In this edition, Dr. Sperry and colleagues have constructed an excellent treatise on the optimal evaluation and management of injuries to the neck. In review of their work, I am struck by the emerging importance of imaging and therapeutic technologies and their evolving role in optimal care of these injuries.
As an example, while a comprehensive understanding of the neck zones remains integral to decision making in the unstable or overtly injured patient, the value of computed tomographic (CT) imaging has evolved as an increasingly valuable element of evaluation for stable patients. In the not so distant past, the zone of injury of the neck dictated the initial operative approach along with the consideration of possible extension to the other incisions. For the stable patient, however, CT and other imaging adjuncts now provide the surgeon an opportunity to more precisely guide an operative plan, a particularly valuable resource at the extremes of zones I and III, where operative intervention may require extension into the chest or advanced skull-based exposures.
The authors also outline briefly the limited data available on the utilization of endovascular adjuncts in the care of vascular injuries to the neck. Endovascular skill sets afford additional options for diagnosis, proximal control of injury with intraluminal balloons to mitigate blood loss during subsequent operative exposure, and even definitive management options. These capabilities are emerging quickly, particularly as many trauma centers incorporate endovascular practitioners and hybrid operating rooms into their trauma teams.
Among stable patients without overt signs of injury, the selection for and timing of potential endovascular therapy remain areas of needed investigation. As the authors outline, data from Denver Health Medical Center and others have blunted the initial enthusiasm for early, aggressive coverage of blunt cerebrovascular injuries (BCVIs) with endovascular stent grafts. Although traumatic pathologies are very different from those of atherosclerotic disease, the concern for higher stroke rates with endovascular versus open treatment is a concern in the wake of multicenter studies.1
Other endovascular adjuncts, however, would seem to represent valuable options for use. In my opinion, the hybrid pairing of endovascular capabilities with open surgical management has significant potential application for vascular injuries to the neck. I envision that there will come a time when endovascular adjuncts will more effectively supplement optimal management in ways that are just now being better appreciated. For stable patients, it would make sense that proximal balloon occlusion used for hemorrhage control should serve as a natural fit in this fashion. If successful, descriptions of Foley catheters through wounds and balloon catheters placed into vessels through open incisions that are welling with blood may become relics of the pre-endovascular era.
In particular, it is intriguing to observe the changes in management with regard to BCVIs. In my practice, most blunt injuries can be observed and treated with anticoagulation/antiplatelet therapy and medical management. Repeat imaging is then obtained ...