Neck Penetrating Tra

CLINICAL PRACTICE GUIDELINES:
PENETRATING NECK TRAUMA

Samuel A. Tisherman, MD
Faran Bokhari, MD
Bryan Collier, DO
J ames Ebert, MD
Michele Holevar, MD
J ohn Cumming, MD
Stanley Kurek, DO
Stuart Leon, MD
Peter Rhee, MD

Correspondence:
Samuel A. Tisherman, MD
Department of Critical Care Medicine
638 Scaife Hall
3550 Terrace Street
Pittsburgh, PA 15261
Phone: 412-647-9914
Fax: 412-802-3308
E-mail: tishermansa@upmc.edu
Penetrating Neck Trauma CPG Page 2
2008 Eastern Association for the Surgery of Trauma
STATEMENT OF THE PROBLEM
Penetrating wounds of the neck are common in the civilian trauma population. Risk of
significant injury to vital structures in the neck is dependent upon the penetrating object. For
gunshot wounds, approximately 50% (higher with high velocity weapons) of victims have
significant injuries, whereas this risk may be only 10-20% with stab wounds.
The management of injuries to the neck that penetrate the platysma is dependent upon the
anatomic level of injury. The neck has been decided into threes zones. Zone I, including the
thoracic inlet, up to the level of the cricothyroid membrane, is treated as an upper thoracic injury.
Zone III, above the angle of the mandible, is treated as a head injury. Zone II, between Zones I
and III, is the area of controversy. Because of the density of vital structures in this zone, multiple
injuries are common (1) and can affect length of stay (2). Mortality, particularly for major
vascular injuries may reach 50% (3). Delayed complications such as pseudoaneurysms or arterio-
venous fistulae can affect long-term outcomes (4). Appropriate and timely management of these
injuries is critical. For the patients with hard signs of significant injury, including active
hemorrhage, expanding hematoma, bruit, pulse deficit, subcutaneous emphysema, hoarseness,
stridor, respiratory distress, or hemiparesis, operative management is indicated. Controversy
arises over management of the patient without significant symptoms. Our management of these
patients has been evolving from an era of mandatory exploration, which led to many non-
therapeutic explorations, to an era of more selective management based on clinical experience
and new imaging capabilities. Is this justified? What are the specific roles of physical
examination and imaging in decision-making? Improved imaging modalities, such as high
resolution computed tomography (CT) or specially-performed CT with angiography, might
further improve management of these patients. In addition, some injuries to neck structures may
not require operative intervention.

Goals of the Guideline
This guideline is designed to answer the following questions regarding the management
of penetrating injuries to Zone II of the neck that penetrate the platysma:
1) Is operative management mandatory or is selective non-operative management
appropriate?
2) Is physical examination adequate to rule out injuries to vascular structures or the
aerodigestive tract?
3) Can duplex ultrasonography (US) or CT angiography rule out an arterial injury in
patients with no hard signs of vascular injury on physical examination, thereby
making arteriography unnecessary?
4) How should specific vascular injuries be managed?
5) Are both contrast studies (barium or gastrograffin swallow) and esophagoscopy
needed to safely rule out esophageal injury?
6) Is there a need for immobilization of the cervical spine?
II. PROCESS
The process utilized by this committee was developed by the Practice Management
Guidelines Committee of the Eastern Association for the Surgery of Trauma (www.east.org).
The committee agreed upon the questions to be considered. Literature for review included the
following terms: human, trauma patients, penetrating, and neck; specific structures were also
searched (larynx, trachea, esophagus, carotid artery, and jugular vein). Medline and EMBASE
were searched from 1966 to 2006.
Articles were distributed among committee members for formal review. Each article was
entered into a review data sheet that summarized the main conclusions of the study and identified
any deficiencies in the study. Furthermore, reviewers classified each reference by the
methodology established by the Agency for Health Care Policy and Research of the U.S.
Department of Health and Human Services as follows: Class I: prospective, randomized, double-
blinded study; Class II: prospective, randomized, non-blinded trial; Class III: retrospective series,
meta-analysis.
An evidentiary table (Table) was constructed using the 145 references that were
identified: Class I, 2 references; Class II, 26 references; and Class III, 105 references. Twelve of
the references could not be classified. Recommendations were made on the basis of the studies
included in this table. Level 1 recommendations, usually based on class I data, were meant to be
convincingly justifiable on scientific evidence alone. Level 2 recommendations, usually
supported by class I and II data, were to be reasonably justifiable by available scientific evidence
and strongly supported by expert opinion. Level 3 recommendations, usually based on Class II
and III data, were to be made when adequate scientific evidence is lacking, but the
recommendation is widely supported by available data and expert opinion.
III. Recommendations
A. Selective workup operation vs selective non-operative management
Recommendations
Level 1:
Selective operative management and mandatory exploration of penetrating injuries to Zone II of
the neck are equally justified and safe.
Level 2:
No recommendations.
Level 3:
No recommendations.

Scientific foundation
Nonoperative management of penetrating neck wounds was common in the early 20
th

century. Based on a review of civilian experience, Fogelman and Stewart (5) recognized in 1956
that mandatory exploration led to less mortality than a strategy of observation. A significant
number of seemingly asymptomatic patients with penetrating neck injuries actually have injuries
(6). In addition, negative neck explorations have little morbidity, though the financial cost is
noteworthy; in 1981, Merion et al (7) estimated the cost of a negative exploration at $1,930.
Although an exploration under local anesthesia is appealing in terms of limiting recovery time
and costs, Almskog et al (8) found that neck explorations under local anesthesia, compared to
general anesthesia, resulted in more hematomas and missed injuries. Consequently, mandatory
exploration under general anesthesia for injuries that penetrate the platysma seemed reasonable
in the 70s and 80s (9). Some small studies even later recommend mandatory exploration (10).
Slowly, uncontrolled studies began to suggest that patients without clear signs of vascular or
visceral injury could be observed (11-29), though observation for up to 48 hours may be
necessary (30), depending upon use of ancillary tests. Evidence of chest injury does not seem to
be an indication for neck exploration (31). Most experience with selective exploration strategies
has been in major trauma centers. Some have specifically recommended that a well-staffed
teaching hospital with a trauma service and immediate availability of radiologic and endoscopic
evaluations is needed (32). Even in community hospitals with experienced surgeons, however,
selective management may be safe (33). The need for ancillary studies during observation
remains unclear.
Saletta et al (34) reviewed 240 patients at Cook County Hospital who underwent
mandatory neck exploration. Sixty three percent had negative explorations and had minimal
morbidity. Thirteen of the 90 patients who had positive explorations did not have any clinical
signs of the injury. Elerding et al (35) reviewed 75 patients who had undergone mandatory
explorations, of which 56% were negative. In this series, however, all patients who had injuries
had positive physical exams. Bishara et al (36) similarly reported a 53% rate of negative
explorations with mandatory explorations. Twenty-three percent of injuries were not suspected
clinically, especially venous and pharyngoesophageal injuries.
In the early 1970s, data suggesting the safety of a selective approach began to emerge.
Sheely et al (37) reported improved outcomes of patients with penetrating injuries to the neck
over a 22 year period with a move toward early operation for patients with obvious vascular or
visceral injury and careful observation based on lack of clinical suspicion of injury, recognizing
greater awareness of potential esophageal injuries. Ayuyao et al (38) studied 134 patients who
had undergone mandatory explorations. Sixty eight percent were negative. Because of this high
rate of negative explorations, they managed the next 109 patients selectively. Sixty-nine of these
patients were successfully observed without operations.
J urkovich et al (39) compared the results of mandatory exploration (the preference of the
attending surgeon) in 47 patients with a selective approach in 53 patients utilizing 43 angiograms
and 14 endoscopies. In the mandatory exploration group, there were 25 negative explorations.
Twelve injuries were found but only 5 patients benefited from the studies. Noyes et al (40)
examined the accuracy of a selective management strategy. Arteriography and
laryngoscopy/bronchoscopy were 100% accurate, whereas esophagograms were 90% accurate
and esophagoscopy was 86% accurate.
Meyer et al (41) questioned this new approach of selective exploration for penetrating
neck injuries. In a series of 113 patients, they obtained arteriograms, laryngotracheoscopy,
esophagoscopy and esophagography in each patient prior to a mandatory exploration. Forty-eight
injuries were identified in 35 explorations. Of concern was the fact that 5 patients had 6 major
injuries that were not identified by the preoperative testing. Thus they believed that a mandatory
exploration approach was indicated.
In a series of 128 asymptomatic patients who were observed by Biffl et al (42) primarily
based on physical examination, only 1 patient had a missed injury (from an ice pick). Only 15%
of these patients required adjuvant tests. Sriussadaporn et al (43) also successfully observed 17
asymptomatic patients. Only 2 of 40 patients who underwent exploration did not need the
operation, though they appeared to have deep wounds. In asymptomatic patients, Nason et al
(44) found that 67% underwent negative explorations. All Zone II vascular injuries were
symptomatic.
Narrod and Moore (45, 46) reviewed their 10-year experience with penetrating neck
trauma. In the first 6 years, mandatory exploration led to a 56% rate of negative explorations. In
the next 4 years, a selective management strategy was employed. Forty-one of 48 patients who
underwent exploration had significant injuries (46), whereas 29 asymptomatic patients were
observed without any missed injuries. Few ancillary studies were performed in this group.
In a large, retrospective study from J ohannesburg, South Africa, Velmahos et al (47)
compared results with patients who underwent immediate surgical exploration vs constant
monitoring. In the exploration group, 3% of the explorations were unnecessary; mortality was
4.2%. In the monitoring group, 9% had missed injuries; mortality was 4%. Criteria for
observation vs exploration were not clear making the interpretation of the 9% missed injury rate
difficult.
The only randomized trial comparing mandatory neck exploration with a selective
approach based on physical examination and radiographs was performed by Golueke et al (48) in
160 patients. There was no difference in hospital stay, morbidity or mortality.
Management of transcervical gunshot wounds deserves separate consideration because of
the high likelihood of major injury (49). Hirshberg et al (50) explored 41 patients with
transcervical gunshot wounds. Twenty-eight had more than one zone of the neck involved.
Although 7 patients did not have major injuries, 34 patients had 52 major injuries to cervical
structures mainly involving vessels and the upper airway. Sixteen presented with life-threatening
problems. They recommended mandatory exploration. In contrast, Demetriades et al (51) found
that a selective approach based upon physical examination, angiography, esophagoscopy and
esophagography was safe.
Management of neck wounds in the military setting may be different than that in the
civilian world. Prgomet et al (52) found that injuries that did not penetrate the platysma did not
cause significant injuries. Forty-nine of 84 patients who underwent immediate exploration had
injuries to vital structures. They also found that it was safe to close the wound primarily if it was
seen within 6 hours of injury. In their experience, even extensive laryngotracheal injuries could
be repaired safely (53).
There is little data on selective management of penetrating neck injuries in children.
Small studies (54, 55) suggest that a selective management strategy is safe.
B. Diagnosis of arterial injury
Recommendations
Level 1:
No recommendations.
Level 2:
CT angiography or duplex ultrasonography can be used in lieu of arteriography to rule out an
arterial injury in penetrating injuries to Zone II of the neck.
Level 3:
CT of the neck (even without CT angiography) can be used to rule out a significant vascular
injury if it demonstrates that the trajectory of the penetrating object is remote from vital
structures. With injuries in proximity to vascular structures, minor vascular injuries such as
intimal flaps may be missed.

Scientific Foundation
In the era of mandatory neck exploration for penetrating trauma, there seemed to be little
need for angiography, though some (9) suggested that the angiogram could assist in operative
planning and thereby minimize morbidity, or rule out the need for exploration (56, 57). Physical
examination, however, seemed unreliable for ruling out arterial injury (58). Delayed
pseudoaneuryms and neurologic events have been described in originally asymptomatic patients,
prompting some to advocate angiography in all such patients (59). A negative arteriogram in a
stable patient can rule out an arterial injury (60). North et al (61) reviewed the records of 139
stable patients with penetrating neck trauma. Patients who had at least soft signs of vascular
injury (absent pulse, bruit, hematoma, or altered neurologic status) had a 30% incidence of
vascular injury by angiography, whereas only 2 of 78 asymptomatic patients had injuries (one
minor and one that did not affect management). Gunshot wounds were more likely than stab
wounds to cause vascular injury. Similarly, Hartling et al (62) found that 43 patients with stab
wounds to the neck and minimal symptoms had no significant injuries by angiography. Even in
the 18 patients with physical findings consistent with a vascular injury, only 2 had significant
injuries. Rivers et al (63) similarly questioned the value of angiography. Of 63 angiograms in 61
patients, only 6 were abnormal. Three were thought to be spurious on subsequent review, two
were clinically insignificant, and one required surgery. No significant arterial injuries were
identified by arteriography in the absence of suggestive physical findings. No major arterial
injuries were discovered during exploration that were missed preoperatively. Angiograms did not
alter the course of management.
In contrast, Sclafani et al (64) found that 10 of 26 patients who had positive angiograms
for penetrating vascular injury to the neck had undergone the angiogram solely because of
proximity. Physical examination had a sensitivity of 61% and specificity of 80%. They also
found no differences in their results based upon mechanism of injury. They suggested that
proximity should not be abandoned as an indication for angiography in these patients.
Menawat et al (65) performed angiography for proximity or soft signs of vascular injury.
Fifteen injuries were found on 45 angiograms. Forty-two patients without any signs of injury
were successfully observed without angiography or operation. Overall, only 1 patient had a
significant injury that was not predicted by physical examination.
In contrast, Nemzek et al (66) found that proximity, based on the addition of plain films
or CT of the neck showing prevertebral soft-tissue swelling, missile fragmentation, or missiles
adjacent to major vessels can be useful but are nonspecific radiographic signs.
To examine the cost effectiveness of angiography, J arvik et al (67) studied 111 patients
with penetrating neck trauma. Forty five of the 48 patients with vascular injuries had abnormal
clinical findings. Management in the other 3 patients was not altered by the angiogram. They
calculated the cost of screening angiography in asymptomatic patients to be approximately $3.08
million per central nervous system event.
Demetriades et al (68) prospectively compared physical examination and duplex US
imaging to angiography in 82 stable patients with penetrating neck injuries. Only 11 patients had
vascular injuries by angiography and only 2 of these needed to be repaired. The serious injuries
were detected or suspected on physical examination, but 6 lesions that did not require treatment
were missed (sensitivity 100% for serious injuries, but 45% for all injuries). By duplex US
imaging, 10 of 11 injuries, including all serious ones, were identified, for an overall sensitivity of
91% (100% for clinically important lesions) and specificity of 99%. Further studies by
Demetriades et al (69) included 223 patients. Of the 160 asymptomatic patients, 11 had injuries
that did not require treatment. Overall, duplex US was 92% sensitive (100% for findings that
required an operation) and 100% specific for defining an injury. Bynoe et al (70) similarly found
that duplex US was 95% sensitive and 99% specific for vascular injuries after both neck and
extremity trauma. The only missed injuries were 2 shotgun pellet injuries that did not need
repair.
In a prospective, double-blind study, Montalvo et al (71) found that US identified all 10
significant injuries in 52 patients with penetrating neck trauma. Duplex US did not identify
reversible carotid narrowing in one patient and did not visualize 2 vertebral arteries. Another
report by the same group (72) found in 55 patients that duplex US had 100% sensitivity and 85%
specificity.
Corr et al (73) reported that duplex US picked up 2 intimal flaps that were not identified
on angiography.
Helical CT angiography is the newest technology to be tested for identifying vascular
injuries from penetrating neck trauma. Because it might also be useful for identifying or ruling
out other injuries, e.g., aerodigestive tract injury, this modality is particularly intriguing as a one
stop shop to evaluate asymptomatic patients for selective operative management. The speed and
resolution of this modality continues to improve. Gracias et al (74) have already recommended
that if a CT demonstrates trajectories that are remote from vital structures, the need for additional
invasive studies can be eliminated.
Munera et al (75) prospectively studied 60 patients, who had 10 vascular injuries. There
was one missed injury by CT angiography because the study actually did not include the entire
neck. They later (76) suggested that patients with bruits or thrill at admission may be better
treated by undergoing conventional angiography because of the potential for endovascular
therapy. Helical CT angiography is limited by artifact due to metal, which may obscure arterial
segments; therefore, these patients should undergo conventional angiography.
In the setting of a mandatory exploration protocol, Mazolewski et al (77) found that CT
angiography, compared to operative findings, was 100% sensitive and 91% specific in 14
patients.
C. Diagnosis of esophageal injury
Recommendations
Level 1:
No recommendations.
Level 2:
Either contrast esophagography or esophagoscopy can be used to rule out an esophageal
perforation that requires operative repair. Diagnostic workup should be expeditious because
morbidity increases if repair is delayed by more than 24 hours.
Level 3:
No recommendations.

The problem with penetrating injuries to the esophagus is that there are frequently no
findings on physical examination. Esophagography can miss the injury (78). This is of grave
concern since late referral and management can lead to significant morbidity and mortality (79-
81). Early diagnosis and management, often with primary repair, leads to good outcomes (82-
84). Even gunshot wounds can be closed primarily (85); more complex repairs may lead to
strictures (86). Location of the injury can affect outcome as injuries above the arytenoid
cartilages can be managed without intervention, whereas more inferior injuries require neck
drainage to prevent a deep tissue infection (87). Madiba et al (88) also found that patients with
small injuries and contained perforation on contrast studies could be observed without operation
unless there was another indication for exploration. All 26 patients with injuries had
odynophagia. Of 17 patients managed non-operatively, only 1 developed local sepsis. Six
patients had associated tracheal injuries. In addition, patients with tracheal injuries have worse
outcomes if they have concomitant esophageal injuries (89, 90).
Weigelt et al (91) utilized a strategy of esophagography followed by rigid esophagoscopy
if the esophagogram were equivocal to identify esophageal injuries in patients who had no or
minimal symptoms after penetrating neck trauma. All 10 injuries in 118 patients were identified.
Wood et al (92) found that esophagography alone was 100% sensitive and 96% specific in 225
patients. Ngakane et al (93) reviewed 109 patients with penetrating neck trauma. All patients
with gunshot wounds underwent esophagography, while patients with stab wounds were only
studied if they had pain with swallowing. Twenty-nine studies were performed and 4 injuries
were identified. All were observed without intervention. Repeat contrast studies demonstrated
resolution of the injury.
In 23 patients with esophageal injuries, Armstrong et al (86) found that esophagography
only identified 62% of the injuries whereas rigid esophagoscopy detected all injuries. Srinivasan
et al (94) found reasonable accuracy with flexible endoscopy. In 55 patients, flexible endoscopy
identified the only 2 injuries, but suggested an injury in 4 patients, resulting in 4 negative
explorations, for an overall sensitivity of 100% and specificity of 92%.

D. Value of the physical exam
Recommendations
Level 1:
No recommendations.
Level 2:
No recommendations.
Level 3:
1) Careful physical examination, including auscultation of the carotid arteries, is >95% sensitive
for detecting arterial injuries that require repair. Given the potential morbidity of missed injuries,
imaging is still recommended.
2) Physical examination is inadequate to rule out injuries to the aerodigestive tract.

