Neck Trauma


Article Author:
Titilola Alao


Article Editor:
Muhammad Waseem


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
2/28/2019 8:26:48 PM

Introduction

The management of neck trauma can be challenging and sometimes overwhelming, as this anatomical region contains many vital structures. These structures may pose a diagnostic and therapeutic dilemma in the emergency department.[1][2][3]

Neck Anatomy

For descriptive and clinical management purposes, the neck is divided into three zones: zones 1, 2, and 3. In penetrating trauma, zone designations have anatomic, diagnostic, and management implications. Since the zone system is helpful in guiding management decisions, it is preferable to employ the zone system when describing traumatic injuries. Understanding of the anatomy of the neck, especially the location of important structures, is essential to providing optimal care.

Zone 1: This is the area between the clavicles and the cricoid cartilage. This zone contains vital structures which include the innominate vessels, the origin of the common carotid artery, the subclavian vessels and the vertebral artery, the brachial plexus, the trachea, the esophagus, the apex of the lung, and the thoracic duct. Furthermore, surgical exposure and access can be difficult in this zone, because of the presence of the clavicle and bony structures of the thoracic inlet.

Zone II: This is the area between the cricoid cartilage and the angle of the mandible. The following structures are located here: the carotid and vertebral arteries, the internal jugular veins, trachea, and the esophagus. This zone has comparatively easy access for clinical examination and surgical exploration. It is the largest zone and the most commonly injured in the neck.

Zone III:  This is the area between the angle of the mandible and the base of the skull. This area contains the distal carotid and vertebral arteries and the pharynx. Since it is very close to the base of the skull, this area is less amenable to physical examination and difficult to explore during surgical evaluation.

Anatomically, the neck is also described in triangles. The sternocleidomastoid muscle separates the neck into two triangles. The anterior triangle contains most of the major anatomic structures of the neck including larynx, trachea, pharynx, esophagus, and major vascular structures. The posterior triangle contains muscles, the spinal accessory nerve, and the spinal column.

Etiology

Three major mechanisms have been described in neck trauma:

  1. Blunt trauma: This includes motor vehicle accidents and sports injuries. There may be delayed presentation of laryngeal, vascular, and digestive tract injuries if blunt trauma occurs. Also, beware that occult cervical spine injury may be present in patients with blunt neck trauma. In addition, a shoulder harness (seatbelt) may also be responsible for shearing trauma to the anterior neck.
  2. Penetrating trauma: This comprises as much as 5% to 10% of all trauma injuries. Examples include gunshot wounds and stab wounds. It is the violation of the platysma that determines penetrating injury. Wounds which penetrate the platysma have the potential for severe injury. Consequently, it is wise to consider damage to the vital structures if the platysma is violated. Stab wounds involve low-energy penetration.
  3. Near-hanging or strangulation: External neck pressure causes cerebral hypoxia due to venous and arterial obstruction. 

The most commonly injured area is zone 2, which can easily be accessed surgically. However, in zones 1 and 3 injuries, exposure and vascular control are more difficult to achieve.[4]

Epidemiology

The mortality rate for penetrating neck injuries is as high as 10%. The most common cause of death from penetrating neck trauma is a vascular injury. The area of highest risk is to injuries at the base of the neck, in zone 1. The leading causes of delayed mortality are due to esophageal injuries, which may not be apparent on initial presentation.

Beware that up to 50% of gunshot wounds are accompanied by significant injuries. These carry a mortality rate of 10% to 15%.  Stab wounds cause serious injury in 20% to 30% of cases, with an overall mortality rate of 5%. The most common cause of delayed mortality is due to esophageal injury, which may not be readily apparent on initial presentation. [5][6]

Pathophysiology

The pathophysiology of neck injury depends on the mechanism of injury. The neck contains many critical organ systems adjacent to one another. It is for this reason that even innocuous-appearing wounds have the potential to cause either immediate or delayed life-threatening injuries or complications. It is rare to have a cervical injury without a neurological deficit in patients with penetrating neck trauma.[7]

With a low-risk National Emergency X-radiography Utilization Study I (NEXUS I) criteria, spinal cord injuries are unlikely to occur. These criteria obtain only if the patient is:

  • Alert and awake
  • Not intoxicated
  • Has no signs or symptoms of neurologic injury
  • Has no spinous process tenderness.

