specifically computerised tomography. Early detection of neck artery dissection will trigger clinical protocols that call for multi-disciplinary team management of this condition. In general, guideline-based recommendation for the management of neck artery dissection involving an intimal flap is by anti-platelet therapy while treatment of neck artery dissection that results in a pseudo-aneurysm or thrombosis is managed by surgical intervention or endovascular techniques. Close follow up combined with antithrombotic treatment is recommended in these individuals, the goal being prevention of stroke.

Protect That Neck! Management of Blunt and Penetrating Neck Trauma.

Blunt and penetrating vascular injuries to the neck represent a significant burden of mortality and disability among trauma patients. Blunt cerebrovascular injury can present with signs of stroke either immediately or in a delayed fashion. Most injuries are detected with computed tomography angiogram and managed by antiplatelet agents or unfractionated heparin. In contrast, for patients presenting with penetrating neck injuries, assessment for hard signs of vascular and aerodigestive injury should be done and prompt emergent surgical consultation if present. Overall management priorities for penetrating neck injuries focus on airway management, hemorrhage control, and damage control resuscitation before definitive surgical repair.

[Acute care of soft tissue injuries in the head and neck region]. / Akutversorgung von Weichteilverletzungen im Kopf-Hals-Bereich.

BACKGROUND: Soft tissue injuries are a common consequence of head and neck trauma. With injuries being highly individual and varying depending on the underlying trauma, it is difficult to establish standardized guidelines for head and neck trauma in general. The main goal of this study was to showcase the distribution of soft tissue injury types and the principles pertaining to acute care of the individual clinical presentations. MATERIALS AND METHODS: A retrospective evaluation was carried out using all trauma-relevant ICD-10 codes for trauma to the head (S00.- to S09.-) and neck (S10.- to S19.-) among patients who were treated at the authors' clinic-a certified national trauma center-during a period of 10 years (2012 to and including 2021). RESULTS: A total of 8375 patients with head and neck trauma were treated during the observation period, i.e., an average of 836 patients per year. Within this collective, 2981 trauma cases involving soft tissue injuries were documented. Superficial injuries to the head (S00.-) and open wounds to the head (S01.-) were the most common head and neck soft tissue injuries, with 1649 and 920 cases, respectively. CONCLUSION: The case numbers of soft tissue injuries generally show an inverse correlation to the required underlying trauma: diagnoses of the categories S00 and S01 occur very often; injuries which only occur after severe trauma, such as traumatic amputation at neck level (S18), are rare. According to current literature, penetrating neck traumas should be treated using a no-zone approach. In Europe, penetrating neck injuries are rather rare because of low crime rates and strict weapon laws.

Pediatric Penetrating Neck Trauma Resulting From a Metal Boat Cleat: A Case Report.

BACKGROUND: Clinical decision making for pediatric neck trauma is challenging because data and reports are sparse. We present a case report showing current recommendations for managing pediatric neck injuries. CASE PRESENTATION: This is the case of an 11-year-old boy who presented to our Level I trauma center after a slip and fall on a metal boat cleat (metal fixture used to secure rope). He suffered a penetrating injury to his neck, requiring operative exploration. This case report provides an overview on the rare incidence of pediatric penetrating neck trauma and treatment options. CONCLUSION: This case highlights penetrating neck injuries, which are uncommon in the pediatric population. This case report is unusual due to the method of injury and nature of the object. Neck trauma via a metal boat cleat is particularly rare. A comprehensive understanding of the anatomy of the neck, mechanism of injury, thorough clinical examination, and proper workup are essential to providing effective care.

Management of Head and Neck Injuries by the Sideline Physician.

Although rare, sport-related injuries to the head and neck can be life threatening; therefore, timely and appropriate treatment is critical. Preparation is key for the sideline physician and begins well before arriving on the sideline. Knowing the athletic trainer and support staff, establishing a chain of command and emergency action plan, and having all the appropriate equipment readily available are important for game or practice preparedness. At the athletic event, physicians should have a clear line of sight to the field of play and easy access to reach the field when necessary. When performing an on-field assessment of any athlete who is not moving, whether conscious, unconscious, or with decreased consciousness, head and neck injury must be assumed, and the injured athlete should be placed on a spine board with cervical spine stabilization and transported to the emergency department for further evaluation. Generally, helmets and pads are left on while the injured athlete is being transported. Concussion is among the most common head and neck injuries in athletes, and if concussion is suspected, the athlete cannot return to the game on the same day. Nasal fractures do not always require immediate closed reduction; however, orbital, maxillary, or mandibular fractures require transport to the emergency department. For tooth avulsion, time is important; reimplantation should be attempted within 30 minutes of injury.