Early reports suggested that the physical examination is unreliable to rule out a vascular
injury. McCormick and Burch (95) found physical examination of neck and extremity injuries
yielded a 20% false negative rate and a 42% false positive rate. Metzdorff and Lowe (96) found
an overall 80% accuracy of physical examination. Apffelstaedt et al (97) found that clinical signs
were absent in 30% of patients with positive neck explorations and in 58% of patients with
negative neck explorations, support their approach of mandatory exploration.
More recently, Demetriades et al (98) studied 335 patients with penetrating neck injuries.
Sixty patients underwent exploration for positive physical examination findings or a positive
workup, whereas 269 asymptomatic patients were observed. Only 2 of the latter patients later
required elective procedures. In a subsequent paper, this group demonstrated that physical
examination did not miss any major vascular or esophageal injuries that required intervention;
though minor injuries were identified by angiography (1 of 8 required intervention) and
esophagography. Using a selective approach based upon careful and repeated physical
examinations, Gerst et al (99) observed 58 asymptomatic patients without sequelae. Of the 52
patients who underwent prompt exploration based upon physical examination, 17% did not have
significant injuries. Beitsch et al (100) similarly found that only 1 of 71 asymptomatic patients
had a vascular injury detected by angiography. Thus, in this patient population physical
examination ruled out 99% of vascular injuries and the yield for angiography was 1.4%.
Atteberry et al (101) found that if patients did not have physical examination findings of arterial
injury (active bleeding, expanding hematoma or hematoma larger than 10 cm, a bruit or thrill, or
a neurologic deficit) no vascular injuries were present based on angiography, duplex ultrasound,
or clinical follow-up. They observed patients for at least 23 hours.
Conversely, Sekharan et al (102) found that only 2 of 30 patients who underwent
exploration for hard signs of vascular injury did not have a significant injury. Twenty-three of
114 asymptomatic patients underwent angiography for proximity or involvement of another
zone. Only one of these patients needed an operation. All 91 other patients with negative
physical examinations were safely observed without imaging. Azuaje et al (103) found that 68%
of patients with positive physical examination had a positive angiogram. Of the 89 patients with
negative physical examinations, only 3 had positive angiograms, but none needed operations.
Overall, physical examinations had sensitivity of 93% and a negative predictive value of 97%.
Both sensitivity and negative predictive value for injuries requiring operation were 100%.
Subcutaneous emphysema or crepitance are physical findings suggestive of aerodigestive
tract injuries that may require operative intervention. Goudy et al (104) reviewed the cases of 19
patients with emphysema or crepitance. Twenty-one percent had dysphagia, 63% had stridor or
hoarseness. Most underwent direct laryngoscopy and esophagoscopy. Patients without
demonstrable injuries or small tears were successfully observed without exploration.
The best study, though small, that attempted to determine if imaging adds to physical
examination in the evaluation of patients with penetrating neck injuries was that by Gonzalez et
al (105). Forty-two patients who did not have obvious need for operation at admission underwent
soft tissue dynamic CT of the neck and esophagography before mandatory exploration. All
tracheal and carotid injuries were identified by physical examination. Two of 4 esophageal
injuries (both from stab wounds) were missed by both CT and esophagography. CT was better
than physical examination for identifying venous injuries, but most of these did not require
intervention.

E. Management of specific vascular injuries
Recommendations
Level 1:
No recommendations.
Level 2:
1) Except for minimal intimal irregularities or small pseudoaneurysms without neurologic
deficits, penetrating injuries to the internal carotid artery should be repaired, even when severe
neurologic deficits are present.
2) Angiographic approaches to the vertebral artery are preferred to operative approaches for
patients with bleeding from vertebral artery injuries.
3) Ligation of the jugular vein is appropriate for complex injuries or unstable patients.
Level 3:
No recommendations.

Carotid artery injuries. The issues that arise regarding carotid artery injuries involve the
questions of reconstruction, ligation or leaving the vessel occluded, vs non-operative
management. In addition, operative strategies may include extending the incision beyond the
neck via median sternotomy or anterior thoracotomy to obtain adequate vascular control (106).
Weaver et al (107) reviewed the results of reconstruction vs ligation vs non-operative
management in 80 patients with penetrating carotid artery injuries. Arterial reconstruction
provided the best outcome compared to ligation, except for non-occlusive minimal intimal
injuries that required only observation. The main issue appeared to be ischemia. Concerns for
hemorrhagic transformation of the ischemic brain in patients with pre-operative neurologic
deficits (12) with reperfusion were unwarranted. Khoury et al (108) reviewed their experience
with penetrating neck trauma in Beirut. Better outcomes were associated with early arterial
repair, though hemodynamics also affected outcome.
Rao et al (109) advocated a selective approach to potential carotid artery injuries in stable
patients. They recommended angiography for all injuries to zones I or III. For Zone II injuries,
angiography was performed based on proximity. The carotid artery was ligated in 3 patients
without neurologic deficits. All other carotid artery injuries were successfully repaired, some
with polytetrafluoroethylene (PTFE).
Kuehne et al (110) examined the impact of a management algorithm for penetrating
carotid artery injuries. Prior to implementation of the protocol, management was based on
surgeon preference. Of 36 patients, 6 deteriorated, 6 improved, and 24 had no change after
repair, ligation, or non-operative management. The new algorithm included routine angiography
for stable patients and reconstruction of injured vessels, unless the vessel was already occluded
or the injury was minimal. Except for 1 patient who died prior to carotid artery repair, all patients
either stayed the same or improved with this management strategy.
Mittal et al (111) proposed a grading scale for carotid artery injuries. In their series, all
patients with internal carotid artery injuries were managed with interposition grafts. Common
carotid artery injuries were treated either with primary repair or interposition grafts depending
upon severity.
Advances in endovascular therapy may significantly change our strategies for
management of vascular injuries. Diaz-Daza et al (112) demonstrated good results with
embolization and/or stents in 8 patients with 17 vascular injuries of the head and neck resulting
in pseudoaneurysms, fistulae, or hemorrhage.

Vertebrals. Studies of vertebral artery injuries have not compared management strategies. They
have focused mainly on the potential benefits of radiologic embolization (113, 114). Golueke et
al (115) suggested that occlusion of the vessel was rarely an issue as long as the posterior inferior
cerebellar artery was intact. If intervention was needed, proximal and distal, if possible,
embolization simplified management. Complex pseudoaneurysms and arteriovenous fistulae can
be managed with this approach (116). Even when surgical approaches were incomplete or
unsuccessful, embolization could still be successful (117). Yee et al (118) and Demetriades et al
(119) similarly found embolization to be successful. Surgical approaches were recommended for
severe hemorrhage. Non-operative management was appropriate for minimal injuries.
In 43 patients with vertebral artery injuries, Reid and Weigelt (120) reported no issues of
neurologic sequelae secondary to vertebral-basilar ischemia after proximal and distal control was
attained operatively. Minor injuries were successfully observed.

Venous. If arterial injuries are managed non-operatively, or by radiologic embolization, there is
a possibility of missing a significant venous injury. Sclafani and Sclafani (121) reported on
successful angiographic embolization of penetrating vascular injuries to the face and neck. Even
though 18% of the injuries involved arteriovenous fistulae, no clinically significant venous
injuries were missed by angiography.
Regarding the operative management of venous injuries, Robbs and Reddy (122) and
Nair et al (123) demonstrated the safety of ligation for injuries to the great veins of the neck or
thorax, particularly if the patient were unstable or the needed repair would be complex. Although
transient edema occurred, chronic venous stasis was not seen.

F. Cervical Spine Immobilization
Recommendations
Level 1:
No recommendations.
Level 2:
Immobilization of the cervical spine is unnecessary unless there is overt neurologic deficit or an
adequate physical examination can not be performed, e.g., the unconscious victim.
Level 3:
No recommendations.