Zone 1 is a dangerous area and injuries in this region are potentially lethal. There is a potential for injury to the following important structures:

  • Great vessels in the neck
  • Mediastinum
  • Cervical and thoracic esophagus

A high mortality rate accompanies zone 1 injuries. Vascular injuries are the most common of cervical injuries and occur in up to 40% of patients with penetrating neck trauma. A vascular injury should be suspected in the presence of the following hard signs. (Hard signs suggest the presence of a serious injury that needs immediate attention or intervention).

Signs suggestive of vascular injury:

  • Rapidly expanding or pulsatile hematoma
  • Severe hemorrhage or difficult to control bleeding
  • Shock refractory to fluid resuscitation
  • Decreased or absent pulse
  • Vascular bruit or thrill
  • Neurologic deficit (On physical examination, this is suggestive of cerebral ischemia)

Signs suggestive of esophageal injury:

  • Massive hemoptysis
  • Significant hematemesis
  • Respiratory distress 

The soft signs of penetrating neck trauma include minor hemoptysis, hematemesis, dysphonia, dysphagia, subcutaneous, or mediastinal air, non-expanding hematoma. Beware that penetrating injuries involving zones 1 and 3 have a higher risk for occult vascular injury. Also, beware of the possibility of significant concurrent wounds in these zones to the head, chest, or abdomen. Suspect airway injury if dyspnea, hemoptysis, subcutaneous air, stridor, hoarseness, and dysphonia are present. Esophageal injuries may not be clinically apparent initially. In addition, beware that normal radiographs do not exclude esophageal injury.

History and Physical

The most important part of the evaluation is a careful and thorough physical examination. Obtain essential information about the mechanism of injury, is vital. This should include responses the following considerations:

When: Timing of the injury

Where: Location of both the injury and number of wound sites (suspected entry and exit wounds), as well as their nearness to vital structures.

How: The type of wounding agent used, such as a knife, handgun, etc.

Events surrounding the timing of the injury: This information can be obtained from the emergency management report and the law enforcement report.

Any other existing or underlying medical condition(s).

It is important to determine the extent of the injury and identify any associated injuries. Beware that are uncommonly isolated injuries, particularly in cases involving blunt trauma. Always attempt to identify any associated injuries.

Evaluate the neck for hemorrhage, hematoma, ecchymosis, edema, or any anatomic distortion. Auscultate for carotid bruits, stridor. Examine the neck for any tenderness or subcutaneous emphysema. The presence of certain findings provides clues for clinically significant vascular and aerodigestive injuries. Beware that signs and symptoms may be delayed. Bubbling or air emanating from a wound may suggest a tracheal injury. Crepitus may indicate that air has moved into the soft tissue space and should suggest prompt evaluation for injury to the trachea, esophagus, or pulmonary tree. A careful evaluation of the wound to determine the extent of the injury is required. Assess for penetration of the platysma. However, wounds should never be probed blindly, as this may cause uncontrolled bleeding. A full neurologic examination should also be performed.

Evaluation

Evaluation of neck injuries warrants notification of a trauma team or surgeon if either is available. Since physical examination may not be reliable in ruling out injuries in patients with neck trauma, one should consider a low threshold for obtaining additional imaging studies and/or a surgical consultation. Periodic examination is required to identify deterioration in clinical status as well as any ongoing. The value of a thorough secondary survey to evaluate for additional injuries cannot be over-emphasized in such patients. Diagnostic testing is performed for stable patients manifesting soft signs of injury and, sometimes even for those who are asymptomatic at initial presentation. [8][9]

Chest Radiography

Obtain anterior and lateral neck and chest radiographs in any patient presenting with significant neck trauma and look for hemothorax, pneumothorax, or pneumomediastinum. These should be obtained especially for patients with zone 1.