[Update on neck trauma]. / Update Halstraumata.

BACKGROUND: Important organs and structures are located in the cervical region. In case of blunt and penetrating trauma, emergency situations may arise. OBJECTIVE: Emergency management as well as diagnostic and therapeutic steps pertaining to neck injuries are presented. CONCLUSION: Shock therapy and airway management are essential, fast management of neck injuries highly relevant.

5-Year management and outcomes of penetrating neck injury in a trauma center. Penetrating neck injury.

BACKGROUND: Penetrating neck injuries represent 5-10% of all traumatic injuries, these bring with them a high rate of morbidity and mortality due to vital structures that could be injured in this area. The aim of this study was to determine the epidemiological and clinical characteristics of penetrating neck injuries. METHODS: This was a retrospective, unicentric and descriptive study that included all patients who underwent neck exploration surgery. RESULTS: A total of 70 neck exploration cases were reviewed, 34 (49%) didn't had any injury. Thirty (43%) had at least one hard sign, 42 (60%) patients showed at least one soft sign. Statistical analysis showed only surgical time (252±199.5 vs. 155±76.4; p=0.020) and transfusions (1.87±3 vs. 0.4±0.856; p=0.013) were statistically significant. We report a mortality of 2 (3%) patients. CONCLUSIONS: Our prevalence of neck surgical exploration without vascular injury was slightly higher (49% vs. 40%) than literature. We highlight the importance of not performing neck explorations in all patients who present a penetrating injury. We did not obtain differences between groups for hard signs and soft signs. We were not able to identify whether or not there would be an injury based on clinical characteristics. Imaging studies should be performed to avoid unnecessary neck explorations; however, depending on the clinical scenario some surgery cannot be avoided.

Non-accidental head and neck injuries in children and adolescents.

Child abuse or maltreatment has been a global problem and research shows that more than half of the cases present with head and neck injuries. This study aimed to propose an online referencing platform for dental professionals to know more about signs of child abuse and neglect (CAN) and how suspicious head and neck injuries might look like in real-life scenarios by proposing a 3D design. The study was divided into two parts: i) Integrative literature review, ii) Survey. The first part included an integrative literature review to check if there are enough publications by dentists containing real-life images of injuries related to CAN. Using appropriate keywords and searching across four well-known databases 264 publications relevant to CAN were found, of which, only 3 contained real-life images. Part II of the study included a JISC online survey, consisting of two sections, amongst general dentists, pediatric and forensic dentists. The first section of the survey was about the basic knowledge related to CAN management. A total of 61 dentists from 10 different countries filled the survey, of which 83.1% had seen common head and neck injuries involved in CAN, 61% knew about the dentist's role in reporting such cases, and 66.1% were familiar with local law enforcements to contact. The second section of the survey involved going through real-life scenarios to check the participants understanding of how to tackle a real-life case concluding that only 4-10 participants managed to figure the aspects vital to check before reporting such cases which include a proper detailed history, any previous injuries and their stage of progression, clinical examination of injuries and finally whether the injuries are consistent with the history given. To conclude, there is insufficient representation of the real-life head and neck injuries for dentists to see related to child abuse. Also, all specialists agreed that they require further training regarding CAN management with real-life examples. To address this, a 3d model of commonly seen head and neck injuries in CAN along with some other tools, was created for training and educational purposes and was embedded in a website https://3datlasofchildabuse.webflow.io/.

Reading the signs in penetrating cervical vascular injuries: Analysis of hard/soft signs and initial management from a nationwide vascular trauma database.