The question arises as to whether or not routine immobilization of the cervical spine is
indicated in patients with penetrating neck trauma and no obvious injury to the spine. Arishita et
al (124) reviewed the experience during the Vietnam War with penetrating neck injuries. No
immobilization was performed. Of these 472 patients, only 4 might have benefited from
immobilization. They pointed out, however, that the risk of performing immobilization in a
hazardous environment like this is substantial as 10% of casualties occur while helping other
victims.
Barkana et al (125) pointed out that an immobilization device could cover up critical
physical examination findings. In their review of military casualties in Israel, 8 of 36 patients
who survived to hospitalization had important findings covered by the collar. Although 12
patients had fractures of the cervical spine, none of these were unstable and none needed surgical
stabilization. Given this very low risk of an unstable spinal fracture, they recommended only
immobilizing patients with neurologic deficits, patients for whom one can not obtain a physical
examination, and patients with concomitant blunt trauma.
In a review of civilian trauma victims who had been assaulted, Rhee et al (126) found
that neurologic deficits from penetrating assault were established and final at the time of
presentation. They felt that concern for protecting the neck should not hinder the evaluation
process or life saving procedures.
IV. Future Directions
Selective management of penetrating injuries to Zone II of the neck has become common
for asymptomatic patients. The roles of physical examination, arteriography, duplex US, CT
angiography, esophagography, and esophogoscopy remain unclear. At the moment, the single
imaging modality that holds the greatest potential for ruling out vascular, tracheal, and
esophageal injuries is CT angiography. Additional trials are needed to confirm this hypothesis.
As the resolution of CT images improve, accuracy will surely increase. Rapid definitive imaging
studies may allow early discharge of patients with neck injuries.
The management of arterial injuries has been evolving as interventional radiologists gain
experience with manipulation of the carotid arteries with balloon angioplasty and stent placement
for non-trauma situations, such as strokes. Endovascular intervention is already standard for
vertebral injuries. Ideally randomized clinical trials should be considered to demonstrate the
benefits of these approaches. As interventional radiologists and vascular surgeons become more
adept with these techniques and case series accumulate, randomization may become unethical.
Perhaps now is the time to do the definitive trials.
REFERENCES
1. Bumpous J M, Whitt PD, Ganzel TM, McClane SD. Penetrating injuries of the visceral
compartment of the neck. American J ournal of Otolaryngology. 2000;21:190-194.
2. Atta HM. Organ injury scaling system can be used to predict length of stay in patients
with penetrating neck injuries. American Surgeon. 1999;65:575-577.
3. Bladergroen M, Brockman R, Luna G, et al. A twelve-year survey of cervicothoracic
vascular injuries. American J ournal of Surgery. 1989;157:483-486.
4. Amirjamshidi A, Abbassioun K, Rahmat H. Traumatic aneurysms and arteriovenous
fistulas of the extracranial vessels in war injuries. Surgical Neurology. 2000;53:136-145.
5. Fogelman M, Stewart R. Penetrating wounds of the neck. Am J Surg. 1956;91:581-596.
6. Markey J C, J r., Hines J L, Nance FC. Penetrating neck wounds: A review of 218 cases.
American Surgeon. 1975;41:77-83.
7. Merion RM, Harness J K, Ramsburgh SR, Thompson NW. Selective management of
penetrating neck trauma. Cost implications. Archives of Surgery. 1981;116:691-696.
8. Almskog BA, Angeras U, Hall-Angeras M, Malmgren S. Penetrating wounds of the neck.
Experience from a swedish hospital. Acta Chirurgica Scandinavica. 1985;151:419-423.
9. Roon AJ , Christensen N. Evaluation and treatment of penetrating cervical injuries.
J ournal of Trauma-Injury Infection & Critical Care. 1979;19:391-397.
10. Walsh MS. The management of penetrating injuries of the anterior triangle of the
neck.[see comment]. Injury. 1994;25:393-395.
11. May M, Chadaratana P, West J W, Ogura J H. Penetrating neck wounds: Selective
exploration. Laryngoscope. 1975;85:57-75.
12. Bostwick J , 3rd, Schneider WJ , J urkiewicz MJ , Stone HH. Penetrating injuries of the face
and neck. Southern Medical J ournal. 1976;69:550-553.
13. Blass DC, J ames EC, Reed RJ , 3rd, et al. Penetrating wounds of the neck and upper
thorax. J ournal of Trauma-Injury Infection & Critical Care. 1978;18:2-7.
14. Lundy LJ , J r., Mandal AK, Lou MA, Alexander J L. Experience in selective operations in
the management of penetrating wounds of the neck. Surgery, Gynecology & Obstetrics.
1978;147:845-848.
15. Meinke AH, Bivins BA, Sachatello CR. Selective management of gunshot wounds to the
neck. Report of a series and review of the literature. American J ournal of Surgery.
1979;138:314-319.
16. Campbell FC, Robbs J V. Penetrating injuries of the neck: A prospective study of 108
patients. British J ournal of Surgery. 1980;67:582-586.
17. Pate J W, Casini M. Penetrating wounds of the neck: Explore or not? American Surgeon.
1980;46:38-43.
18. Massac E, J r., Siram SM, Leffall LD, J r. Penetrating neck wounds. American J ournal of
Surgery. 1983;145:263-265.
19. Shuck J M, Gregory J , Edwards WS. Selective management of penetrating neck wounds.
Annals of Emergency Medicine. 1983;12:159-161.
20. Rao PM, Bhatti MF, Gaudino J , et al. Penetrating injuries of the neck: Criteria for
exploration. J ournal of Trauma-Injury Infection & Critical Care. 1983;23:47-49.
21. Demetriades D, Stewart M. Penetrating injuries of the neck. Annals of the Royal College
of Surgeons of England. 1985;67:71-74.
22. Cohen ES, Breaux CW, J ohnson PN, Leitner CA. Penetrating neck injuries: Experience
with selective exploration. Southern Medical J ournal. 1987;80:26-28.
23. Ramadan HH, Samara MA, Hamdan US, Shahinian HK. Penetrating neck injuries during
the lebanese war: Aubmc experience. American university of beirut medical center.
Laryngoscope. 1987;97:975-977.
24. Mansour MA, Moore EE, Moore FA, Whitehill TA. Validating the selective management
of penetrating neck wounds. American J ournal of Surgery. 1991;162:517-520; discussion
520-511.
25. Roden DM, Pomerantz RA. Penetrating injuries to the neck: A safe, selective approach to
management. American Surgeon. 1993;59:750-753.
26. Luntz M, Nusem S, Kronenberg J . Management of penetrating wounds of the neck.
European Archives of Oto-Rhino-Laryngology. 1993;250:369-374.
27. Sofianos C, Degiannis E, Van den Aardweg MS, et al. Selective surgical management of
zone ii gunshot injuries of the neck: A prospective study. Surgery. 1996;120:785-788.
28. Klyachkin ML, Rohmiller M, Charash WE, et al. Penetrating injuries of the neck:
Selective management evolving.[see comment]. American Surgeon. 1997;63:189-194.
29. Hersman G, Barker P, Bowley DM, Boffard KD. The management of penetrating neck
injuries. International Surgery. 2001;86:82-89.
30. Stroud WH, Yarbrough DR, 3rd. Penetrating neck wounds. American J ournal of Surgery.
1980;140:323-326.
31. Goldberg PA, Knottenbelt J D, van der Spuy J W. Penetrating neck wounds: Is evidence of
chest injury an indication for exploration? Injury. 1991;22:7-8.
32. Ordog GJ , Albin D, Wasserberger J , et al. 110 bullet wounds to the neck. J ournal of
Trauma-Injury Infection & Critical Care. 1985;25:238-246.
33. Cabasares HV. Selective surgical management of penetrating neck trauma. 15-year
experience in a community hospital. American Surgeon. 1982;48:355-358.
34. Saletta J D, Lowe RJ , Lim LT, et al. Penetrating trauma of the neck. J ournal of Trauma-
Injury Infection & Critical Care. 1976;16:579-587.
35. Elerding SC, Manart FD, Moore EE. A reappraisal of penetrating neck injury
management. J ournal of Trauma-Injury Infection & Critical Care. 1980;20:695-697.
36. Bishara RA, Pasch AR, Douglas DD, et al. The necessity of mandatory exploration of
penetrating zone ii neck injuries. Surgery. 1986;100:655-660.
37. Sheely CH, 2nd, Mattox KL, Reul GJ , J r., et al. Current concepts in the management of
penetrating neck trauma. J ournal of Trauma-Injury Infection & Critical Care.
1975;15:895-900.
38. Ayuyao AM, Kaledzi YL, Parsa MH, Freeman HP. Penetrating neck wounds. Mandatory
versus selective exploration. Annals of Surgery. 1985;202:563-567.
39. J urkovich GJ , Zingarelli W, Wallace J , Curreri PW. Penetrating neck trauma: Diagnostic
studies in the asymptomatic patient. J ournal of Trauma-Injury Infection & Critical Care.
1985;25:819-822.
40. Noyes LD, McSwain NE, J r., Markowitz IP. Panendoscopy with arteriography versus
mandatory exploration of penetrating wounds of the neck. Annals of Surgery.
1986;204:21-31.
41. Meyer J P, Barrett J A, Schuler J J , Flanigan DP. Mandatory vs selective exploration for
penetrating neck trauma. A prospective assessment. Archives of Surgery. 1987;122:592-
597.
42. Biffl WL, Moore EE, Rehse DH, et al. Selective management of penetrating neck trauma
based on cervical level of injury. American J ournal of Surgery. 1997;174:678-682.
43. Sriussadaporn S, Pak-Art R, Tharavej C, et al. Selective management of penetrating neck
injuries based on clinical presentations is safe and practical. International Surgery.
2001;86:90-93.
44. Nason RW, Assuras GN, Gray PR, et al. Penetrating neck injuries: Analysis of
experience from a canadian trauma centre. Canadian J ournal of Surgery. 2001;44:122-
126.
45. Narrod J A, Moore EE. Initial management of penetrating neck wounds--a selective
approach. J ournal of Emergency Medicine. 1984;2:17-22.
46. Narrod J A, Moore EE. Selective management of penetrating neck injuries. A prospective
study. Archives of Surgery. 1984;119:574-578.
47. Velmahos GC, Souter I, Degiannis E, et al. Selective surgical management in penetrating
neck injuries. Canadian J ournal of Surgery. 1994;37:487-491.
48. Golueke PJ , Goldstein AS, Sclafani SJ , et al. Routine versus selective exploration of
penetrating neck injuries: A randomized prospective study. J ournal of Trauma-Injury
Infection & Critical Care. 1984;24:1010-1014.
49. Atta HM, Walker ML. Penetrating neck trauma: Lack of universal reporting guidelines.
50. Hirshberg A, Wall MJ , J ohnston RH, J r., et al. Transcervical gunshot injuries. American
J ournal of Surgery. 1994;167:309-312.
51. Demetriades D, Theodorou D, Cornwell E, et al. Transcervical gunshot injuries:
Mandatory operation is not necessary. J ournal of Trauma-Injury Infection & Critical
Care. 1996;40:758-760.
52. Prgomet D, Danic D, Milicic D, Leovic D. Management of war-related neck injuries
during the war in croatia, 1991-1992. European Archives of Oto-Rhino-Laryngology.
1996;253:294-296.
53. Danic D, Prgomet D, Milicic D, et al. War injuries to the head and neck. Military
Medicine. 1998;163:117-119.
54. Cooper A, Barlow B, Niemirska M, Gandhi R. Fifteen years' experience with penetrating
trauma to the head and neck in children. J ournal of Pediatric Surgery. 1987;22:24-27.
55. Hall J R, Reyes HM, Meller J L. Penetrating zone-ii neck injuries in children. J ournal of
56. Thomas AN, Goodman PC, Roon AJ . Role of angiography in cervicothoracic trauma.
J ournal of Thoracic & Cardiovascular Surgery. 1978;76:633-638.
57. O'Donnell VA, Atik M, Pick RA. Evaluation and management of penetrating wounds of
the neck: The role of emergency angiography. American J ournal of Surgery.
1979;138:309-313.
58. Smith RF, Elliot J P, Hageman J H, et al. Acute penetrating arterial injuries of the neck
and limbs. Archives of Surgery. 1974;109:198-205.
59. Dunbar LL, Adkins RB, Waterhouse G. Penetrating injuries to the neck. Selective
management. American Surgeon. 1984;50:198-204.
60. Hiatt J R, Busuttil RW, Wilson SE. Impact of routine arteriography on management of
penetrating neck injuries. J ournal of Vascular Surgery. 1984;1:860-866.
61. North CM, Ahmadi J , Segall HD, Zee CS. Penetrating vascular injuries of the face and
neck: Clinical and angiographic correlation. AJ R American J ournal of Roentgenology.
1986;147:995-999.
62. Hartling RP, McGahan J P, Lindfors KK, Blaisdell FW. Stab wounds to the neck: Role of
angiography. Radiology. 1989;172:79-82.
63. Rivers SP, Patel Y, Delany HM, Veith FJ . Limited role of arteriography in penetrating
neck trauma. J ournal of Vascular Surgery. 1988;8:112-116.
64. Sclafani SJ , Cavaliere G, Atweh N, et al. The role of angiography in penetrating neck
trauma. J ournal of Trauma-Injury Infection & Critical Care. 1991;31:557-562; discussion
562-553.
65. Menawat SS, Dennis J W, Laneve LM, Frykberg ER. Are arteriograms necessary in
penetrating zone ii neck injuries? J ournal of Vascular Surgery. 1992;16:397-400;
discussion 400-391.
66. Nemzek WR, Hecht ST, Donald PJ , et al. Prediction of major vascular injury in patients
with gunshot wounds to the neck. Ajnr: American J ournal of Neuroradiology.
1996;17:161-167.
67. J arvik J G, Philips GR, 3rd, Schwab CW, et al. Penetrating neck trauma: Sensitivity of
clinical examination and cost-effectiveness of angiography. Ajnr: American J ournal of
Neuroradiology. 1995;16:647-654.
68. Demetriades D, Theodorou D, Cornwell E, 3rd, et al. Penetrating injuries of the neck in
patients in stable condition. Physical examination, angiography, or color flow doppler
imaging. Archives of Surgery. 1995;130:971-975.
69. Demetriades D, Theodorou D, Cornwell E, et al. Evaluation of penetrating injuries of the
neck: Prospective study of 223 patients.[see comment]. World J ournal of Surgery.
1997;21:41-47; discussion 47-48.
70. Bynoe RP, Miles WS, Bell RM, et al. Noninvasive diagnosis of vascular trauma by
duplex ultrasonography. J ournal of Vascular Surgery. 1991;14:346-352.
71. Montalvo BM, LeBlang SD, Nunez DB, J r., et al. Color doppler sonography in
penetrating injuries of the neck. Ajnr: American J ournal of Neuroradiology. 1996;17:943-
951.
72. Ginzburg E, Montalvo B, LeBlang S, et al. The use of duplex ultrasonography in
penetrating neck trauma. Archives of Surgery. 1996;131:691-693.
73. Corr P, Abdool Carrim AT, Robbs J . Colour-flow ultrasound in the detection of
penetrating vascular injuries of the neck. South African Medical J ournal. 1999;89:644-
646.
74. Gracias VH, Reilly PM, Philpott J , et al. Computed tomography in the evaluation of
penetrating neck trauma: A preliminary study. Archives of Surgery. 2001;136:1231-1235.
75. Munera F, Soto J A, Palacio D, et al. Diagnosis of arterial injuries caused by penetrating
trauma to the neck: Comparison of helical ct angiography and conventional angiography.
Radiology. 2000;216:356-362.
76. Munera F, Soto J A, Palacio DM, et al. Penetrating neck injuries: Helical ct angiography
for initial evaluation. Radiology. 2002;224:366-372.
77. Mazolewski PJ , Curry J D, Browder T, Fildes J . Computed tomographic scan can be used
for surgical decision making in zone ii penetrating neck injuries. J ournal of Trauma-
78. Splener CW, Benfield J R. Esophageal disruption from blunt and penetrating external
trauma. Archives of Surgery. 1976;111:663-667.
79. Asensio J A, Berne J , Demetriades D, et al. Penetrating esophageal injuries: Time interval
of safety for preoperative evaluation--how long is safe? J ournal of Trauma-Injury
80. Asensio J A, Chahwan S, Forno W, et al. Penetrating esophageal injuries: Multicenter
study of the american association for the surgery of trauma. J ournal of Trauma-Injury
81. Hatzitheofilou C, Strahlendorf C, Kakoyiannis S, et al. Penetrating external injuries of the
oesophagus and pharynx.[erratum appears in br j surg 1993 nov;80(11):1491]. British
J ournal of Surgery. 1993;80:1147-1149.
82. Symbas PN, Hatcher CR, J r., Vlasis SE. Esophageal gunshot injuries. Annals of Surgery.
1980;191:703-707.
83. Cheadle W, Richardson J D. Options in management of trauma to the esophagus. Surgery,
Gynecology & Obstetrics. 1982;155:380-384.
84. Shama DM, Odell J . Penetrating neck trauma with tracheal and oesophageal injuries.
British J ournal of Surgery. 1984;71:534-536.
85. Popovsky J . Perforations of the esophagus from gunshot wounds. J ournal of Trauma-
86. Armstrong WB, Detar TR, Stanley RB. Diagnosis and management of external
penetrating cervical esophageal injuries. Annals of Otology, Rhinology & Laryngology.
1994;103:863-871.
87. Stanley RB, J r., Armstrong WB, Fetterman BL, Shindo ML. Management of external
penetrating injuries into the hypopharyngeal-cervical esophageal funnel. J ournal of
88. Madiba TE, Muckart DJ . Penetrating injuries to the cervical oesophagus: Is routine
exploration mandatory? Annals of the Royal College of Surgeons of England.
2003;85:162-166.
89. Minard G, Kudsk KA, Croce MA, et al. Laryngotracheal trauma. American Surgeon.
1992;58:181-187.
90. Grewal H, Rao PM, Mukerji S, Ivatury RR. Management of penetrating laryngotracheal
injuries. Head & Neck. 1995;17:494-502.
91. Weigelt J A, Thal ER, Snyder WH, 3rd, et al. Diagnosis of penetrating cervical
esophageal injuries. American J ournal of Surgery. 1987;154:619-622.
92. Wood J , Fabian TC, Mangiante EC. Penetrating neck injuries: Recommendations for
selective management. J ournal of Trauma-Injury Infection & Critical Care. 1989;29:602-
605.
93. Ngakane H, Muckart DJ , Luvuno FM. Penetrating visceral injuries of the neck: Results of
a conservative management policy. British J ournal of Surgery. 1990;77:908-910.
94. Srinivasan R, Haywood T, Horwitz B, et al. Role of flexible endoscopy in the evaluation
of possible esophageal trauma after penetrating injuries. American J ournal of
Gastroenterology. 2000;95:1725-1729.
95. McCormick TM, Burch BH. Routine angiographic evaluation of neck and extremity
injuries. J ournal of Trauma-Injury Infection & Critical Care. 1979;19:384-387.
96. Metzdorff MT, Lowe DK. Operation or observation for penetrating neck wounds? A
retrospective analysis. American J ournal of Surgery. 1984;147:646-649.
97. Apffelstaedt J P, Muller R. Results of mandatory exploration for penetrating neck trauma.
World J ournal of Surgery. 1994;18:917-919; discussion 920.
98. Demetriades D, Charalambides D, Lakhoo M. Physical examination and selective
conservative management in patients with penetrating injuries of the neck. British J ournal
of Surgery. 1993;80:1534-1536.
99. Gerst PH, Sharma SK, Sharma PK. Selective management of penetrating neck trauma.
100. Beitsch P, Weigelt J A, Flynn E, Easley S. Physical examination and arteriography in
patients with penetrating zone ii neck wounds. Archives of Surgery. 1994;129:577-581.
101. Atteberry LR, Dennis J W, Menawat SS, Frykberg ER. Physical examination alone is safe
and accurate for evaluation of vascular injuries in penetrating zone ii neck trauma.
J ournal of the American College of Surgeons. 1994;179:657-662.
102. Sekharan J , Dennis J W, Veldenz HC, et al. Continued experience with physical
examination alone for evaluation and management of penetrating zone 2 neck injuries:
Results of 145 cases. J ournal of Vascular Surgery. 2000;32:483-489.
103. Azuaje RE, J acobson LE, Glover J , et al. Reliability of physical examination as a
predictor of vascular injury after penetrating neck trauma. American Surgeon.
2003;69:804-807.
104. Goudy SL, Miller FB, Bumpous J M. Neck crepitance: Evaluation and management of
suspected upper aerodigestive tract injury. Laryngoscope. 2002;112:791-795.
105. Gonzalez RP, Falimirski M, Holevar MR, Turk B. Penetrating zone ii neck injury: Does
dynamic computed tomographic scan contribute to the diagnostic sensitivity of physical
examination for surgically significant injury? A prospective blinded study.[see
comment]. J ournal of Trauma-Injury Infection & Critical Care. 2003;54:61-64;
discussion 64-65.
106. Thavendran A, Wijemanne NY, Soysa A, Rasaretnam R. Penetrating injuries of the neck.
Injury. 1975;7:58-60.
107. Weaver FA, Yellin AE, Wagner WH, et al. The role of arterial reconstruction in
penetrating carotid injuries. Archives of Surgery. 1988;123:1106-1111.
108. Khoury G, Hajj H, Khoury SJ , et al. Penetrating trauma to the carotid vessels. European
J ournal of Vascular Surgery. 1990;4:607-610.
109. Rao PM, Ivatury RR, Sharma P, et al. Cervical vascular injuries: A trauma center
experience. Surgery. 1993;114:527-531.
110. Kuehne J P, Weaver FA, Papanicolaou G, Yellin AE. Penetrating trauma of the internal
carotid artery. Archives of Surgery. 1996;131:942-947; discussion 947-948.
111. Mittal VK, Paulson TJ , Colaiuta E, et al. Carotid artery injuries and their management.
J ournal of Cardiovascular Surgery. 2000;41:423-431.
112. Diaz-Daza O, Arraiza FJ , Barkley J M, Whigham CJ . Endovascular therapy of traumatic
vascular lesions of the head and neck. Cardiovascular & Interventional Radiology.
2003;26:213-221.
113. Debrun G, Legre J , Kasbarian M, et al. Endovascular occlusion of vertebral fistulae by
detachable balloons with conservation of the vertebral blood flow. Radiology.
1979;130:141-147.
114. Halbach VV, Higashida RT, Hieshima GB. Treatment of vertebral arteriovenous fistulas.
AJ R American J ournal of Roentgenology. 1988;150:405-412.
115. Golueke P, Sclafani S, Phillips T, et al. Vertebral artery injury--diagnosis and
management. J ournal of Trauma-Injury Infection & Critical Care. 1987;27:856-865.
116. Albuquerque FC, J avedan SP, McDougall CG. Endovascular management of penetrating
vertebral artery injuries. J ournal of Trauma-Injury Infection & Critical Care.
2002;53:574-580.
117. Ben-Menachem Y, Fields WS, Cadavid G, et al. Vertebral artery trauma: Transcatheter
embolization. Ajnr: American J ournal of Neuroradiology. 1987;8:501-507.
118. Yee LF, Olcott EW, Knudson MM, Lim RC, J r. Extraluminal, transluminal, and
observational treatment for vertebral artery injuries. J ournal of Trauma-Injury Infection
& Critical Care. 1995;39:480-484; discussion 484-486.
119. Demetriades D, Theodorou D, Asensio J , et al. Management options in vertebral artery
injuries. British J ournal of Surgery. 1996;83:83-86.
120. Reid J D, Weigelt J A. Forty-three cases of vertebral artery trauma. J ournal of Trauma-
121. Sclafani AP, Sclafani SJ . Angiography and transcatheter arterial embolization of vascular
injuries of the face and neck. Laryngoscope. 1996;106:168-173.
122. Robbs J V, Reddy E. Management options for penetrating injuries to the great veins of the
neck and superior mediastinum. Surgery, Gynecology & Obstetrics. 1987;165:323-326.
123. Nair R, Robbs J V, Muckart DJ . Management of penetrating cervicomediastinal venous
trauma. European J ournal of Vascular & Endovascular Surgery. 2000;19:65-69.
124. Arishita GI, Vayer J S, Bellamy RF. Cervical spine immobilization of penetrating neck
wounds in a hostile environment.[see comment]. J ournal of Trauma-Injury Infection &
Critical Care. 1989;29:332-337.
125. Barkana Y, Stein M, Scope A, et al. Prehospital stabilization of the cervical spine for
penetrating injuries of the neck - is it necessary?[see comment]. Injury. 2000;31:305-309.
126. Rhee P, Kuncir EJ , J ohnson L, et al. Cervical spine injury is highly dependent on the
mechanism of injury following blunt and penetrating assault. J ournal of Trauma-Injury

T
a
b
l
e

1
.

E
v
i
d
e
n
t
i
a
r
y

T
a
b
l
e
#
F
i
r
s
t

a
u
t
h
o
r
Y
e
a
r
R
e
f
e
r
e
n
c
e
C
l
a
s
s
C
o
n
c
l
u
s
i
o
n
s
1
B
u
m
p
o
u
s

J
M
2
0
0
0
A
m

J

O
t
o
l
a
r
y
n
g
o
l

2
1
:
1
9
0
-
4
I
I
I
Z
o
n
e

I
I

i
s

t
h
e

m
o
s
t

c
o
m
m
o
n

a
r
e
a

o
f

i
n
j
u
r
y

a
n
d

m
o
s
t

p
a
t
i
e
n
t
s

w
i
l
l

r
e
q
u
i
r
e

n
e
c
k

e
x
p
l
o
r
a
t
i
o
n
.

M
a
j
o
r

v
a
s
c
u
l
a
r

i
n
j
u
r
i
e
s

a
r
e

e
v
i
d
e
n
t

w
i
t
h

e
x
p
a
n
d
i
n
g

h
e
m
a
t
o
m
a
,

d
e
c
l
i
n
i
n
g

m
e
n
t
a
l

s
t
a
t
u
s
,

p
e
r
s
i
s
t
e
n
t

b
l
e
e
d
i
n
g

f
r
o
m

t
h
e

w
o
u
n
d

o
r

f
r
o
m

t
h
e

a
e
r
o
d
i
g
e
s
t
i
v
e

t
r
a
c
t
.

A
n
g
i
o
g
r
a
p
h
y

i
s

h
e
l
p
f
u
l

i
f

s
u
r
g
e
r
y

i
s

n
o
t

i
m
m
e
d
i
a
t
e
l
y

w
a
r
r
a
n
t
e
d
.

A

s
i
g
n
i
f
i
c
a
n
t

n
u
m
b
e
r

o
f

p
a
t
i
e
n
t
s

w
i
l
l

h
a
v
e

l
o
n
g

t
e
r
m

s
e
q
u
e
l
a
e

i
n
c
l
u
d
i
n
g

h
o
a
r
s
e
n
e
s
s

o
r

d
y
s
p
h
a
g
i
a

a
n
d

t
h
e
y

m
a
y

r
e
q
u
i
r
e

p
e
r
s
i
s
t
e
n
t

t
r
a
c
h
e
o
t
o
m
y
.
2
A
t
t
a

H
M
1
9
9
9
A
m

S
u
r
g

6
5
:
5
7
5
-
7
I
I
I

T
h
e

O
r
g
a
n

I
n
j
u
r
y

S
c
a
l
e

c
a
n

b
e

u
s
e
d

t
o

p
r
e
d
i
c
t

t
h
e

l
e
n
g
t
h

o
f

h
o
s
p
i
t
a
l

s
t
a
y
.

3
B
l
a
d
e
r
g
r
o
e
n

M
1
9
8
9
A
m

J

S
u
r
g

1
5
7
:
4
8
3
-
6
I
I
I
A
g
g
r
e
s
s
i
v
e

r
e
s
u
s
c
i
t
a
t
i
o
n
,

e
v
a
l
u
a
t
i
o
n
,

a
n
d

o
p
e
r
a
t
i
v
e

i
n
t
e
r
v
e
n
t
i
o
n

a
r
e

n
e
e
d
e
d
f
o
r

t
h
e
s
e

p
a
t
i
e
n
t
s
.
4
A
m
i
r
j
a
m
s
h
i
d
i

A
2
0
0
0
S
u
r
g

N
e
u
r
o

5
3
:
1
3
6
-
4
5
I
I
I

E
a
r
l
y

r
e
c
o
g
n
i
t
i
o
n

o
f

s
t
i
g
m
a
s

s
u
g
g
e
s
t
i
n
g

p
o
s
s
i
b
l
e

f
o
r
m
a
t
i
o
n

o
f

e
x
t
r
a
c
r
a
n
i
a
l

t
r
a
u
m
a
t
i
c

v
a
s
c
u
l
o
p
a
t
h
i
e
s

s
u
c
h

a
s

a
n
e
u
r
y
s
m
s

o
r

a
r
t
e
r
i
o
v
e
n
o
u
s

f
i
s
t
u
l
a
s

s
h
o
u
l
d

b
e

h
i
g
h
l
i
g
h
t
e
d

f
o
r

e
v
a
l
u
a
t
i
o
n
.

P
e
r
f
o
r
m
i
n
g

a
n
g
i
o
g
r
a
p
h
y

p
r
o
m
p
t
l
y

i
n

s
u
s
p
e
c
t
e
d

c
a
s
e
s

c
a
n

p
i
c
k

u
p

s
u
c
h

t
r
a
u
m
a
t
i
c

v
a
s
c
u
l
a
r

l
e
s
i
o
n
s

e
a
r
l
i
e
r
.

U
s
i
n
g

s
i
m
p
l
e
r

s
u
r
g
i
c
a
l

t
e
c
h
n
i
q
u
e
s

i
n

s
i
t
u
a
t
i
o
n
s

i
n

w
h
i
c
h

m
o
r
e

s
o
p
h
i
s
t
i
c
a
t
e
d

e
n
d
o
v
a
s
c
u
l
a
r

e
q
u
i
p
m
e
n
t

i
s

u
n
a
v
a
i
l
a
b
l
e

c
a
n

b
e

l
i
f
e
-
s
a
v
i
n
g
.
5
F
o
g
e
l
m
a
n

M
1
9
5
6
A
m

J

S
u
r
g

9
1
:
5
8
1
-
5
9
6
I
I
I
M
a
n
d
a
t
o
r
y

e
x
p
l
o
r
a
t
i
o
n

l
e
d

t
o

l
e
s
s

m
o
r
t
a
l
i
t
y

t
h
a
n

a

s
t
r
a
t
e
g
y

o
f

o
b
s
e
r
v
a
t
i
o
n
.
6
M
a
r
k
e
y

J
C
1
9
7
5
A
m

S
u
r
g

4
1
:
7
7
-
8
3
I
I
I
T
h
e
y

r
e
c
o
m
m
e
n
d

e
x
p
l
o
r
i
n
g

e
v
e
r
y
o
n
e

w
i
t
h

i
n
j
u
r
y

p
a
s
t

t
h
e

p
l
a
t
y
s
m
a

a
s

n
e
g
a
t
i
v
e

e
x
p
l
o
r
a
t
i
o
n

h
a
s

l
o
w

m
o
r
b
i
d
i
t
y
.
7
M
e
r
i
o
n

R
M
1
9
8
1
A
r
c
h

S
u
r
g

1
1
6
:
6
9
1
-
6
I
I
I
S
e
l
e
c
t
i
v
e

m
a
n
a
g
e
m
e
n
t

i
s

s
a
f
e
.