Angiography

Angiography is the initial study to evaluate for vascular injury. This may provide information about injuries to additional structures and may delineate the path of the projectile. Since it is less invasive, it is more commonly used to define vascular neck injury.

Conventional Angiography

A four-vessel angiography with venous-phase imaging has a sensitivity of greater than 99%. This is the “gold standard” for evaluating the vascular injury. If performed, should include the carotid and vertebral vessels, the intracranial portion of the carotid artery in zone 3 injuries, and the aortic arch with its branches in zone 1 injuries.

Duplex Ultrasonography

Duplex ultrasonography can be obtained in stable patients. It is noninvasive and relatively inexpensive, but it is operator dependent.  In addition, non-occlusive injuries may be missed if the flow is preserved, such as with intimal flaps and pseudoaneurysms. Its role in zone III evaluation is also limited.

Esophagography 

Esophagography should be performed if an esophageal perforation is suspected.

Treatment / Management

Since the neck houses vital structures, prompt evaluation, and rapid intervention are required. The initial assessment should be performed according to the ATLS protocols. An immediate trauma service consultation should be obtained for patients with suspicion of vascular, tracheal, or esophageal injury.[10][11][12]

Priorities in the management of patients with neck trauma are like those for any other patient with a life-threatening condition.  The primary priorities are securing the airway, maintaining ventilation, controlling hemorrhage, and treating shock.  At the same time, check vital signs and determine the stability of the patient. Patients with neck may have other life-threatening injuries that may take precedence.

Airway: As always, the priority is airway stabilization, particularly in patients with neck trauma, while maintaining cervical spine immobilization. Remember that in-line stabilization should always be maintained when there is a concern for a cervical spine injury. Up to 10% of patients with penetrating neck injuries may present with airway compromise. Be aware that despite a stable initial appearance, airway compromise can ensue rapidly.

Beware that swelling, distorted anatomy, and hematoma formation may contribute to impending airway obstruction in facial or neck trauma. Therefore, early airway control should be considered as the conditions may rapidly worsen.

Breathing: Evaluate the breathing and assess for any hemothorax or pneumothorax, particularly with penetrating zone 1 injuries

Circulation: Direct, simple pressure on the open wounds should be used to control bleeding in the emergency department. Wounds that have air sucking or bubbling should be covered with Vaseline gauze. No blind probing of the wound and no clamping of the vessels should occur in the emergency department. It is important not to occlude both carotid arteries or obstruct the patient's airway. Avoid nasogastric tube placement in patients with penetrating neck injury because of the risk of hematoma rupture. The agitation of the patient during tube insertion may precipitate bleeding.

Further management of the patient with penetrating neck trauma depends on the anatomic zone of injury, clinical presentation, and hemodynamic stability. Determine the zone of injury, as this will determine evaluation and management strategy.

Zone 1: Since up to one-third of patients with a clinically significant zone 1 injury may have no symptoms at their initial presentation, many centers advocate vascular evaluation of the aortic arch and great vessels, with an esophageal evaluation.

Zone 2: This area has easier surgical access and poses a low risk for adverse sequelae from exploration. The decision for surgical exploration depends on the symptoms.

Symptomatic penetrating zone 2 injuries should undergo neck exploration.

Asymptomatic patients with penetrating zone 2 injuries may be treated with either mandatory exploration or directed evaluation and serial examinations.

Indications for an angiogram: a stable patient with persistent hemorrhage or neurologic deficits. The presence of Horner syndrome (sympathetic nerve plexus injury) and hoarseness (recurrent laryngeal nerve injury). This suggests a violation of carotid sheath.

Zone 3

In this zone, there is potential for injury to major blood vessels and the cranial nerves close to the skull base. Beware that patients with arterial injuries may be asymptomatic at their initial presentation, and surgical exposure and control of bleeding in this location may be quite difficult.  In addition, many vascular injuries are amenable to definitive treatment by an interventional radiologist. Therefore, the injury can be potentially treated in the same setting like the one in which the diagnostic angiogram is done.