BACKGROUND: Algorithms for management of penetrating cervical vascular injuries (PCVIs) commonly call for immediate surgery with "hard signs" and imaging before intervention with "soft signs." We sought to analyze the association between initial examination and subsequent evaluation and management approaches. METHODS: Analysis of PCVIs from the American Association for the Surgery of Trauma Prospective Observational Vascular Injury Treatment vascular injury registry from 25 US trauma centers was performed. Patients were categorized by initial examination findings of hard signs or soft signs, and subsequent imaging and surgical exploration/repair rates were compared. RESULTS: Of 232 PCVI patients, 110 (47%) had hard signs (hemorrhage, expanding hematoma, or ischemia) and 122 (53%) had soft signs. With hard signs, 61 (56%) had immediate operative exploration and 44% underwent computed tomography (CT) imaging. After CT, 20 (18%) required open surgical repair, and 7% had endovascular intervention. Of note, 21 (19%) required no operative intervention. A total of 122 patients (53%) had soft signs on initial examination; 37 (30%) had immediate surgery, and 85 (70%) underwent CT imaging. After CT, 9% had endovascular repair, 7% had open surgery, and 65 (53%) were observed. No difference in mortality was observed for hard signs patients undergoing operative management versus observation alone (23% vs. 17%, p = 0.6). Those with hemorrhage as the primary hard signs most often required surgery (76%), but no interventions were required in 19% of hemorrhage, 20% of ischemia, and 24% of expanding hematoma. CONCLUSION: Although hard signs in PCVIs are associated with the need for operative intervention, initial CT imaging can facilitate endovascular options or nonoperative management in a significant subgroup. Hard signs should not be considered an absolute indication for immediate surgical exploration. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level IV.

Nonfatal Strangulation: More Than Meets the Eye.

ABSTRACT: Nonfatal strangulation is a relatively newly recognized mechanism of injury that may not be taken seriously because of lack of physical injuries that many times accompany it. This comparison case series supports the importance of considering not only visually detected injuries but also symptoms the patient may be experiencing when determining diagnostics necessary to guide a treatment plan. A visually detectable injury is dependent on multiple factors. Bruises may occur with minimal pressure but may not be visible immediately after assault. Contrary to this, extensive bruising of the neck is not an accurate indicator of damage to underlying structures. The authors' experiences in these two cases signify the necessity of a comprehensive assessment utilizing both physical symptoms and assessments as the basis for determining nonfatal strangulation treatment plans.

Symptoms and Physical Exam Findings in Sexual Assault-related Non-fatal Strangulation.

OBJECTIVE: Our goal was to investigate the frequency of specific signs and symptoms following sexual assault-related non-fatal strangulation (NFS) and to explore the interaction between assault characteristics and physical exam findings. METHODS: This retrospective observational study included all adults (>18 years) reporting strangulation during sexual assault who presented for a forensic sexual assault exam at one of six urban community hospitals contracted with a single forensic nurse agency. Demographic information, narrative elements, and physical exam findings were abstracted from standardized sexual assault reporting forms. We analyzed data with descriptive statistics and compared specific variables using chi-square testing. RESULTS: Of the 580 subjects 99% were female, with a median age of 27 (interquartile range 22-35 years). The most common injury location was the neck (57.2%), followed by the mouth (29.1%). We found that 19.1% of the victims had no injuries evident on physical exam and 29.8% reported a loss of consciousness. Eye/eyelid and neck findings did not significantly differ between subjects who reported blows to the head in addition to strangulation and those who did not. The time that elapsed between assault and exam did not significantly correlate with the presence of most head and torso physical exam findings, except for nose injury (P = 0.02). CONCLUSION: Slightly more than half of the victims who reported strangulation during sexual assault had visible neck injuries. Other non-anogenital findings were present even less frequently, with a substantial portion of victims having no injuries documented on physical exam. The perpetrators' use of blows to the head may account for many of the non-anogenital injuries observed, but not for the neck and eye/eyelid injuries, which may be more specific to non-fatal strangulation. More research is needed to definitively establish strangulation as the causal mechanism for these findings, and to determine whether any long-term neurologic or vascular sequelae resulted from the observed injuries.

[Surgical treatment of combined neck injury]. / Khirurgicheskoe lechenie mnozhestvennykh povrezhdenii shei.

The authors report acute neck injury followed by damage to larynx, trachea and pharynx. Features of treatment of this lesion are analyzed.