A
n
g
i
o
g
r
a
p
h
y

a
n
d

e
s
o
p
h
a
g
e
a
l

s
t
u
d
i
e
s

a
r
e

n
e
e
d
e
d
.
8
A
l
m
s
k
o
g

B
A
1
9
8
5
A
c
t
a

C
h
i
r
u
r
g

S
c
a
n
d

1
5
1
:
4
1
9
-
2
3
I
I
I
T
h
e
y

p
r
o
p
o
s
e

t
h
a
t

a
l
l

p
a
t
i
e
n
t
s

w
i
t
h

w
o
u
n
d
s

p
e
n
e
t
r
a
t
i
n
g

t
h
e

p
l
a
t
y
s
m
a

s
h
o
u
l
d
b
e

e
x
p
l
o
r
e
d

w
i
t
h

g
e
n
e
r
a
l

a
n
e
s
t
h
e
s
i
a
.

T
h
i
s

i
s

d
u
e

t
o

i
n
a
d
e
q
u
a
t
e

h
e
m
o
s
t
a
s
i
s

(
h
e
m
a
t
o
m
a

f
o
r
m
a
t
i
o
n
)

a
n
d

m
i
s
s
e
d

i
n
j
u
r
i
e
s

w
h
e
n

u
s
i
n
g

l
o
c
a
l

a
n
e
s
t
h
e
s
i
a
.
9
R
o
o
n

A
J
1
9
7
9
J

T
r
a
u
m
a

1
9
:
3
9
1
-
7
I
I
A
l
l

p
a
t
i
e
n
t
s

w
i
t
h

p
l
a
t
y
s
m
a

p
e
n
e
t
r
a
t
i
o
n

s
h
o
u
l
d

u
n
d
e
r
g
o

o
p
e
r
a
t
i
o
n

s
i
n
c
e

p
h
y
s
i
c
a
l

e
x
a
m

i
s

i
n
s
e
n
s
i
t
i
v
e

a
n
d

m
o
r
b
i
d
i
t
y

a
n
d

m
o
r
t
a
l
i
t
y

a
r
e

l
o
w
.

S
e
l
e
c
t
i
v
e

a
n
g
i
o
g
r
a
p
h
y

c
a
n

h
e
l
p

i
n

t
h
e

p
l
a
n
n
i
n
g

o
f

o
p
e
r
a
t
i
o
n
s
.
1
0
W
a
l
s
h

M
S
1
9
9
4
I
n
j
u
r
y

2
5
:
3
9
3
-
5
I
I
I
P
o
l
i
c
y

o
f

m
a
n
d
a
t
o
r
y

e
x
p
l
o
r
a
t
i
o
n

i
s

j
u
s
t
i
f
i
e
d
.
1
1
M
a
y

M
1
9
7
5
L
a
r
y
n
g
o
s
c
o
p
e

8
5
:
5
7
-
7
5
I
I
I
A
s
y
m
p
t
o
m
a
t
i
c

p
a
t
i
e
n
t
s

w
i
t
h
o
u
t

h
a
r
d

o
r

s
o
f
t

s
i
g
n
s

s
h
o
u
l
d

n
o
t

b
e

e
x
p
l
o
r
e
d
.

T
h
i
s

s
t
u
d
y

j
u
s
t
i
f
i
e
s

s
e
l
e
c
t
i
v
e

r
a
t
h
e
r

t
h
a
n

r
o
u
t
i
n
e

e
x
p
l
o
r
a
t
i
o
n
.
P
a
g
e

1

o
f

1
3
T
a
b
l
e

1
.

E
v
i
d
e
n
t
i
a
r
y

T
a
b
l
e
1
2
B
o
s
t
w
i
c
k

J
,

3
r
d
1
9
7
6
S
o
u
t
h

M
e
d

J
o
u
r
n
a
l

6
9
:
5
5
0
-
3
I
I
I
T
h
e

m
o
s
t

c
o
m
m
o
n

o
r
g
a
n

i
n
j
u
r
y

t
h
a
t

i
s

f
a
t
a
l

i
s

i
n
j
u
r
y

t
o

t
h
e

c
a
r
o
t
i
d
.

M
o
r
b
i
d
i
t
y

i
s

p
r
i
m
a
r
i
l
y

r
e
l
a
t
e
d

t
o

n
e
u
r
o
l
o
g
i
c
a
l

d
e
t
e
r
i
o
r
a
t
i
o
n
.

C
a
r
o
t
i
d

i
n
j
u
r
y

r
e
p
a
i
r

s
h
o
u
l
d

o
c
c
u
r

w
h
e
n

t
h
e
r
e

h
a
s

b
e
e
n

n
o

p
r
e
-
e
x
i
s
t
i
n
g

n
e
u
r
o
l
o
g
i
c
a
l

d
e
f
i
c
i
t
.

R
e
i
n
s
t
i
t
u
t
i
o
n

o
f

c
e
r
e
b
r
a
l

f
l
o
w

t
o

a

p
r
e
v
i
o
u
s
l
y

a
c
u
t
e
l
y

i
s
c
h
e
m
i
c

b
r
a
i
n

a
d
d
s

g
r
e
a
t
e
r

r
i
s
k

o
f

i
n
t
r
a
c
e
r
e
b
r
a
l

h
e
m
o
r
r
h
a
g
e
.

C
o
n
s
i
d
e
r
a
t
i
o
n

t
o

c
a
r
o
t
i
d

l
i
g
a
t
i
o
n

s
h
o
u
l
d

b
e

g
i
v
e
n

i
n

t
h
e
s
e

s
i
t
u
a
t
i
o
n
s
.

W
h
e
n

t
h
e

g
e
n
e
r
a
l

c
o
n
d
i
t
i
o
n

o
f

t
h
e

p
a
t
i
e
n
t

p
e
r
m
i
t
s
,

b
a
r
i
u
m

s
w
a
l
l
o
w

i
s

e
x
t
r
e
m
e
l
y

r
e
l
i
a
b
l
e

m
e
t
h
o
d

f
o
r

d
e
m
o
n
s
t
r
a
t
i
n
g

e
s
o
p
h
a
g
e
a
l

p
e
r
f
o
r
a
t
i
o
n
.
1
3
B
l
a
s
s

D
C
1
9
7
8
J

T
r
a
u
m
a

1
8
:
2
-
7
I
I
I
S
m
a
l
l
,

r
e
t
r
o
s
p
e
c
t
i
v
e

s
t
u
d
y
.

D
e
c
i
s
i
o
n

t
o

o
p
e
r
a
t
e
,

o
r

n
o
t
,

u
n
c
l
e
a
r
.
1
4
L
u
n
d
y

L
J
1
9
7
8
S
u
r
g

G
y
n
e
c
o
l

O
b
s
t
e
t

1
4
7
:
8
4
5
-
8
I
I
I
S
e
l
e
c
t
i
v
e

m
a
n
a
g
e
m
e
n
t

i
s

s
a
f
e
,

b
u
t

r
e
q
u
i
r
e
s

c
a
p
a
b
i
l
i
t
y

f
o
r

a
p
p
r
o
p
r
i
a
t
e

d
i
a
g
n
o
s
t
i
c

t
e
s
t
s

a
n
d

c
l
o
s
e

o
b
s
e
r
v
a
t
i
o
n

b
y

n
u
r
s
e
s

a
n
d

h
o
u
s
e
s
t
a
f
f
.
1
5
M
e
i
n
k
e

A
H
1
9
7
9
A
m

J

S
u
r
g

1
3
8
:
3
1
4
-
9
I
I
I
T
h
i
s

e
x
p
e
r
i
e
n
c
e

a
n
d

a

r
e
v
i
e
w

o
f

t
h
e

l
i
t
e
r
a
t
u
r
e

s
u
p
p
o
r
t

t
h
e

c
o
n
c
e
p
t

o
f

s
e
l
e
c
t
i
v
e

m
a
n
a
g
e
m
e
n
t

o
f

p
e
n
e
t
r
a
t
i
n
g

n
e
c
k

i
n
j
u
r
i
e
s

w
i
t
h

a
c
t
i
v
e

o
b
s
e
r
v
a
t
i
o
n
.
1
6
C
a
m
p
b
e
l
l

F
C
1
9
8
0
B
r
i
t

J

S
u
r
g

6
7
:
5
8
2
-
6
I
I
A

s
e
l
e
c
t
i
v
e

p
o
l
i
c
y

f
o
r

s
u
r
g
i
c
a
l

i
n
t
e
r
v
e
n
t
i
o
n

i
s

s
a
f
e
.

A

m
i
n
i
m
a
l

m
o
r
b
i
d
i
t
y

a
n
d

m
o
r
t
a
l
i
t
y

c
a
n

b
e

o
b
t
a
i
n
e
d

b
y

a
d
e
q
u
a
t
e

p
r
e
o
p
e
r
a
t
i
v
e

e
v
a
l
u
a
t
i
o
n

w
h
i
c
h

i
n
c
l
u
d
e
s

t
h
e

u
s
e

o
f

c
o
n
t
r
a
s
t

r
a
d
i
o
g
r
a
p
h
y

&

a
n
g
i
o
g
r
a
p
h
y
.

1
7
P
a
t
e

J
W
1
9
8
0
A
m

S
u
r
g

4
6
:
3
8
-
4
3
I
I
I
M
e
t
h
o
d
o
l
o
g
y

n
o
t

c
o
n
s
i
s
t
e
n
t

w
i
t
h

c
u
r
r
e
n
t

s
t
a
n
d
a
r
d
s

o
f

c
a
r
e
.

C
a
r
e
f
u
l

a
n
d

r
e
p
e
a
t
e
d

p
h
y
s
i
c
a
l

e
x
a
m
i
n
a
t
i
o
n
s

a
n
d

o
b
s
e
r
v
a
t
i
o
n
s

s
u
p
p
l
e
m
e
n
t
e
d

b
y

s
i
m
p
l
e

r
a
d
i
o
g
r
a
p
h

e
x
a
m
i
n
a
t
i
o
n
s

a
l
l
o
w
e
d

s
e
l
e
c
t
i
o
n

o
f

a

l
a
r
g
e

g
r
o
u
p

o
f

p
a
t
i
e
n
t
s

w
h
o

w
e
r
e

s
a
t
i
s
f
a
c
t
o
r
i
l
y

t
r
e
a
t
e
d

b
y

s
i
m
p
l
e

w
o
u
n
d

c
l
o
s
u
r
e

a
n
d

c
l
i
n
i
c
a
l

o
b
s
e
r
v
a
t
i
o
n
s
.

A
g
g
r
e
s
s
i
v
e

e
m
e
r
g
e
n
c
y

r
o
o
m

m
a
n
a
g
e
m
e
n
t

a
n
d

a
d
e
q
u
a
t
e

e
x
p
o
s
u
r
e

a
n
d

r
e
p
a
i
r

o
f

v
a
s
c
u
l
a
r

i
n
j
u
r
i
e
s

p
r
e
v
e
n
t
e
d

c
e
r
e
b
r
a
l

d
a
m
a
g
e

s
o

c
o
m
m
o
n

i
n

p
r
e
v
i
o
u
s

r
e
p
o
r
t
s
.
1
8
M
a
s
s
a
c

E
1
9
8
3
A
m

J

S
u
r
g

1
4
5
:
2
6
3
-
5
I
I
I
O
u
r

m
o
r
b
i
d
i
t
y

a
n
d

m
o
r
t
a
l
i
t
y

r
a
t
e
s

a
r
e

s
l
i
g
h
t
l
y

l
o
w
e
r

t
h
a
n

t
h
o
s
e

r
e
p
o
r
t
e
d

i
n

m
o
s
t

s
e
r
i
e
s
.

T
h
i
s

r
e
v
i
e
w

s
u
p
p
o
r
t
s

t
h
e

c
o
n
c
e
p
t

t
h
a
t

t
h
e
r
a
p
y

f
o
r

p
e
n
e
t
r
a
t
i
n
g

i
n
j
u
r
i
e
s

t
o

t
h
e

n
e
c
k

s
h
o
u
l
d

b
e

i
n
d
i
v
i
d
u
a
l
i
z
e
d
.
1
9
S
h
u
c
k

J
M
1
9
8
3
A
n
n

E
m
e
r
g

M
e
d

1
2
:
1
5
9
-
6
1
I
I
I
S
e
l
e
c
t
i
v
e

m
a
n
a
g
e
m
e
n
t

o
f

n
e
c
k

i
n
j
u
r
i
e
s

s
h
o
u
l
d

b
e

d
o
n
e
.
2
0
R
a
o

P
M
1
9
8
3
J

T
r
a
u
m
a

2
3
:
4
7
-
9
I
I
R
e
c
o
m
m
e
n
d

a

p
o
l
i
c
y

o
f

s
e
l
e
c
t
i
v
e

m
a
n
a
g
e
m
e
n
t
2
1
D
e
m
e
t
r
i
a
d
e
s

D
1
9
8
5
A
n
n

R
o
y
a
l

C
o
l
l

S
u
r
g

E
n
g
l

6
7
:
7
1
-
4
I
I
I
S
e
l
e
c
t
i
v
e

m
a
n
a
g
e
m
e
n
t

i
s

o
k
.
2
2
C
o
h
e
n

E
S
1
9
8
7
S
o
u
t
h

M
e
d

J
o
u
r
n
a
l

8
0
:
2
6
-
8
I
I
I
S
e
l
e
c
t
i
v
e

e
x
p
l
o
r
a
t
i
o
n

o
f

p
e
n
e
t
r
a
t
i
n
g

n
e
c
k

w
o
u
n
d
s

i
s

b
o
t
h

s
a
f
e

a
n
d

r
e
a
s
o
n
a
b
l
e
.
2
3
C
o
l
d
w
e
l
l

D
M
2
0
0
0
J

T
r
a
u
m
a

4
8
:
4
7
0
-
2
I
I
I
C
a
r
o
t
i
d

a
r
t
e
r
y

p
s
e
u
d
o
a
n
e
u
r
y
s
m
s

c
a
n

b
e

m
a
n
a
g
e
d

w
i
t
h

e
n
d
o
v
a
s
c
u
l
a
r

s
t
e
n
t
s
.
P
a
g
e

2

o
f

1
3
T
a
b
l
e

1
.

E
v
i
d
e
n
t
i
a
r
y

T
a
b
l
e
2
4
M
a
n
s
o
u
r

M
A
1
9
9
1
A
m

J

S
u
r
g

1
6
2
:
5
1
7
-
2
0
I
I
S
e
l
e
c
t
i
v
e

n
e
c
k

e
x
p
l
o
r
a
t
i
o
n

i
s

e
f
f
i
c
a
c
i
o
u
s

a
n
d

s
a
f
e
.
2
5
R
o
d
e
n

D
M
1
9
9
3
A
m

S
u
r
g

5
9
:
7
5
0
-
3
I
I
I
T
h
e

s
e
l
e
c
t
i
v
e

a
p
p
r
o
a
c
h

t
o

t
h
e

o
p
e
r
a
t
i
v
f
e

m
a
n
a
g
e
m
e
n
t

o
f

t
h
e
s
e

p
a
t
i
e
n
t
s

i
s

s
a
f
e

&

e
f
f
e
c
t
i
v
e

i
n

i
d
e
n
t
i
f
y
i
n
g

t
h
o
s
e

p
a
t
i
e
n
t
s

i
n

n
e
e
d

o
f

o
p
e
r
a
t
i
o
n

&

s
e
l
e
c
t
i
n
g

o
u
t

t
h
o
s
e

p
a
t
i
e
n
t
s

w
h
o

m
a
y

b
e

s
a
f
e
l
y

o
b
s
e
r
v
e
d
.
2
6
L
u
n
t
z

M
1
9
9
3
E
u
r
o
p

A
r
c
h

O
t
o
-
R
h
i
n
o
-
L
a
r
y
n
g
o
l

2
5
0
:
3
6
9
-
7
4
I
I
I
P
a
t
i
e
n
t
s

w
i
t
h

p
e
n
e
t
r
a
t
i
n
g

n
e
c
k

i
n
j
u
r
i
e
s

s
h
o
u
l
d

b
e

d
i
f
f
e
r
e
n
t
i
a
t
e
d

i
n
t
o

t
w
o

b
a
s
i
c

c
a
t
e
g
o
r
i
e
s
:

i
m
m
e
d
i
a
t
e
l
y

l
i
f
e
-
t
h
r
e
a
t
e
n
i
n
g

a
n
d

n
o
t

i
m
m
e
d
i
a
t
e
l
y

l
i
f
e
-
t
h
r
e
a
t
e
n
i
n
g
.

I
m
m
e
d
i
a
t
e
l
y

l
i
f
e
-
t
h
r
e
a
t
e
n
i
n
g

f
e
a
t
u
r
e
s
,

i
n
c
l
u
d
e

o
v
e
r
t

m
a
s
s
i
v
e

b
l
e
e
d
i
n
g
,

e
x
p
a
n
d
i
n
g

h
e
m
a
t
o
m
a
,

n
o
n
-
e
x
p
a
n
d
i
n
g

h
e
m
a
t
o
m
a

i
n

t
h
e

p
r
e
s
e
n
c
e

o
f

h
e
m
o
d
y
n
a
m
i
c

i
n
s
t
a
b
i
l
i
t
y
,

h
e
m
o
m
e
d
i
a
s
t
i
n
u
m
,

h
e
m
o
t
h
o
r
a
x
.

a
n
d

h
y
p
o
v
o
l
e
m
i
c

s
h
o
c
k
,

r
e
q
u
i
r
e

I
n

i
m
m
e
d
i
a
t
e

s
u
r
g
i
c
a
l

e
x
p
l
o
r
a
t
i
o
n
.

T
h
o
s
e

p
a
t
i
e
n
t
s

w
i
t
h
o
u
t

i
m
m
e
d
i
a
t
e
l
y

l
i
f
e
-
t
h
r
e
a
t
e
n
i
n
g

i
n
j
u
r
i
e
s
,

b
u
t

w
i
t
h

a
n
y

s
i
g
n
s

o
f

v
a
s
c
u
l
a
r

c
o
m
p
l
i
c
a
t
i
o
n
,

s
i
g
n
s

o
f

u
p
p
e
r

a
e
r
o
d
i
g
e
s
t
i
v
e

t
r
a
c
t

l
e
s
i
o
n
s
,

o
r

p
e
r
i
p
h
e
r
a
l

n
e
u
r
o
l
o
g
i
c
a
l

d
e
f
i
c
i
t
s
,

s
h
o
u
l
d

u
n
d
e
r
g
o

t
h
o
r
o
u
g
h

i
m
a
g
i
n
g

t
o

d
e
t
e
r
m
i
n
e

t
h
e

n
e
e
d

f
o
r

a
n
d

n
a
t
u
r
e

o
f

p
o
s
s
i
b
l
e

s
u
r
g
i
c
a
l

i
n
t
e
r
v
e
n
t
i
o
n
.
2
7
S
o
f
i
a
n
o
s

C
1
9
9
6
S
u
r
g
e
r
y

1
2
0
:
7
8
5
-
8
I
I
C
o
n
s
e
r
v
a
t
i
v
e

m
a
n
a
g
e
m
e
n
t

w
i
t
h

s
e
l
e
c
t
i
v
e
l
y

s
u
p
p
l
e
m
e
n
t
e
d

a
p
p
r
o
p
r
i
a
t
e

i
n
v
e
s
t
i
g
a
t
i
o
n
s

i
s

a

v
i
a
b
l
e

p
r
o
p
o
s
i
t
i
o
n

i
n

t
h
i
s

t
y
p
e

o
f

i
n
j
u
r
y
.
2
8
K
l
y
a
c
h
k
i
n

M
L
1
9
9
7
A
m

S
u
r
g

6
3
:
1
8
9
-
9
4
I
I
I
T
h
e

d
a
t
a

s
u
p
p
o
r
t

t
h
e

a
p
p
l
i
c
a
t
i
o
n

o
f

t
h
e

s
e
l
e
c
t
i
v
e

m
a
n
a
g
e
m
e
n
t

a
l
g
o
r
i
t
h
m

f
o
r

z
o
n
e

I
I

n
e
c
k

w
o
u
n
d
s
.