Bottom Line

  1. Zones 1 and 3:  Difficult access, and exposure, vascular control may be challenging
  2. No mandatory exploration, however, angiography is suggested.

For Unstable Patients

All unstable patients with evidence of vascular or aero-digestive injury should receive further evaluation by performing an invasive intervention. These patients should be transferred to the operating room for definitive care depending on the type and location of injury as well as associated injuries.

For Stable Patients

  1. Whether to perform mandatory exploration of all zone 2 injuries
  2. Whether to obtain invasive intervention.in all zone 1 and 3 injuries

With improvements in multidetector  (angiography, “mandatory” neck exploration for platysma violation and “mandatory” arteriography for zones 1 and 3 injuries are falling out of favor. It is important that all patients with platysma muscle violation be admitted to the surgical service or the observation unit for ongoing observation, regardless of their stability.

Blunt Trauma

Up to 5% of traumatic injuries to the neck are due to blunt trauma. Motor vehicle accidents are the most frequent cause. It occurs when an unrestrained passenger may strike the neck on a dashboard or steering wheel.

Blunt trauma can damage the vessels by the following mechanisms

  1. Direct damage
  2. Excessive rotation and/or hyperextension: This causes stretching of the arteries and veins resulting in a shear injury.

It is often associated with other significant injuries. Beware that there are uncommonly isolated injuries, particularly in blunt trauma; therefore, always identify any associated injuries. 

Differential Diagnosis

  • Injury to the spinal cord
  • Strangulation

Complications

  • Airway obstruction
  • Aspiration
  • Vocal cord paralysis
  • Perforated esophagus
  • Severe vascular injury
  • Necrotizing infection
  • Stroke
  • Air embolism
  • Pneumothorax, hemothorax

Enhancing Healthcare Team Outcomes

In general, all trauma is managed by a multidisciplinary team of specialists that also includes nurses, physical therapists, dietitians, social workers, and occupational therapists. Those sustaining neck injuries associated with neurological deficits often require prolonged treatment that may extend for months. Thus, a visiting nurse is ideal to follow up on these patients. For those who have difficulty swallowing because of injury to the esophagus, one may even require a temporary feeding tube. In addition, those with a tracheostomy often require a home care nurse until they are weaned off the tracheal tube.  Only through multidisciplinary care can the outcomes be improved and the quality of life of these patients be improved.[13][14][2]

Outcomes

Overall, injuries to zone 1 have the highest morbidity and mortality. Zone ll injuries are the most common after penetrating trauma, but because they can be readily accessible, they also have the best prognosis. Injuries to Zone ll can be challenging because access to some structures may not be easy. The prognosis of these injuries is guarded. In individuals who suffer complete transection of the spinal cord, the injury is almost always fatal. Individuals who do retain neurological function including preservation of rectal tone, usually have a good outcome. However, if the neurological deficits persist, the outcomes are poor. When the vasculature structures are injured by blunt trauma, the outcomes are worse compared to penetrating injuries. In many neck injuries, one also has to search for airway and esophageal injuries as they may not always be apparent. Overall, the mortality rate for patients suffering penetrating trauma to the neck varies from 2-5%, but if a major blood vessel has ruptured, this is often fatal in about 70% of cases.[15] (Level V)


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Neck Trauma - Questions

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A patient suffered a slash to his right neck. The wound is over the mid-portion of sternocleidomastoid. There is a large hematoma and brisk bleeding when uncovered. He is stable. What is the next step in management?



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A patient has suffered an injury to the left subclavian artery from a gunshot wound to the neck. The injury is in which zone division?



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A patient suffered a slash to his right neck. The wound is over the mid portion of sternocleidomastoid. There is a large hematoma and brisk bleeding when uncovered. He is stable. What should be done next?



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During a neck operation for a knife wound the thoracic duct is damaged. What should be done?



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A patient is seen in the emergency department after a stab wound to the anterior neck. On examination, there is a one-inch laceration over the skin, and there is subcutaneous emphysema. The knife injury appears in zone 1. What should be the next step in this patient's management?



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Which of the following is FALSE about blunt traumatic injuries to the neck?



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A laryngeal fracture may present with which of the following?



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Which of the following is a true statement?



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A 27-year-old suffers a clothesline injury to his neck. There is evidence of laryngeal injury. If the recurrent laryngeal nerve is damaged, what will be the position of the cords on the ipsilateral side?



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A police officer suffers a slash to his right neck while responding to a domestic dispute He is holding his neck, and the wound is over the mid portion of the sternocleidomastoid. There is a large hematoma and brisk bleeding when it is uncovered. The patient is stable. What is the next step in the management of this patient?



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A hostage ran out of a building holding his neck. On exam, you notice that a puncture wound to his neck. In the emergency room, blood appears to be gushing out from one particular point. Which of the following is most appropriate for the management of this patient?



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Which of the following is the correct classification for a penetrating injury to the carotid and subclavian arteries?



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Which of the following is most appropriate for the treatment of blunt injury to the innominate artery?



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An 18-year-old is stabbed in the upper chest and presents with bright red blood oozing from just above the left clavicle. Which of the following is most appropriate for the management of this patient?



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A patient has been stabbed in the neck and presents with an expanding neck hematoma. What is the next step in the management of this patient?



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Which of the following is true regarding the repair of an injured common carotid artery?



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Low-energy penetrating missile trauma to the neck most commonly results in what type of injury?



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A SWAT officer is brought in to the emergency room by his fellow officers with profuse bleeding from a gunshot wound to the anterior neck. What is the most appropriate first step in management of this patient?



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Which of the following arteries must be ligated immediately to stop bleeding from the deep cervical artery?



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Following a penetrating injury in the submandibular triangle, the tongue of a patient deviates left on protrusion. Which of the following nerves is injured?



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A subject was found in a pool and is transported by paramedics after a shallow water diving accident. The lifeguard had done mouth to mask breathing. The patient is on a backboard and the cervical spine is immobilized. Which is the most important factor to be evaluated?



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A 7-year-old girl is found at the bottom of a swimming pool. Initially, she was in full arrest, but after 5 minutes she showed sinus tachycardia but no respiratory effort. Intubation was done in the field and cervical collar placed. After transport to the emergency room, she was unresponsive with a blood pressure of 100/60 mmHg, pulse 105, temperature 34.3 degrees Celsius, and oxygen saturation 100 percent. The pupils were 3 mm and sluggishly responsive to light. There is no response to pain. The lungs show wheezing on the left and coarse breath sounds bilaterally. The monitor shows sinus tachycardia. There is no rectal tone. Which of the following should be the next step in management?



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A 17 year old male was a restrained passenger in a rollover motor vehicle collision one hour before arrival. There was a long extrication time and patient was pinned in his seat with seatbelt against his neck. Ecchymosis is across right side of neck only. There is no midline cervical spine tenderness. Review of systems is negative besides ankle pain. HR 98 BP 130/91 RR 18 PaO2 98%. Which imaging study will help you detect an injury to the patient's neck with this traumatic mechanism?



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A patient is seen in the emergency department following a blunt injury to the neck. Radiographs reveal subcutaneous emphysema and an elevated hyoid bone. Because the patient is dyspneic, it is decided that he should be intubated. Which of the following is appropriate in managing this patient during intubation?



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You are in the emergency room when emergency medical services rush in a 17-year old who was just slashed with a knife on his right neck. The patient is alert and his vitals are normal. However, as soon as you remove the dressing you notice a large hematoma at the mid-point of the sternocleidomastoid muscle. There appears to be diffuse bleeding from underneath the muscle. What is the next step?



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A 40-year-old male with no significant medical history has presented to the emergency department after an assault by his wife. The patient reports that he and wife got into a verbal altercation which became physical when she stabbed him in the neck with a sharp object. On physical examination, the patient appears anxious, although in no acute distress. His vital signs are stable, you note a 3-mm puncture wound on right side of his neck, oozing blood with penetration of platysma and no hard signs. What is the appropriate next step in his management?



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A 17-year-old female brought by the paramedics into the emergency department after being stabbed on the right side of her neck. Which of the following is considered a hard sign, requiring immediate operating room management?