P
r
e
o
p
e
r
a
t
i
v
e

a
n
c
i
l
l
a
r
y

d
i
a
g
n
o
s
t
i
c

t
e
s
t
s

w
o
u
l
d

h
a
v
e

f
u
r
t
h
e
r

r
e
d
u
c
e
d

t
h
e

n
e
g
a
t
i
v
e

e
x
p
l
o
r
a
t
i
o
n

r
a
t
e
.
2
9
H
e
r
s
m
a
n

G
2
0
0
1
I
n
t
e
r
n
a
t

S
u
r
g

8
6
:
8
2
-
9
I
I
I
M
o
r
e

o
f

a

r
e
v
i
e
w

o
f

t
h
e

c
h
a
n
g
e

i
n

p
r
a
c
t
i
c
e

f
r
o
m

m
a
n
d
a
t
o
r
y

e
x
p
l
o
r
a
t
i
o
n

t
o

s
e
l
e
c
t
i
v
e

m
a
n
a
g
e
m
e
n
t
.

N
o

c
o
n
c
l
u
s
i
o
n
s

c
a
n

b
e

d
r
a
w
n

f
r
o
m

t
h
e
i
r

d
a
t
a
.
3
0
S
t
r
o
u
d

W
H
1
9
8
0
A
m

J

S
u
r
g

1
4
0
:
3
2
3
-
6
I
I
I
M
a
n
d
a
t
o
r
y

e
x
p
l
o
r
a
t
i
o
n

i
s

n
o
t

n
e
c
e
s
s
a
r
y
,

b
u
t

i
f

n
o
n
o
p
e
r
a
t
i
v
e

m
a
n
a
g
e
m
e
n
t

i
s

p
u
r
s
u
e
d
,

e
x
p
l
o
r
a
t
i
o
n

m
a
y

b
e

n
e
e
d
e
d

i
f

a
n
y

c
h
a
n
g
e

i
n

c
l
i
n
i
c
a
l

c
o
u
r
s
e

o
c
c
u
r
s
.

O
b
s
e
r
v
a
t
i
o
n

f
o
r

4
8

h
o
u
r
s

i
s

r
e
c
o
m
m
e
n
d
e
d
.
3
1
G
o
l
d
b
e
r
g

P
A
1
9
9
1
I
n
j
u
r
y

2
2
:
7
-
8
I
I
C
o
n
c
o
m
i
t
a
n
t

p
e
n
e
t
r
a
t
i
n
g

c
h
e
s
t

i
n
j
u
r
y

i
s

n
o
t

a
n

i
n
d
i
c
a
t
i
o
n

f
o
r

e
x
p
l
o
r
a
t
i
o
n

o
f

t
h
e

n
e
c
k
.
P
a
g
e

3

o
f

1
3
T
a
b
l
e

1
.

E
v
i
d
e
n
t
i
a
r
y

T
a
b
l
e
3
2
O
r
d
o
g

G
J
1
9
8
5
J

T
r
a
u
m
a

2
5
:
2
3
8
-
4
6
I
I
I
A

s
u
b
s
t
a
n
t
i
a
l

n
u
m
b
e
r

o
f

p
a
t
i
e
n
t
s

w
i
t
h

p
e
n
e
t
r
a
t
i
n
g

t
r
a
u
m
a

t
o

t
h
e

n
e
c
k

c
a
n

b
e

s
e
l
e
c
t
i
v
e
l
y

m
a
n
a
g
e
d

d
e
p
e
n
d
i
n
g

o
n

t
h
e

s
y
m
p
t
o
m
s
,

s
i
g
n
s
,

s
i
t
e

a
n
d

d
i
r
e
c
t
i
o
n

o
f

t
r
a
j
e
c
t
o
r
y
,

a
n
d

w
h
e
t
h
e
r

t
h
e

t
i
m
e

b
e
t
w
e
e
n

i
n
j
u
r
y

a
n
d

e
n
t
r
a
n
c
e

t
o

t
h
e

h
o
s
p
i
t
a
l

i
s

g
r
e
a
t
e
r

t
h
a
n

6

h
o
u
r
s
.

P
a
t
i
e
n
t
s

w
h
o

a
r
e

s
t
a
b
l
e

a
n
d

l
a
c
k

p
h
y
s
i
c
a
l

s
i
g
n
s

o
f

o
b
v
i
o
u
s

m
a
j
o
r

n
e
c
k

i
n
j
u
r
y

c
a
n

b
e

e
v
a
l
u
a
t
e
d

b
y

d
i
a
g
n
o
s
t
i
c

r
a
d
i
o
l
o
g
i
c

a
n
d

e
n
d
o
s
c
o
p
i
c

t
e
c
h
n
i
q
u
e
s
.

I
f

n
o

s
i
g
n
i
f
i
c
a
n
t

i
n
j
u
r
y

i
s

f
o
u
n
d
,

o
b
s
e
r
v
a
t
i
o
n

w
i
t
h

r
e
p
e
a
t
e
d

p
h
y
s
i
c
a
l

e
x
a
m
s

a
n
d

2
4

h
o
u
r

a
v
a
i
l
a
b
i
l
i
t
y

o
f

r
a
d
i
o
l
o
g
i
c

a
n
d

e
n
d
o
s
c
o
p
i
c

m
o
d
a
l
i
t
i
e
s

m
u
s
t

b
e

a
d
h
e
r
e
d

t
o
.
3
3
C
a
b
a
s
a
r
e
s

H
V
1
9
8
2
A
m

S
u
r
g

4
8
:
3
5
5
-
8
I
I
I
S
e
l
e
c
t
i
v
e

m
a
n
a
g
e
m
e
n
t

i
s

s
a
f
e
.

P
r
o
m
p
t

o
p
e
r
a
t
i
o
n
,

w
h
e
n

a
p
p
r
o
p
r
i
a
t
e
,

c
a
n

s
p
a
r
e

p
a
t
i
e
n
t
s

u
n
n
e
c
e
s
s
a
r
y

a
n
d

c
o
s
t
l
y

t
e
s
t
i
n
g
.
3
4
S
a
l
e
t
t
a

J
D
1
9
7
6
J

T
r
a
u
m
a

1
6
:
5
7
9
-
8
7
I
I
I
P
o
l
i
c
y

o
f

m
a
n
d
a
t
o
r
y

e
x
p
l
o
r
a
t
i
o
n

i
s

j
u
s
t
i
f
i
e
d
.
3
5
E
l
e
r
d
i
n
g

S
C
1
9
8
0
J

T
r
a
u
m
a

2
0
:
6
9
5
-
7
I
I
I
S
e
l
e
c
t
i
v
e

m
a
n
a
g
e
m
e
n
t

b
a
s
e
d

o
n

p
h
y
s
i
c
a
l

e
x
a
m
i
n
a
t
i
o
n

i
s

a
p
p
r
o
p
r
i
a
t
e
.
3
6
B
i
s
h
a
r
a

R
A
1
9
8
6
S
u
r
g
e
r
y

1
0
0
:
6
5
5
-
6
0
I
I
I
M
a
n
d
a
t
o
r
y

e
x
p
l
o
r
a
t
i
o
n

i
s

s
a
f
e

a
n
d

a
p
p
r
o
p
r
i
a
t
e
.

C
l
i
n
i
c
a
l

e
v
a
l
u
a
t
i
o
n

p
r
e
o
p

n
o
t

w
h
a
t

i
s

u
s
e
d

f
o
r

s
e
l
e
c
t
i
v
e

m
a
n
a
g
e
m
e
n
t
.
3
7
S
h
e
e
l
y

C
H
1
9
7
5
J

T
r
a
u
m
a

1
5
:
8
9
5
-
9
0
0
I
I
I
C
a
r
e
f
u
l
l
y

s
e
l
e
c
t
e
d

p
a
t
i
e
n
t
s

c
a
n

b
e

o
b
s
e
r
v
e
d

f
o
r

e
v
o
l
u
t
i
o
n

o
f

n
e
c
k

i
n
j
u
r
i
e
s

w
i
t
h

a

r
e
s
u
l
t
a
n
t

l
o
w

m
o
r
b
i
d
i
t
y

a
n
d

m
o
r
t
a
l
i
t
y
3
8
A
y
u
y
a
o

A
M
1
9
8
5
A
n
n

S
u
r
g

2
0
2
:
5
6
3
-
7
I
I
I
T
h
e

f
r
e
q
u
e
n
c
y

o
f

o
p
e
r
a
t
i
o
n
s

f
o
r

p
e
n
e
t
r
a
t
i
n
g

n
e
c
k

w
o
u
n
d
s

w
i
t
h
o
u
t

s
t
r
u
c
t
u
r
a
l

i
n
j
u
r
i
e
s

w
a
s

m
i
n
i
m
i
z
e
d

i
n

t
h
e

s
e
l
e
c
t
i
v
e

e
x
p
l
o
r
a
t
i
o
n

g
r
o
u
p
.
3
9
J
u
r
k
o
v
i
c
h

G
J
1
9
8
5
J

T
r
a
u
m
a

2
5
:
8
1
9
-
2
2
I
I
I
I
n

t
h
e

a
b
s
e
n
c
e

o
f

c
l
i
n
i
c
a
l

s
i
g
n
s

o
f

m
a
j
o
r

v
a
s
c
u
l
a
r
,

e
s
o
p
h
a
g
e
a
l
,

a
i
r
w
a
y
,

o
r

n
e
u
r
o
l
o
g
i
c

i
n
j
u
r
y
,

t
h
e

i
n
d
i
c
a
t
i
o
n

f
o
r

a
n
c
i
l
l
a
r
y

d
i
a
g
n
o
s
t
i
c

t
e
s
t
i
n
g

m
a
y

b
e
s
t

b
e

d
e
f
i
n
e
d

b
y

t
h
e

a
n
a
t
o
m
i
c

l
o
c
a
t
i
o
n

o
f

t
h
e

i
n
j
u
r
y
.

Z
o
n
e

I
I

i
n
j
u
r
i
e
s

a
r
e

r
a
r
e
l
y

o
c
c
u
l
t
.

A
s
y
m
t
o
m
a
t
i
c

p
a
t
i
e
n
t
s

m
a
y

s
a
f
e
l
y

b
e

o
b
s
e
r
v
e
d

o
n
l
y
.

Z
o
n
e

I

i
n
j
u
r
i
e
s

s
h
o
u
l
d

b
e

a
g
g
r
e
s
s
i
v
e
l
y

e
v
a
l
u
a
t
e
d

b
y

C
X
R
,

a
r
t
e
r
i
o
g
r
a
p
h
y
,

&

f
l
u
o
r
o
-
e
s
o
p
h
a
g
o
g
r
a
p
h
y
.

Z
o
n
e

I
I

i
n
j
u
r
i
e
s

w
a
r
r
a
n
t

a
r
t
e
r
i
o
g
r
a
p
h
y
.

A
e
r
o
d
i
g
e
s
t
i
v
e

t
r
a
c
t

s
t
u
d
i
e
s

o
f

i
n
j
u
r
i
e
s

t
o

t
h
i
s

n
e
c
k

z
o
n
e

a
r
e

u
s
e
l
e
s
s
.

4
0
N
o
y
e
s

L
D
1
9
8
6
A
n
n

S
u
r
g

2
0
4
:
2
1
-
3
1
I
I
I
C
o
m
p
a
r
e
d

t
o

m
a
n
d
a
t
o
r
y

e
x
p
l
o
r
a
t
i
o
n
,

a
n
g
i
o
g
r
a
p
h
y

w
i
t
h

p
a
n
e
n
d
o
s
c
o
p
y

i
s

a
n

e
q
u
a
l
l
y

s
a
f
e

a
n
d

a
c
c
e
p
t
a
b
l
e

m
e
t
h
o
d

o
f

i
n
i
t
i
a
l

e
x
p
l
o
r
a
t
i
o
n

f
o
r

s
t
a
b
l
e

p
a
t
i
e
n
t
s

w
i
t
h

p
e
n
e
t
r
a
t
i
n
g

n
e
c
k

w
o
u
n
d
s
.
4
1
M
e
y
e
r

J
P
1
9
8
7
A
r
c
h

S
u
r
g

1
2
2
:
5
9
2
-
7
I
I
I
P
o
t
e
n
t
i
a
l
l
y

l
e
t
h
a
l

v
a
s
c
u
l
a
r

a
n
d

v
i
s
c
e
r
a
l

s
t
r
u
c
t
u
r
e
s

i
n

t
h
e

n
e
c
k

m
a
y

g
o

u
n
d
e
t
e
c
t
e
d

i
f

s
e
l
e
c
t
i
v
e

e
x
p
l
o
r
a
t
i
o
n

c
r
i
t
e
r
i
a

a
r
e

u
s
e
d

i
n

t
h
e

d
e
c
i
s
i
o
n

t
o

e
x
p
l
o
r
e

p
e
n
e
t
r
a
t
i
n
g

w
o
u
n
d
s

t
o

z
o
n
e

I
I

o
f

t
h
e

n
e
c
k
.
4
2
B
i
f
f
l

W
L
1
9
9
7
A
m

J

S
u
r
g

1
7
4
:
6
7
8
-
8
2
I
I
S
e
l
e
c
t
i
v
e

m
a
n
a
g
e
m
e
n
t

i
s

s
a
f
e

a
n
d

d
o
e
s

n
o
t

m
a
n
d
a
t
e

d
i
a
g
n
o
s
t
i
c

t
e
s
t
i
n
g
.
4
3
S
r
i
u
s
s
a
d
a
p
o
r
n

S
2
0
0
1
I
n
t
e
r
n
a
t

S
u
r
g

8
6
:
9
0
-
3
I
I
I
S
e
l
e
c
t
i
v
e

m
a
n
a
g
e
m
e
n
t

b
a
s
e
d

o
n

c
l
i
n
i
c
a
l

f
i
n
d
i
n
g
s

i
s

s
a
f
e
.
P
a
g
e

4

o
f

1
3
T
a
b
l
e

1
.

E
v
i
d
e
n
t
i
a
r
y

T
a
b
l
e
4
4
N
a
s
o
n

R
W
2
0
0
1
C
a
n
a
d

J

S
u
r
g

4
4
:
1
2
2
-
6
I
I
I
S
e
l
e
c
t
i
v
e

m
a
n
a
g
e
m
e
n
t

m
a
y

b
e

a
p
p
r
o
p
r
i
a
t
e
,

b
u
t

t
h
e

c
r
i
t
e
r
i
a

f
o
r

o
b
s
e
r
v
a
t
i
o
n

a
r
e

u
n
c
l
e
a
r
.
4
5
N
a
r
r
o
d

J
A
1
9
8
4
J

E
m
e
r
g

M
e
d

2
:
1
7
-
2
2
I
I
I
M
a
n
d
a
t
o
r
y

e
x
p
l
o
r
a
t
i
o
n

o
f

p
e
n
e
t
r
a
t
i
n
g

a
n
t
e
r
i
o
r

n
e
c
k

w
o
u
n
d
s

i
s

u
n
n
e
c
e
s
s
a
r
y

a
n
d

u
s
e

o
f

a

s
e
l
e
c
t
i
v
e

a
p
p
r
o
a
c
h

t
o

t
h
e
i
r

e
v
a
l
u
a
t
i
o
n

i
s

b
o
t
h

s
a
f
e

a
n
d

c
o
s
t
-
e
f
f
e
c
t
i
v
e
.

O
b
s
e
r
v
a
t
i
o
n

d
o
e
s

n
o
t

m
a
n
d
a
t
e

e
x
t
e
n
s
i
v
e

a
n
c
i
l
l
a
r
y

d
i
a
g
n
o
s
t
i
c

t
e
s
t
i
n
g

f
o
r

l
e
v
e
l

I
I

a
n
d

I
I
I

i
n
j
u
r
i
e
s
.

F
o
r

l
e
v
e
l

I

i
n
j
u
r
i
e
s
,

a
r
t
e
r
i
o
g
r
a
p
h
y

i
s

p
e
r
f
o
r
m
e
d

a
n
d

i
f

t
h
e

w
o
u
n
d

a
p
p
r
o
a
c
h
e
s

t
h
e

m
e
d
i
a
s
t
i
n
u
m
,

e
s
o
p
h
a
g
e
a
l

c
o
n
t
r
a
s
t

s
t
u
d
i
e
s

a
n
d

e
n
d
o
s
c
o
p
i
c

e
v
a
l
u
a
t
i
o
n

a
r
e

p
e
r
f
o
r
m
e
d

i
n

s
e
l
e
c
t
e
d

p
a
t
i
e
n
t
s
.

I
n

t
h
i
s

s
t
u
d
y
,

t
h
e

s
e
n
s
i
t
i
v
i
t
y

o
f

e
s
o
p
h
a
g
o
s
c
o
p
y

a
n
d

e
s
o
p
h
a
g
e
a
l

c
o
n
t
r
a
s
t

s
t
u
d
i
e
s

w
a
s

l
e
s
s

t
h
a
n

7
0
%
,

t
h
e
r
e
f
o
r
e

i
n
j
u
r
i
e
s

w
i
t
h

a
b
n
o
r
m
a
l

s
o
f
t

t
i
s
s
u
e

a
i
r

u
n
d
e
r
g
o

m
a
n
d
a
t
o
r
y

e
x
p
l
o
r
a
t
i
o
n

d
e
s
p
i
t
e

t
h
e

r
i
s
k

o
f

n
e
g
a
t
i
v
e

e
x
p
l
o
r
a
t
i
o
n
.

4
6
N
a
r
r
o
d

J
A
1
9
8
4
A
r
c
h

S
u
r
g

1
1
9
:
5
7
4
-
8
I
I
S
e
l
e
c
t
i
v
e

e
x
p
l
o
r
a
t
i
o
n

f
o
r

p
e
n
e
t
r
a
t
i
n
g

n
e
c
k

i
n
j
u
r
i
e
s

i
s

s
a
f
e

a
n
d

c
o
s
t
-
e
f
f
e
c
t
i
v
e
.
O
b
s
e
r
v
a
t
i
o
n

d
o
e
s

n
o
t

m
a
n
d
a
t
e

e
x
t
e
n
s
i
v
e

a
n
c
i
l
l
a
r
y

t
e
s
t
i
n
g

f
o
r

l
e
v
e
l

I
I

a
n
d

I
I
I

i
n
j
u
r
i
e
s
.

4
7
V
e
l
m
a
h
o
s

G
C
1
9
9
4
C
a
n
a
d

J

S
u
r
g

3
7
:
4
8
7
-
9
1
I
I
L
a
r
g
e

s
t
u
d
y

o
f

s
e
l
e
c
t
i
v
e

m
a
n
a
g
e
m
e
n
t
,

b
u
t

9
%

m
i
s
s
e
d

i
n
j
u
r
i
e
s

s
e
e
m
s

h
i
g
h
.
4
8
G
o
l
u
e
k
e

P
J
1
9
8
4
J

T
r
a
u
m
a

2
4
:
1
0
1
0
-
4
I
M
a
n
d
a
t
o
r
y

a
n
d

s
e
l
e
c
t
i
v
e

s
t
r
a
t
e
g
i
e
s

a
r
e

e
q
u
i
v
a
l
e
n
t
.
4
9
A
t
t
a

H
M
1
9
9
8
A
m

S
u
r
g

6
4
:
2
2
2
-
5
I
I
I
T
r
a
n
s
c
e
r
v
i
c
a
l

i
n
j
u
r
i
e
s

a
r
e

m
o
r
e

l
e
t
h
a
l

t
h
a
n

o
t
h
e
r

t
y
p
e
s

o
f

i
n
j
u
r
i
e
s

t
o

t
h
e

n
e
c
k
.
5
0
H
i
r
s
h
b
e
r
g

A
1
9
9
4
A
m

J

S
u
r
g

1
6
7
:
3
0
9
-
1
2
I
I
I
T
r
a
n
s
c
e
r
v
i
c
a
l

p
e
n
e
t
r
a
t
i
o
n

m
a
y

b
e

a

p
r
e
d
i
c
t
o
r

o
f

m
a
j
o
r

i
n
j
u
r
y
,

s
u
p
p
o
r
t
i
n
g

a
n

a
p
p
r
o
a
c
h

o
f

m
a
n
d
a
t
o
r
y

n
e
c
k

e
x
p
l
o
r
a
t
i
o
n
.
5
1
D
e
m
e
t
r
i
a
d
e
s

D
1
9
9
6
J

T
r
a
u
m
a

4
0
:
7
5
8
-
6
0
I
I

T
h
i
s

s
t
u
d
y

d
o
e
s

n
o
t

s
u
p
p
o
r
t

m
a
n
d
a
t
o
r
y

o
p
e
r
a
t
i
o
n

f
o
r

a
l
l

t
r
a
n
s
c
e
r
v
i
c
a
l

g
u
n
s
h
o
t

w
o
u
n
d
s
.

A

c
a
r
e
f
u
l

c
l
i
n
i
c
a
l

e
x
a
m
i
n
a
t
i
o
n

c
o
m
b
i
n
e
d

w
i
t
h

t
h
e

a
p
p
r
o
p
r
i
a
t
e

d
i
a
g
n
o
s
t
i
c

i
n
v
e
s
t
i
g
a
t
i
o
n
s

s
h
o
u
l
d

d
e
t
e
r
m
i
n
e

t
h
e

t
r
e
a
t
m
e
n
t

m
o
d
a
l
i
t
y
.

A
b
o
u
t

8
0
%

o
f

t
h
e
s
e

p
a
t
i
e
n
t
s

c
a
n

s
a
f
e
l
y

b
e

m
a
n
a
g
e
d

n
o
n
o
p
e
r
a
t
i
v
e
l
y
.
5
2
P
r
g
o
m
e
t

D
1
9
9
6
E
u
r
o

A
r
c
h

O
t
o
-
R
h
i
n
o
-
L
a
r
y
n
g
o
l

2
5
3
:
2
9
4
-
6
I
I
I
W
o
u
n
d
s

t
r
e
a
t
e
d

d
u
r
i
n
g

t
h
e

f
i
r
s
t

6

h
o
u
r
s

a
f
t
e
r

i
n
j
u
r
y

s
h
o
u
l
d

b
e

c
l
o
s
e
d

p
r
i
m
a
r
i
l
y

b
u
t

w
i
t
h

o
b
l
i
g
a
t
o
r
y

d
r
a
i
n
a
g
e
.

S
e
c
o
n
d
a
r
y

c
l
o
s
u
r
e

i
s

b
e
t
t
e
r

f
o
r

w
o
u
n
d
s

t
r
e
a
t
e
d

m
o
r
e

t
h
a
n

6

h
o
u
r
s

a
f
t
e
r

i
n
j
u
r
y

o
r

i
n

c
a
s
e
s

w
i
t
h

l
a
r
g
e
r

t
i
s
s
u
e

d
e
f
e
c
t
s

r
e
q
u
i
r
i
n
g

l
a
r
g
e
r

l
o
c
a
l

o
r

f
r
e
e

g
r
a
f
t

f
l
a
p
s

f
o
r

c
l
o
s
u
r
e
.
5
3
D
a
n
i
c

D
1
9
9
8
M
i
l
i
t
a
r
y

M
e
d
i
c
i
n
e

1
6
3
:
1
1
7
-
9
I
I
I
P
r
i
m
a
r
y

c
l
o
s
u
r
e

o
f

w
a
r

w
o
u
n
d
s

t
o

t
h
e

h
e
a
d

a
n
d

n
e
c
k

(
s
u
p
p
o
r
t
e
d

b
y

a
n
t
i
b
i
o
t
i
c

t
h
e
r
a
p
y
)

a
n
d

r
e
c
o
n
s
t
r
u
c
t
i
o
n

o
f

e
x
t
e
n
s
i
v
e

l
a
r
y
n
g
o
t
r
a
c
h
e
a
l

i
n
j
u
r
i
e
s

w
i
t
h

t
h
e

m
e
d
i
a
l

l
a
y
e
r

o
f

t
h
e

c
e
r
v
i
c
a
l

d
e
e
p

f
a
s
c
i
a

w
e
r
e

u
s
e
d

f
o
r

t
h
e

f
i
r
s
t

t
i
m
e

a
s

w
a
r

s
u
r
g
e
r
y

p
r
o
c
e
d
u
r
e
s
.
5
4
C
o
o
p
e
r

A
1
9
8
7
J

P
e
d

S
u
r
g

2
2
:
2
4
-
7
I
I
I
S
e
l
e
c
t
i
v
e

m
a
n
a
g
e
m
e
n
t

o
f

n
e
c
k

i
n
j
u
r
i
e
s

s
e
e
m
s

a
p
p
r
o
p
r
i
a
t
e

i
n

c
h
i
l
d
r
e
n
.
P
a
g
e

5

o
f

1
3
T
a
b
l
e

1
.

E
v
i
d
e
n
t
i
a
r
y

T
a
b
l
e
5
5
H
a
l
l

J
R
1
9
9
1
J

T
r
a
u
m
a

3
1
:
1
6
1
4
-
7
I
I
I
N
o
n
o
p
e
r
a
t
i
v
e

o
b
s
e
r
v
a
t
i
o
n

o
f

p
e
n
e
t
r
a
t
i
n
g

z
o
n
e
-
I
I

n
e
c
k

i
n
j
u
r
i
e
s

i
s

s
a
f
e

a
n
d

t
h
e

m
a
n
a
g
e
m
e
n
t

o
f

c
h
o
i
c
e

i
f

a
c
t
i
v
e

o
b
s
e
r
v
a
t
i
o
n

c
a
n

b
e

p
e
r
f
o
r
m
e
d

a
n
d

t
h
e

f
a
c
i
l
i
t
i
e
s

f
o
r

i
m
m
e
d
i
a
t
e

o
p
e
r
a
t
i
v
e

i
n
t
e
r
v
e
n
t
i
o
n

a
r
e

a
v
a
i
l
a
b
l
e
.
5
6
T
h
o
m
a
s

A
N
1
9
7
8
J

T
h
o
r
a
c

C
a
r
d
i
o
v
a
s
c

S
u
r
g

7
6
:
6
3
3
-
8
I
I
I
I
n

s
t
a
b
l
e

p
a
t
i
e
n
t
s
,

a
n
g
i
o
g
r
a
p
h
y

h
e
l
p
s

a
v
o
i
d

u
n
n
e
c
e
s
s
a
r
y

o
p
e
r
a
t
i
o
n
s

a
n
d

h
e
l
p
e
d

p
l
a
n

a
p
p
r
o
p
r
i
a
t
e

o
p
e
r
a
t
i
o
n
s
.
5
7
O
'
D
o
n
n
e
l
l

V
A
1
9
7
9
A
m

J

S
u
r
g

1
3
8
:
3
0
9
-
1
3
I
I
I
S
e
l
e
c
t
i
v
e

m
a
n
a
g
e
m
e
n
t

b
a
s
e
d

o
n

a
n
g
i
o
g
r
a
p
h
y

i
s

s
a
f
e

a
n
d

e
f
f
e
c
t
i
v
e
.
5
8
S
m
i
t
h

R
F
1
9
7
4
A
r
c
h

S
u
r
g

1
0
9
:
1
9
8
-
2
0
5
I
I
I
N
o

f
i
r
m

c
o
n
c
l
u
s
i
o
n
s

r
e
g
a
r
d
i
n
g

i
n
d
i
c
a
t
i
o
n
s

f
o
r

a
n
g
i
o
g
r
a
p
h
i
c

e
v
a
l
u
a
t
i
o
n

c
a
n

b
e

d
r
a
w
n
,

b
u
t

p
h
y
s
i
c
a
l

e
x
a
m

a
l
o
n
e

i
s

u
n
r
e
l
i
a
b
l
e
.
5
9
D
u
n
b
a
r

L
L
1
9
8
4
A
m

S
u
r
g

5
0
:
1
9
8
-
2
0
4
I
I
I
S
e
l
e
c
t
i
v
e

m
a
n
a
g
e
m
e
n
t

i
s

s
a
f
e

w
h
e
n

e
s
o
p
h
a
g
r
a
m
s

a
n
d

a
n
g
i
o
g
r
a
m
s

a
r
e

i
n
c
l
u
d
e
d
.
6
0
H
i
a
t
t

J
R
1
9
8
4
J

V
a
s
c

S
u
r
g

1
:
8
6
0
-
6
I
I
I
N
e
g
a
t
i
v
e

a
n
g
i
o
g
r
a
m

a
l
l
o
w
s

s
a
f
e

n
o
n
o
p
e
r
a
t
i
v
e

m
a
n
a
g
e
m
e
n
t
.
6
1
N
o
r
t
h

C
M
1
9
8
6
A
m

J

R
o
e
n
t
g
e
n
o
l

1
4
7
:
9
9
5
-
9
I
I
V
a
s
c
u
l
a
r

i
n
j
u
r
y

i
n
c
i
d
e
n
c
e

w
a
s

3
0
%

w
h
e
n

t
h
e
r
e

w
a
s

a
n

a
b
s
e
n
t

p
u
l
s
e
,

b
r
u
i
t
,

h
e
m
a
t
o
m
a

o
r

a
l
t
e
r
a
t
i
o
n

o
f

n
e
u
r
o
l
o
g
i
c

s
t
a
t
u
s
.

P
a
t
i
e
n
t
s

w
e
r
e

u
n
l
i
k
e
l
y

t
o

h
a
v
e

c
l
i
n
i
c
a
l
l
y

s
i
g
n
i
f
i
c
a
n
t

v
a
s
c
u
l
a
r

t
r
a
u
m
a

i
f

t
h
e

a
b
o
v
e

s
i
g
n
s

w
e
r
e

m
i
s
s
i
n
g
.

H
i
g
h
e
r

r
a
t
e

(
5
0
%
)

o
f

v
a
s
c
u
l
a
r

i
n
j
u
r
y

w
i
t
h

t
r
a
u
m
a

a
b
o
v
e

t
h
e

a
n
g
l
e

o
f

t
h
e

m
a
n
d
i
b
l
e
.

G
u
n
s
h
o
t

w
o
u
n
d
s

c
a
u
s
e

v
a
s
c
u
l
a
r

i
n
j
u
r
y

m
o
r
e

f
r
e
q
u
e
n
t
l
y

t
h
a
n

s
t
a
b
w
o
u
n
d
s
.
6
2
H
a
r
t
l
i
n
g

R
P
1
9
8
9
R
a
d
i
o
l
o
g
y

1
7
2
:
7
9
-
8
2
I
I
I
O
c
c
u
l
t

v
a
s
c
u
l
a
r

t
r
a
u
m
a

i
s

u
n
l
i
k
e
l
y

i
n

p
a
t
i
e
n
t
s

w
i
t
h

m
i
n
o
r

p
h
y
s
i
c
a
l

f
i
n
d
i
n
g
s
.

A
n
g
i
o
g
r
a
p
h
y

i
s

i
n
d
i
c
a
t
e
d

i
n

z
o
n
e

I
I

a
n
d

I
I
I

i
n
j
u
r
i
e
s

a
s
s
o
c
i
a
t
e
d

w
i
t
h

m
a
j
o
r

p
h
y
s
i
c
a
l

f
i
n
d
i
n
g
s
,

b
u
t

n
o
t

i
n

t
h
o
s
e

w
i
t
h

m
i
n
o
r

p
h
y
s
i
c
a
l

f
i
n
d
i
n
g
s
.
6
3
R
i
v
e
r
s

S
P
1
9
8
8
J

V
a
s
c

S
u
r
g

8
:
1
1
2
-
6
I
I
I
A
r
t
e
r
i
o
g
r
a
p
h
y

f
o
r

p
e
n
e
t
r
a
t
i
n
g

n
e
c
k

t
r
a
u
m
a

i
s

u
s
u
a
l
l
y

u
n
n
e
c
e
s
s
a
r
y

f
o
r

o
b
s
e
r
v
a
t
i
o
n

o
f

p
a
t
i
e
n
t
s

i
n

s
t
a
b
l
e

c
o
n
d
i
t
i
o
n

w
i
t
h
o
u
t

s
u
g
g
e
s
t
i
v
e

p
h
y
s
i
c
a
l

f
i
n
d
i
n
g
s
.

T
h
o
r
o
u
g
h

n
e
c
k

e
x
p
l
o
r
a
t
i
o
n

w
i
t
h

d
i
s
s
e
c
t
i
o
n

o
f

t
h
e

c
a
r
o
t
i
d

s
h
e
a
t
h

i
n

p
a
t
i
e
n
t
s

w
i
t
h

p
h
y
s
i
c
a
l

e
x
a
m
i
n
a
t
i
o
n

c
r
i
t
e
r
i
a

f
o
r

s
u
r
g
e
r
y

e
l
i
m
i
n
a
t
e
s

t
h
e

n
e
e
d

f
o
r

a
n
g
i
o
g
r
a
p
h
y

i
n

m
o
s
t

c
a
s
e
s

a
n
d

a
v
o
i
d
s

t
h
e

c
o
n
s
e
q
u
e
n
c
e
s

o
f

a

p
o
s
s
i
b
l
e

f
a
l
s
e
-
n
e
g
a
t
i
v
e

s
t
u
d
y
.
6
4
S
c
l
a
f
a
n
i

S
J
1
9
9
1
J

T
r
a
u
m
a

3
1
:
5
5
7
-
6
2
I
I
I
P
h
y
s
i
c
a
l

e
x
a
m
i
n
a
t
i
o
n

i
s

i
n
s
u
f
f
i
c
i
e
n
t
.

A
n
g
i
o
g
r
a
p
h
y

o
r

e
x
p
l
o
r
a
t
i
o
n

i
s

i
n
d
i
c
a
t
e
d

i
f

p
l
a
t
y
s
m
a

i
s

v
i
o
l
a
t
e
d
.
6
5
M
e
n
a
w
a
t

S
S
1
9
9
2
J

V
a
s
c

S
u
r
g

1
6
:
3
9
7
-
4
0
0
I
I
I
L
o
c
a
t
i
o
n

a
n
d

p
h
y
s
i
c
a
l

e
x
a
m
i
n
a
t
i
o
n

c
a
n

r
u
l
e

o
u
t

a

m
a
j
o
r

a
r
t
e
r
i
a
l

i
n
j
u
r
y

n
e
c
e
s
s
i
t
a
t
i
n
g

o
p
e
r
a
t
i
o
n
.
6
6
N
e
m
z
e
k

W
R
1
9
9
6
A
m

J

N
e
u
r
o
r
a
d

1
7
:
1
6
1
-
7
I
I
I
P
r
e
v
e
r
t
e
b
r
a
l

s
o
f
t

t
i
s
s
u
e

s
w
e
l
l
i
n
g

a
n
d

b
u
l
l
e
t

f
r
a
g
m
e
n
t
a
t
i
o
n

i
n

p
r
o
x
i
m
i
t
y

t
o

a

v
e
s
s
e
l

a
r
e

n
o
n
-
s
p
e
c
i
f
i
c

f
i
n
d
i
n
g
s

a
n
d

a
r
e

p
r
e
s
e
n
t

i
n

m
a
n
y

p
a
t
i
e
n
t
s

w
i
t
h

n
e
g
a
t
i
v
e

a
n
g
i
o
.

N
o

c
o
m
m
e
n
t

o
n

c
o
m
p
u
t
e
d

t
o
m
o
g
r
a
p
h
y
.
6
7
J
a
r
v
i
k

J
G
1
9
9
5
A
m

J

N
e
u
r
o
r
a
d
i
o
l

1
6
:
6
4
7
-
5
4
I
I
C
l
i
n
i
c
a
l

e
x
a
m

i
s

g
o
o
d

a
n
d

n
o
t

d
o
i
n
g

a
n
g
i
o
g
r
a
m
s

s
a
v
e
s

3
.
0
8

m
i
l
l
i
o
n

d
o
l
l
a
r
s

p
e
r

c
e
n
t
r
a
l

n
e
r
v
o
u
s

s
y
s
t
e
m

e
v
e
n
t

p
r
e
v
e
n
t
e
d
.
P
a
g
e

6

o
f

1
3
T
a
b
l
e

1
.

E
v
i
d
e
n
t
i
a
r
y

T
a
b
l
e
6
8
D
e
m
e
t
r
i
a
d
e
s

D
1
9
9
5
A
r
c
h

S
u
r
g

1
3
0
:
9
7
1
-
5
I
I
D
o
p
p
l
e
r

a
n
d

p
h
y
s
i
c
a
l

e
x
a
m

h
a
v
e

1
0
0
%

s
e
n
s
i
t
i
v
i
t
y

f
o
r

c
l
i
n
i
c
a
l
l
y

i
m
p
o
r
t
a
n
t

l
e
s
i
o
n
s

i
n

t
h
e

v
a
s
c
u
l
a
t
u
r
e

o
f

t
h
e

n
e
c
k
.
6
9
D
e
m
e
t
r
i
a
d
e
s

D
1
9
9
7
W
o
r
l
d

J

S
u
r
g

2
1
:
4
1
-
7
I
I
P
h
y
s
i
c
a
l

e
x
a
m
i
n
a
t
i
o
n

i
s

s
u
f
f
i
c
i
e
n
t

t
o

i
d
e
n
t
i
f
y

p
a
t
i
e
n
t
s

w
h
o

r
e
q
u
i
r
e

a
r
t
e
r
i
a
l

o
r

e
s
o
p
h
a
g
e
a
l

e
v
a
l
u
a
t
i
o
n
.