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What structure can be found in zone 1 of the neck?



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Neck Trauma - References

References

Strudwick K,McPhee M,Bell A,Martin-Khan M,Russell T, Review article: Best practice management of neck pain in the emergency department (part 6 of the musculoskeletal injuries rapid review series). Emergency medicine Australasia : EMA. 2018 Aug 30     [PubMed]
Sandstrom CK,Nunez DB, Head and Neck Injuries: Special Considerations in the Elderly Patient. Neuroimaging clinics of North America. 2018 Aug     [PubMed]
Richard SA,Zhang CW,Wu C,Ting W,Xiaodong X, Traumatic Penetrating Neck Injury with Right Common Carotid Artery Dissection and Stenosis Effectively Managed with Stenting: A Case Report and Review of the Literature. Case reports in vascular medicine. 2018     [PubMed]
Sawhney C,Arora MK,Kumar S,Barik PK,Ranjan P, Initial management in blunt trauma neck. Journal of anaesthesiology, clinical pharmacology. 2018 Apr-Jun     [PubMed]
George E,Khandelwal A,Potter C,Sodickson A,Mukundan S,Nunez D,Khurana B, Blunt traumatic vascular injuries of the head and neck in the ED. Emergency radiology. 2018 Aug 10     [PubMed]
Trofa DP,Park CN,Noticewala MS,Lynch TS,Ahmad CS,Popkin CA, The Impact of Body Checking on Youth Ice Hockey Injuries. Orthopaedic journal of sports medicine. 2017 Dec     [PubMed]
Heneghan NR,Smith R,Tyros I,Falla D,Rushton A, Thoracic dysfunction in whiplash associated disorders: A systematic review. PloS one. 2018     [PubMed]
Klima J,Kang J,Meldrum A,Pankiewicz S, Neck Injury Response in High Vertical Accelerations and its Algorithmical Formalization to Mitigate Neck Injuries. Stapp car crash journal. 2017 Nov     [PubMed]
Al-Habib A,Albadr F,Ahmed J,Aleissa A,Al Towim A, Quantitative assessment of vertebral artery anatomy in relation to cervical pedicles: surgical considerations based on regional differences. Neurosciences (Riyadh, Saudi Arabia). 2018 Apr     [PubMed]
Nikles J,Yelland M,Bayram C,Miller G,Sterling M, Management of Whiplash Associated Disorders in Australian general practice. BMC musculoskeletal disorders. 2017 Dec 29     [PubMed]
Schroeder JW,Ptak T,Corey AS,Ahmed O,Biffl WL,Brennan JA,Chandra A,Ginsburg M,Hanley M,Hunt CH,Johnson MM,Kennedy TA,Patel ND,Policeni B,Reitman C,Steigner ML,Stiver SI,Strax R,Whitehead MT,Dill KE, ACR Appropriateness Criteria{sup}®{/sup} Penetrating Neck Injury. Journal of the American College of Radiology : JACR. 2017 Nov     [PubMed]
Drain JP,Weinberg DS,Ramey JS,Moore TA,Vallier HA, Indications for CT-Angiography of the Vertebral Arteries After Trauma. Spine. 2018 May 1     [PubMed]
Illing E,Burgin SJ,Schmalbach CE, Current opinion in otolaryngology: update on vascular injuries in craniomaxillofacial fractures. Current opinion in otolaryngology     [PubMed]
Polistena A,Di Lorenzo P,Sanguinetti A,Buccelli C,Conzo G,Conti A,Niola M,Avenia N, Medicolegal implications of surgical errors and complications in neck surgery: A review based on the Italian current legislation. Open medicine (Warsaw, Poland). 2016     [PubMed]
Tobert DG,Le HV,Blucher JA,Harris MB,Schoenfeld AJ, The Clinical Implications of Adding CT Angiography in the Evaluation of Cervical Spine Fractures: A Propensity-Matched Analysis. The Journal of bone and joint surgery. American volume. 2018 Sep 5     [PubMed]

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