D
u
p
l
e
x

i
s

a

r
e
a
s
o
n
a
b
l
e

a
l
t
e
r
n
a
t
i
v
e

t
o

a
n
g
i
o
g
r
a
p
h
y
.
7
0
B
y
n
o
e

R
P
1
9
9
1
J

V
a
s
c

S
u
r
g

1
4
:
3
4
6
-
5
2
I
I
U
l
t
a
s
o
u
n
d

i
s

a
c
c
u
r
a
t
e

a
n
d

c
o
s
t
-
e
f
f
e
c
t
i
v
e
.
7
1
M
o
n
t
a
l
v
o

B
M
1
9
9
6
A
m

J

N
e
u
r
o
r
a
d
i
o
l

1
7
:
9
4
3
-
5
1
I
I
C
o
l
o
r

D
o
p
p
l
e
r

s
o
n
o
g
r
a
p
h
y

i
s

a
s

a
c
c
u
r
a
t
e

a
s

a
n
g
i
o
g
r
a
p
h
y

i
n

s
c
r
e
e
n
i
n
g

c
l
i
n
i
c
a
l
l
y

s
t
a
b
l
e

p
a
t
i
e
n
t
s

w
i
t
h

Z
o
n
e

I
I

o
r

I
I

i
n
j
u
r
i
e
s

a
n
d

n
o

s
i
g
n
s

o
f

a
c
t
i
v
e

b
l
e
e
d
i
n
g
.

7
2
G
i
n
z
b
u
r
g

E
1
9
9
6
A
r
c
h

S
u
r
g

1
3
1
:
6
9
1
-
3
I
I
D
u
p
l
e
x

u
l
t
r
a
s
o
u
n
d

i
s

a

r
e
l
i
a
b
l
e

m
e
t
h
o
d

f
o
r

i
d
e
n
t
i
f
y
i
n
g

v
a
s
c
u
l
a
r

t
r
a
u
m
a

i
n

t
h
e
s
t
a
b
l
e

p
a
t
i
e
n
t
.

A
b
n
o
r
m
a
l

u
l
t
r
a
s
o
u
n
d

r
e
s
u
l
t
s

s
h
o
u
l
d

w
a
r
r
a
n
t

s
u
b
s
e
q
u
e
n
t

a
n
g
i
o
g
r
a
p
h
y
7
3
C
o
r
r

P
1
9
9
9
S

A
f
r
i
c
a
n

M
e
d

J
o
u
r
n
a
l

8
9
:
6
4
4
-
6
I
I
D
u
p
l
e
x

i
s

a

r
e
a
s
o
n
a
b
l
e

s
c
r
e
e
n
i
n
g

t
e
s
t

f
o
r

p
e
n
e
t
r
a
t
i
n
g

a
r
t
e
r
i
a
l

i
n
j
u
r
i
e
s
.
7
4
G
r
a
c
i
a
s

V
H
2
0
0
1
A
r
c
h

S
u
r
g

1
3
6
:
1
2
3
1
-
5
I
I
I
C
T

i
n

s
t
a
b
l
e

s
e
l
e
c
t
e
d

p
a
t
i
e
n
t
s

w
i
t
h

p
e
n
e
t
r
a
t
i
n
g

n
e
c
k

t
r
a
u
m
a

a
p
p
e
a
r
s

s
a
f
e
.

I
n
v
a
s
i
v
e

s
t
u
d
i
e
s

c
a
n

o
f
t
e
n

b
e

e
l
i
m
i
n
a
t
e
d

w
h
e
n

C
T

d
e
m
o
n
s
t
r
a
t
e
s

t
r
a
j
e
c
t
o
r
i
e
s

r
e
m
o
t
e

f
r
o
m

v
i
t
a
l

s
t
r
u
c
t
u
r
e
s
.

F
u
r
t
h
e
r

p
r
o
s
p
e
c
t
i
v
e

s
t
u
d
y

o
f

C
T

s
c
a
n

a
f
t
e
r

p
e
n
e
t
r
a
t
i
n
g

n
e
c
k

t
r
a
u
m
a

i
s

n
e
e
d
e
d
.
7
5
M
u
n
e
r
a

F
2
0
0
0
R
a
d
i
o
l
o
g
y

2
1
6
:
3
5
6
-
6
2
I
I
T
h
e

s
e
n
s
i
t
i
v
i
t
y

a
n
d

s
p
e
c
i
f
i
c
i
t
y

o
f

h
e
l
i
c
a
l

C
T

a
n
g
i
o
g
r
a
p
h
y

a
r
e

h
i
g
h

f
o
r

d
e
t
e
c
t
i
o
n

o
f

m
a
j
o
r

c
a
r
o
t
i
d

a
n
d

v
e
r
t
e
b
r
a
l

a
r
t
e
r
i
a
l

i
n
j
u
r
i
e
s

r
e
s
u
l
t
i
n
g

f
r
o
m

p
e
n
e
t
r
a
t
i
n
g

t
r
a
u
m
a
.

T
h
e

e
n
t
i
r
e

n
e
c
k

m
u
s
t

b
e

i
n
c
l
u
d
e
d

i
n

t
h
e

e
x
a
m
i
n
a
t
i
o
n
.
7
6
M
u
n
e
r
a

F
2
0
0
2
R
a
d
i
o
l
o
g
y

2
2
4
:
3
6
6
-
7
2
I
I
I
H
e
l
i
c
a
l

C
T

a
n
g
i
o
g
r
a
p
h
y

c
a
n

b
e

r
e
l
i
a
b
l
y

u
s
e
d

t
o

e
v
a
l
u
a
t
e

p
e
n
e
t
r
a
t
i
n
g

n
e
c
k

t
r
a
u
m
a

i
n

t
h
e

s
t
a
b
l
e

p
a
t
i
e
n
t
.

P
a
t
i
e
n
t
s

w
i
t
h

b
r
u
i
t
s

o
r

t
h
r
i
l
l

a
t

a
d
m
i
s
s
i
o
n

m
a
y

b
e

b
e
t
t
e
r

m
a
n
a
g
e
d

b
y

c
o
n
v
e
n
t
i
o
n
a
l

a
n
g
i
o
g
r
a
p
h
y

b
e
c
a
u
s
e

o
f

t
h
e

l
i
k
e
l
i
h
o
o
d

o
f

e
n
d
o
v
a
s
c
u
l
a
r

t
h
e
r
a
p
y
.

H
e
l
i
c
a
l

C
T

a
n
g
i
o
g
r
a
p
h
y

i
s

l
i
m
i
t
e
d

b
y

a
r
t
i
f
a
c
t

d
u
e

t
o

m
e
t
a
l

w
h
i
c
h

m
a
y

o
b
s
c
u
r
e

a
r
t
e
r
i
a
l

s
e
g
m
e
n
t
s
;

t
h
e
r
e
f
o
r
e
,

t
h
e
s
e

p
a
t
i
e
n
t
s

s
h
o
u
l
d

u
n
d
e
r
g
o

c
o
n
v
e
n
t
i
o
n
a
l

a
n
g
i
o
g
r
a
p
h
y
.

S
u
b
t
l
e

l
e
s
i
o
n
s

s
u
c
h

a
s

i
n
t
i
m
a
l

f
l
a
p
s

m
a
y

b
e

m
i
s
s
e
d

b
y

h
e
l
i
c
a
l

C
T

a
n
g
i
o
g
r
a
p
h
y

t
h
e
r
e
f
o
r
e

u
n
d
e
r
e
s
t
i
m
a
t
i
n
g

t
h
e

t
o
t
a
l

n
u
m
b
e
r

o
f

i
n
j
u
r
i
e
s
.
7
7
M
a
z
o
l
e
w
s
k
i

P
J
2
0
0
1
J

T
r
a
u
m
a

5
1
:
3
1
5
-
9
I
I
C
T

i
s

g
o
o
d

a
n
d

c
a
n

b
e

u
s
e
d

t
o

e
l
i
m
i
n
a
t
e

t
h
e

n
e
e
d

f
o
r

m
a
n
d
a
t
o
r
y

e
x
p
l
o
r
a
t
i
o
n
.
7
8
S
p
l
e
n
e
r

C
W
1
9
7
6
A
r
c
h

S
u
r
g

1
1
1
:
6
6
3
-
7
I
I
I
E
a
r
l
y

s
i
g
n
s

w
e
r
e

s
u
b
t
l
e
.

S
m
a
l
l

a
m
o
u
n
t
s

o
f

m
e
d
i
a
s
t
i
n
a
l

a
n
d

c
e
r
v
i
c
a
l

a
i
r

t
e
n
d
e
d

t
o

b
e

o
v
e
r
l
o
o
k
e
d

o
r

e
r
r
o
n
e
o
u
s
l
y

a
t
t
r
i
b
u
t
e
d

t
o

o
t
h
e
r

c
a
u
s
e
s
,

s
u
c
h

a
s

a
s
s
o
c
i
a
t
e
d

p
n
e
u
m
o
t
h
o
r
a
x
.

O
n
c
e

s
u
s
p
e
c
t
e
d
,

t
h
e

p
o
s
s
i
b
i
l
i
t
y

o
f

e
s
o
p
h
a
g
e
a
l

d
i
s
r
u
p
t
i
o
n

w
a
s

n
o
t

a
l
w
a
y
s

p
u
r
s
u
e
d

w
i
t
h

o
p
t
i
m
u
m

v
i
g
o
r
.
P
a
g
e

7

o
f

1
3
T
a
b
l
e

1
.

E
v
i
d
e
n
t
i
a
r
y

T
a
b
l
e
7
9
A
s
e
n
s
i
o

J
A
1
9
9
7
J

T
r
a
u
m
a

4
3
:
3
1
9
-
2
4
I
I
I
E
s
o
p
h
a
g
e
a
l

i
n
j
u
r
i
e
s

c
a
r
r
y

a

h
i
g
h

m
o
r
b
i
d
i
t
y

a
n
d

m
o
r
t
a
l
i
t
y
.

T
h
o
u
g
h

t
h
e

s
a
m
p
l
e

s
i
z
e

i
s

s
m
a
l
l
,

t
h
e
r
e

d
o
e
s

a
p
p
e
a
r

t
o

b
e

a
n

i
n
c
r
e
a
s
e
d

m
o
r
b
i
d
i
t
y

a
s
s
o
c
i
a
t
e
d

w
i
t
h

t
h
e

d
i
a
g
n
o
s
t
i
c

w
o
r
k
u
p

a
n
d

i
t
s

i
n
h
e
r
e
n
t

d
e
l
a
y

i
n

o
p
e
r
a
t
i
v
e

r
e
p
a
i
r

o
f

t
h
e
s
e

i
n
j
u
r
i
e
s
.

F
o
r

c
e
n
t
e
r
s

p
r
a
c
t
i
c
i
n
g

s
e
l
e
c
t
i
v
e

m
a
n
a
g
e
m
e
n
t
,

r
a
p
i
d

d
i
a
g
n
o
s
i
s

a
n
d

d
e
f
i
n
i
t
i
v
e

r
e
p
a
i
r

s
h
o
u
l
d

b
e

m
a
d
e

a

h
i
g
h

p
r
i
o
r
i
t
y
.
8
0
A
s
e
n
s
i
o

J
A
2
0
0
1
J

T
r
a
u
m
a

5
0
:
2
8
9
-
9
6
I
I
P
r
e
o
p
e
r
a
t
i
v
e

e
v
a
l
u
a
t
i
o
n

f
o
r

e
s
o
p
h
a
g
e
a
l

i
n
j
u
r
i
e
s

s
h
o
u
l
d

b
e

c
a
r
r
i
e
d

o
u
t

e
x
p
e
d
i
t
i
o
u
s
l
y

t
o

a
v
o
i
d

d
e
l
a
y
s

t
h
a
t

a
r
e

d
e
t
r
i
m
e
n
t
a
l

t
o

t
h
e

p
a
t
i
e
n
t
.
8
1
H
a
t
z
i
t
h
e
o
f
i
l
o
u

C
1
9
9
3
B
r
i
t

J

S
u
r
g

8
0
:
1
1
4
7
-
9
I
I
I
D
i
a
g
n
o
s
e

a
n
d

r
e
p
a
i
r

e
s
o
p
h
a
g
e
a
l

i
n
j
u
r
i
e
s

e
a
r
l
y

(
l
e
s
s

t
h
a
n

2
4

h
r
s
)
.
8
2
S
y
m
b
a
s

P
N
1
9
8
0
A
n
n

S
u
r
g

1
9
1
:
7
0
3
-
7
I
I
I
P
e
r
f
o
r
m

E
G
D

i
n

p
a
t
i
e
n
t
s

w
i
t
h

m
i
s
s
i
l
e

t
r
a
j
e
c
t
o
r
y

n
e
a
r

t
h
e

e
s
o
p
h
a
g
u
s

i
r
r
e
s
p
e
c
t
i
v
e

o
f

p
h
y
s
i
c
a
l

s
i
g
n
s

o
f

e
s
o
p
h
a
g
e
a
l

i
n
j
u
r
y
.

R
e
p
a
i
r

a
l
l

i
n
j
u
r
i
e
s

w
i
t
h

p
l
i
c
a
t
i
o
n

i
n

a
d
d
i
t
i
o
n

t
o

p
r
i
m
a
r
y

r
e
p
a
i
r
.
8
3
C
h
e
a
d
l
e

J
1
9
8
2
S
u
r
g

G
y
n
e
c
o
l

O
b
s
t
e
t

1
5
5
:
3
8
0
-
4
I
I
I
R
e
p
a
i
r

e
s
o
p
h
a
g
e
a
l

i
n
j
u
r
i
e
s
.
8
4
S
h
a
m
a

D
M
1
9
8
4
B
r
i
t

J

S
u
r
g

7
1
:
5
3
4
-
6
I
I
I
T
r
a
c
h
e
a
l

w
o
u
n
d
s

a
r
e

u
s
u
a
l
l
y

r
e
c
o
g
n
i
z
e
d

e
a
r
l
y

b
u
t

c
e
r
v
i
c
a
l

e
s
o
p
h
a
g
e
a
l

i
n
j
u
r
i
e
s

a
r
e

n
o
t
.

E
a
r
l
y

r
e
c
o
g
n
i
t
i
o
n

&

r
e
f
e
r
r
a
l

a
r
e

a
s
s
o
c
i
a
t
e
d

w
i
t
h

l
o
w

m
o
r
b
i
d
i
t
y

&

m
o
r
t
a
l
i
t
y
.

L
a
t
e

r
e
c
o
g
n
i
t
i
o
n

&

r
e
f
e
r
r
a
l

c
a
r
r
y

a

h
i
g
h

m
o
r
b
i
d
i
t
y

a
n
d

m
o
r
t
a
l
i
t
y

r
a
t
e
.

8
5
P
o
p
o
v
s
k
y

J
1
9
8
4
J

T
r
a
u
m
a

2
4
:
3
3
7
-
9
I
I
I
D
u
e

t
o

e
x
t
e
n
s
i
v
e

t
i
s
s
u
e

d
a
m
a
g
e

i
n

G
S
W
s
,

p
r
i
m
a
r
y

r
e
p
a
i
r
s

o
f

t
h
o
r
a
c
i
c

e
s
o
p
h
a
g
e
a
l

p
e
r
f
o
r
a
t
i
o
n
s

h
a
v
e

a

h
i
g
h

i
n
c
i
d
e
n
c
e

o
f

f
a
i
l
u
r
e
.

D
e
f
u
n
c
t
i
o
n
a
l
i
z
a
t
i
o
n

o
f

t
h
e

e
s
o
p
h
a
g
u
s

t
h
r
o
u
g
h

l
i
g
a
t
i
o
n

o
f

t
h
e

d
i
s
t
a
l

e
s
o
p
h
a
g
u
s
,

g
a
s
t
r
o
s
t
o
m
y
,

a
n
d

c
e
r
v
i
c
a
l

e
s
o
p
h
a
g
o
s
t
o
m
y

p
r
o
v
i
d
e
s

a

s
a
f
e
r

m
e
t
h
o
d
.

U
s
e

o
f

a

d
o
u
b
l
e

s
t
r
a
n
d

o
f

a
b
s
o
r
b
a
b
l
e

D
e
x
o
n

t
o

l
i
g
a
t
e

t
h
e

d
i
s
t
a
l

e
s
o
p
h
a
g
u
s

m
a
k
e
s

a

s
e
c
o
n
d

t
h
o
r
a
c
o
t
o
m
y

u
n
n
e
c
e
s
s
a
r
y

f
o
r

l
i
g
a
t
u
r
e

r
e
m
o
v
a
l
.

R
o
u
t
i
n
e

u
s
e

o
f

h
y
p
e
r
a
l
i
m
e
n
t
a
t
i
o
n

a
v
o
i
d
s

t
h
e

n
e
e
d

f
o
r

f
e
e
d
i
n
g

j
e
j
u
n
o
s
t
o
m
y
.

A
l
l

p
a
t
i
e
n
t
s

w
i
t
h

c
e
r
v
i
c
a
l

e
s
o
p
h
a
g
e
a
l

l
e
s
i
o
n
s

a
r
e

r
o
u
t
i
n
e
l
y

e
x
p
l
o
r
e
d

t
h
r
o
u
g
h

a

p
r
e
-
s
t
e
r
n
o
c
l
e
i
d
o
m
a
s
t
o
i
d

i
n
c
i
s
i
o
n

o
n

t
h
e

s
i
d
e

o
f

t
h
e

i
n
j
u
r
y

a
n
d

t
h
e

p
e
r
f
o
r
a
t
i
o
n

c
l
o
s
e
d

w
i
t
h

t
w
o

l
a
y
e
r
s

o
f

n
o
n
a
b
s
o
r
b
a
b
l
e

m
o
n
o
f
i
l
a
m
e
n
t

a
n
d

d
r
a
i
n
e
d
.
8
6
A
r
m
s
t
r
o
n
g

W
B
1
9
9
4
A
n
n

O
t
o
l

R
h
i
n
o
l

L
a
r
y
n
g
o
l

1
0
3
:
8
6
3
-
7
1
I
I
I
T
r
e
a
t

a
s

p
h
a
r
y
n
g
e
a
l

i
n
j
u
r
i
e
s

a
n
d

r
e
p
a
i
r

p
r
i
m
a
r
i
l
y
.

D
i
v
e
r
s
i
o
n

l
e
a
d
s

t
o

c
o
m
p
l
i
c
a
t
i
o
n
s

s
u
c
h

a
s

s
t
r
i
c
t
u
r
e
s
.

8
7
S
t
a
n
l
e
y

R
B
1
9
9
7
J

T
r
a
u
m
a

4
2
:
6
7
5
-
9
I
I
I
I
n
j
u
r
i
e
s

l
o
c
a
t
e
d

i
n

t
h
e

u
p
p
e
r

p
o
r
t
i
o
n

o
f

t
h
e

h
y
p
o
p
h
a
r
y
n
x

c
a
n

b
e

r
o
u
t
i
n
e
l
y

m
a
n
a
g
e
d

w
i
t
h
o
u
t

s
u
r
g
i
c
a
l

i
n
t
e
r
v
e
n
t
i
o
n
.

N
e
c
k

e
x
p
l
o
r
a
t
i
o
n

a
n
d

a
d
e
q
u
a
t
e

d
r
a
i
n
a
g
e

o
f

t
h
e

d
e
e
p

n
e
c
k

s
p
a
c
e
s

a
r
e
,

h
o
w
e
v
e
r
,

m
a
n
d
a
t
o
r
y

f
o
r

a
l
l

p
e
n
e
t
r
a
t
i
n
g

i
n
j
u
r
i
e
s

i
n
t
o

t
h
e

c
e
r
v
i
c
a
l

e
s
o
p
h
a
g
u
s

a
n
d

m
o
s
t

i
n
j
u
r
i
e
s

i
n
t
o

t
h
e

l
o
w
e
r

p
o
r
t
i
o
n

o
f

t
h
e

h
y
p
o
p
h
a
r
y
n
x
.
8
8
M
a
d
i
b
a

T
E
2
0
0
3
A
n
n

R
o
y
a
l

C
o
l
l

S
u
r
g

E
n
g
l

8
5
:
1
6
2
-
6
I
I
I
N
o
n
-
o
p
e
r
a
t
i
v
e

m
a
n
a
g
e
m
e
n
t

o
f

p
e
n
e
t
r
a
t
i
n
g

i
n
j
u
r
i
e
s

t
o

t
h
e

c
e
r
v
i
c
a
l

e
s
o
p
h
a
g
u
s

i
s

s
a
f
e

a
n
d

e
f
f
e
c
t
i
v
e
.
P
a
g
e

8

o
f

1
3
T
a
b
l
e

1
.

E
v
i
d
e
n
t
i
a
r
y

T
a
b
l
e
8
9
M
i
n
a
r
d

G
1
9
9
2
A
m

S
u
r
g

5
8
:
1
8
1
-
7
I
I
I
L
a
r
y
n
g
o
t
r
a
c
h
e
a
l

t
r
a
u
m
a

u
s
u
a
l
l
y

p
r
e
s
e
n
t
s

w
i
t
h

s
y
m
p
t
o
m
s

a
n
d
/
o
r

s
i
g
n
s
,

b
u
t

t
h
e
y

m
a
y

b
e

m
i
n
i
m
a
l

a
n
d

n
o
n
s
p
e
c
i
f
i
c
.

E
m
e
r
g
e
n
c
y

t
r
a
c
h
e
o
s
t
o
m
y

s
h
o
u
l
d

n
o
t

b
e

d
e
l
a
y
e
d

i
f

v
e
n
t
i
l
a
t
i
o
n

i
s

c
o
m
p
r
o
m
i
s
e
d
.

C
o
n
c
o
m
i
t
a
n
t

e
s
o
p
h
a
g
e
a
l

i
n
j
u
r
i
e
s

a
r
e

f
r
e
q
u
e
n
t

a
n
d

p
r
e
d
i
s
p
o
s
e

t
h
e

p
a
t
i
e
n
t

t
o

p
o
s
t
o
p
e
r
a
t
i
v
e

c
o
m
p
l
i
c
a
t
i
o
n
s
.

A
i
r
w
a
y

c
o
m
p
r
o
m
i
s
e

f
r
e
q
u
e
n
t
l
y

c
o
r
r
e
l
a
t
e
s

w
i
t
h

s
e
v
e
r
i
t
y

o
f

i
n
j
u
r
y

a
n
d

r
i
s
k

f
o
r

c
o
m
p
l
i
c
a
t
i
o
n
s
.
9
0
G
r
e
w
a
l

H
1
9
9
5
H
e
a
d

N
e
c
k

1
7
:
4
9
4
-
5
0
2
I
I
I
E
n
d
o
t
r
a
c
h
e
a
l

i
n
t
u
b
a
t
i
o
n

c
a
n

b
e

a
c
c
o
m
p
l
i
s
h
e
d

s
a
f
e
l
y

i
n

s
e
l
e
c
t
e
d

p
a
t
i
e
n
t
s

w
i
t
h

p
e
n
e
t
r
a
t
i
n
g

l
a
r
y
n
g
o
t
r
a
c
h
e
a
l

i
n
j
u
r
i
e
s
.

D
i
g
e
s
t
i
v
e

t
r
a
c
t

i
n
j
u
r
i
e
s

c
a
n

o
f
t
e
n

b
e

c
l
i
n
i
c
a
l
l
y

o
c
c
u
l
t

&

e
a
r
l
y

e
v
a
l
u
a
t
i
o
n

o
f

t
h
e

e
s
o
p
h
a
g
u
s

i
s

v
i
t
a
l
.

I
n

p
a
t
i
e
n
t
s

w
i
t
h

m
i
n
o
r

i
n
j
u
r
i
e
s
,

t
r
a
c
h
e
o
s
t
o
m
y

d
o
e
s

n
o
t

a
p
p
e
a
r

t
o

b
e

m
a
n
d
a
t
o
r
y
.
9
1
W
e
i
g
e
l
t

J
A
1
9
8
7
A
m

J

S
u
r
g

1
5
4
:
6
1
9
-
2
2
I
I
I
F
o
r

s
e
l
e
c
t
i
v
e

m
a
n
a
g
e
m
e
n
t
,

a
r
t
e
r
i
o
g
r
a
p
h
y
,

e
s
o
p
h
a
g
o
g
r
a
p
h
y

a
n
d

r
i
g
i
d

e
s
o
p
h
a
g
o
s
c
o
p
y

(
i
f

e
s
o
p
h
a
g
r
a
m

i
s

e
q
u
i
v
o
c
a
l
)

a
r
e

n
e
c
e
s
s
a
r
y

t
o

r
u
l
e

o
u
t

i
n
j
u
r
i
e
s

t
h
a
t

r
e
q
u
i
r
e

e
x
p
l
o
r
a
t
i
o
n
.
9
2
W
o
o
d

J
1
9
8
9
J

T
r
a
u
m
a

2
9
:
6
0
2
-
5
I
I
I
U
n
s
t
a
b
l
e

p
a
t
i
e
n
t
s

r
e
q
u
i
r
e

i
m
m
e
d
i
a
t
e

e
x
p
l
o
r
a
t
i
o
n
.

S
t
a
b
l
e

p
a
t
i
e
n
t
s

w
i
t
h

e
q
u
i
v
o
c
a
l

p
h
y
s
i
c
a
l

f
i
n
d
i
n
g
s

c
a
n

b
e

m
a
n
a
g
e
d

a
c
c
o
r
d
i
n
g

t
o

r
e
s
u
l
t
s

o
f

e
s
o
p
h
a
g
e
a
l

e
x
a
m
i
n
a
t
i
o
n

a
n
d

a
n
g
i
o
g
r
a
p
h
y
.

P
a
t
i
e
n
t
s

w
i
t
h

l
o
w

p
r
o
b
a
b
i
l
i
t
y

o
f

i
n
j
u
r
y

d
u
e

t
o

l
o
c
a
t
i
o
n

&

c
l
i
n
i
c
a
l

p
r
e
s
e
n
t
a
t
i
o
n

c
a
n

b
e

o
b
s
e
r
v
e
d
.

R
e
g
a
r
d
l
e
s
s

o
f

m
e
t
h
o
d

o
f

m
a
n
a
g
e
m
e
n
t
,

t
h
o
s
e

w
i
t
h

a

p
o
s
s
i
b
i
l
i
t
y

o
f

e
s
o
p
h
a
g
e
a
l

i
n
j
u
r
y

s
h
o
u
l
d

u
n
d
e
r
g
o

e
s
o
p
h
a
g
r
a
m

a
n
d
/
o
r

e
s
o
p
h
a
g
o
s
c
o
p
y
.
9
3
N
g
a
k
a
n
e

H
1
9
9
0
B
r
i
t

J

S
u
r
g

7
7
:
9
0
8
-
1
0
I
I
I
T
r
a
c
h
e
a
l

i
n
j
u
r
y

i
n

t
h
e

a
b
s
e
n
c
e

o
f

l
i
f
e
-
t
h
r
e
a
t
e
n
i
n
g

a
i
r
w
a
y

p
r
o
b
l
e
m
s

c
a
n

b
e

t
r
e
a
t
e
d

s
u
c
c
e
s
s
f
u
l
l
y

w
i
t
h

a

c
o
n
s
e
r
v
a
t
i
v
e

a
p
p
r
o
a
c
h
.

P
a
t
i
e
n
t
s

w
i
t
h

m
i
n
i
m
a
l

s
y
m
p
t
o
m
s

o
f

v
i
s
c
e
r
a
l

i
n
j
u
r
y

f
o
l
l
o
w
i
n
g

p
e
n
e
t
r
a
t
i
n
g

c
e
r
v
i
c
a
l

t
r
a
u
m
a

m
a
y

b
e

s
e
l
e
c
t
e
d

f
o
r

f
u
r
t
h
e
r

e
v
a
l
u
a
t
i
o
n

b
a
s
e
d

o
n

t
h
e

s
i
m
p
l
e

w
a
t
e
r

s
w
a
l
l
o
w
i
n
g

t
e
s
t
.

A

s
e
v
e
r
e

p
a
i
n

r
e
s
p
o
n
s
e

o
n

s
w
a
l
l
o
w
i
n
g

s
h
o
u
l
d

e
l
i
c
i
t

a

c
o
n
t
r
a
s
t

s
w
a
l
l
o
w
.

P
a
t
i
e
n
t
s

w
i
t
h

a

n
o
r
m
a
l

s
t
u
d
y

a
n
d

t
h
o
s
e

w
i
t
h

m
i
n
i
m
a
l

l
e
a
k
a
g
e

o
f

c
o
n
t
r
a
s
t

m
a
t
e
r
i
a
l

c
a
n

b
e

m
a
n
a
g
e
d

n
o
n
-
o
p
e
r
a
t
i
v
e
l
y

h
a
v
i
n
g

a

r
e
p
e
a
t

e
x
a
m

o
n

d
a
y

5
.
9
4
S
r
i
n
i
v
a
s
a
n

R
2
0
0
0
A
m

J

G
a
s
t
r
o
e
n
t
e
r
o
l

9
5
:
1
7
2
5
-
9
I
I
I
E
n
d
o
s
c
o
p
y

i
s

a

s
a
f
e

a
n
d

r
e
l
i
a
b
l
e

m
e
t
h
o
d

f
o
r

e
v
a
l
u
a
t
i
n
g

t
h
e

e
s
o
p
h
a
g
u
s

f
o
r

p
e
n
e
t
r
a
t
i
n
g

t
r
a
u
m
a
.
.
9
5
M
c
C
o
r
m
i
c
k

T
M
1
9
7
9
J

T
r
a
u
m
a

1
9
:
3
8
4
-
7
I
I
P
h
y
s
i
c
a
l

e
x
a
m
i
n
t
a
i
o
n

i
s

u
n
r
e
l
i
a
b
l
e

i
n

r
u
l
i
n
g

i
n

o
r

o
u
t

v
a
s
c
u
l
a
r

t
r
a
u
m
a
,

a
l
t
h
o
u
g
h

n
o

s
u
b
c
a
t
e
g
o
r
i
z
a
t
i
o
n

o
f

n
e
c
k

a
n
d

e
x
t
r
e
m
i
t
y

i
n
j
u
r
i
e
s

w
a
s

d
o
n
e
,

n
o
r

w
a
s

t
h
e
r
e

a

d
e
s
c
r
i
p
t
i
o
n

o
f

h
o
w

s
e
r
i
o
u
s

t
h
e

m
i
s
s
e
d

i
n
j
u
r
i
e
s

w
e
r
e
.
9
6
M
e
t
z
d
o
r
f
f

M
T
1
9
8
4
A
m

J

S
u
r
g

1
4
7
:
6
4
6
-
9
I
I
I
C
l
i
n
i
c
a
l

f
i
n
d
i
n
g
s

a
r
e

a

r
e
l
i
a
b
l
e

i
n
d
i
c
a
t
o
r

o
f

s
i
g
n
i
f
i
c
a
n
t

t
r
a
u
m
a
.
P
a
g
e

9

o
f

1
3
T
a
b
l
e

1
.

E
v
i
d
e
n
t
i
a
r
y

T
a
b
l
e
9
7
A
p
f
f
e
l
s
t
a
e
d
t

J
P
1
9
9
4
W
o
r
l
d

J

S
u
r
g

1
8
:
9
1
7
-
9
I
I
I
P
h
y
s
i
c
a
l

e
x
a
m
i
n
a
t
i
o
n

d
o
e
s

n
o
t

h
e
l
p

d
e
t
e
r
m
i
n
e

w
h
i
c
h

p
a
t
i
e
n
t
s

h
a
v
e

l
i
f
e
-
t
h
r
e
a
t
e
n
i
n
g

i
n
j
u
r
i
e
s
.

M
a
n
d
a
t
o
r
y

e
x
p
l
o
r
a
t
i
o
n

i
s

r
e
c
o
m
m
e
n
d
e
d
.
9
8
D
e
m
e
t
r
i
a
d
e
s

D
1
9
9
3
B
r

J

S
u
r
g

8
0
:
1
5
3
4
-
6
I
I
P
h
y
s
i
c
a
l

e
x
a
m
i
n
a
t
i
o
n

i
s

r
e
l
i
a
b
l
e

i
n

d
e
t
e
c
t
i
n
g

s
i
g
n
i
f
i
c
a
n
t

i
n
j
u
r
i
e
s

i
n

p
e
n
e
t
r
a
t
i
n
g

n
e
c
k

t
r
a
u
m
a
.
9
9
G
e
r
s
t

P
H
1
9
9
0
A
m

S
u
r
g

5
6
:
5
5
3
-
5
I
I
S
e
l
e
c
t
i
v
e

m
a
n
a
g
e
m
e
n
t
,

w
h
e
n

g
u
i
d
e
d

b
y

r
e
p
e
a
t
e
d
,

c
a
r
e
f
u
l

e
x
a
m
i
n
a
t
i
o
n
s
,

i
s

s
a
f
e

a
n
d

a
v
o
i
d
s

u
n
n
e
c
e
s
s
a
r
y

o
p
e
r
a
t
i
o
n
s
.
1
0
0
B
e
i
t
s
c
h

P
1
9
9
4
A
r
c
h

S
u
r
g

1
2
9
:
5
7
7
-
8
1
I
I
I
N
e
i
t
h
e
r

m
a
n
d
a
t
o
r
y

n
e
c
k

e
x
p
l
o
r
a
t
i
o
n

n
o
r

m
a
n
d
a
t
o
r
y

a
r
t
e
r
i
o
g
r
a
p
h
y

i
s

n
e
c
e
s
s
a
r
y
.

P
h
y
s
i
c
a
l

e
x
a
m
i
n
a
t
i
o
n

s
h
o
u
l
d

b
e

u
s
e
d

t
o

a
s
s
e
s
s

f
o
r

p
o
s
s
i
b
i
l
i
t
y

o
f

i
n
j
u
r
y

i
n

p
e
n
e
t
r
a
t
i
n
g

n
e
c
k

t
r
a
u
m
a
.
1
0
1
A
t
t
e
b
e
r
r
y

L
R
1
9
9
4
J

A
m

C
o
l
l

S
u
r
g

1
7
9
:
6
5
7
-
6
2
I
I
V
a
s
c
u
l
a
r

i
n
j
u
r
y

c
a
n

b
e

e
x
c
l
u
d
e
d

b
y

p
h
y
s
i
c
a
l

e
x
a
m
.
1
0
2
S
e
k
h
a
r
a
n

J
2
0
0
0
J

V
a
s
c

S
u
r
g

3
2
:
4
8
3
-
9
I
I

P
a
t
i
e
n
t
s

w
i
t
h

Z
o
n
e

I
I

p
e
n
e
t
r
a
t
i
n
g

n
e
c
k

w
o
u
n
d
s

c
a
n

b
e

s
a
f
e
l
y

a
n
d

a
c
c
u
r
a
t
e
l
y
e
v
a
l
u
a
t
e
d

b
y

p
h
y
s
i
c
a
l

e
x
a
m
i
n
a
t
i
o
n

a
l
o
n
e
.

T
h
e

m
i
s
s
e
d

i
n
j
u
r
y

r
a
t
e

i
s

0
.
7
%

(
1
/
1
4
5
)
,

w
h
i
c
h

i
s

c
o
m
p
a
r
a
b
l
e

t
o

a
n
g
i
o
g
r
a
p
h
y

i
n

a
c
c
u
r
a
c
y
,

b
u
t

l
e
s
s

c
o
s
t
l
y

a
n
d

n
o
n
-
i
n
v
a
s
i
v
e
.
1
0
3
A
z
u
a
j
e

R
E
2
0
0
3
A
m

S
u
r
g

6
9
:
8
0
4
-
7
I
I
I
R
o
u
t
i
n
e

a
n
g
i
o
g
r
a
p
h
y

m
a
y

b
e

u
n
n
e
c
e
s
s
a
r
y

f
o
r

p
a
t
i
e
n
t
s

w
i
t
h

p
e
n
e
t
r
a
t
i
n
g

n
e
c
k

i
n
j
u
r
i
e
s

a
n
d

a

n
e
g
a
t
i
v
e

p
h
y
s
i
c
a
l

e
x
a
m
.
1
0
4
G
o
u
d
y

S
L
2
0
0
2
L
a
r
y
n
g
o
s
c
o
p
e

1
1
2
:
7
9
1
-
5
I
I
I
B
l
u
n
t

t
r
a
u
m
a

c
a
n

r
e
s
u
l
t

i
n

p
e
r
f
o
r
a
t
i
o
n

o
f

t
h
e

a
e
r
o
d
i
g
e
s
t
i
v
e

t
r
a
c
t
.

S
o
m
e

s
t
a
b
l
e

p
a
t
i
e
n
t
s

w
i
t
h

e
v
i
d
e
n
c
e

o
f

u
p
p
e
r

a
e
r
o
d
i
g
e
s
t
i
v
e

t
r
a
c
t

i
n
j
u
r
y

c
a
n

b
e

m
a
n
a
g
e
d

w
i
t
h
o
u
t

s
u
r
g
e
r
y
,

b
u
t

a

h
i
g
h

i
n
d
e
x

o
f

s
u
s
p
i
c
i
o
n

f
o
r

a
i
r
w
a
y

c
o
m
p
r
o
m
i
s
e

a
n
d

a
s
s
o
c
i
a
t
e
d

f
a
c
i
a
l

i
n
j
u
r
i
e
s

m
u
s
t

b
e

c
o
n
s
i
d
e
r
e
d
.

F
l
e
x
i
b
l
e

a
n
d

d
i
r
e
c
t

l
a
r
y
n
g
o
s
c
o
p
y

a
n
d

e
s
o
p
h
a
g
o
s
c
o
p
y

a
r
e

h
i
g
h
l
y

r
e
c
o
m
m
e
n
d
e
d
.

M
o
s
t

o
f

t
h
e

l
a
c
e
r
a
t
i
o
n
s

i
d
e
n
t
i
f
i
e
d

a
r
e

1

t
o

2

c
m

i
n

d
i
a
m
e
t
e
r
.

C
o
n
t
r
a
r
y

t
o

p
r
e
v
i
o
u
s

s
t
u
d
i
e
s
,

p
a
t
i
e
n
t
s

w
i
t
h

t
h
e
s
e

i
n
j
u
r
i
e
s

c
a
n

b
e

m
a
n
a
g
e
d

s
u
c
c
e
s
s
f
u
l
l
y

w
i
t
h
o
u
t

s
u
r
g
i
c
a
l

e
x
p
l
o
r
a
t
i
o
n
.

E
a
c
h

p
a
t
i
e
n
t

m
u
s
t

b
e

c
l
o
s
e
l
y

f
o
l
l
o
w
e
d

a
n
d

e
l
e
c
t
i
v
e

n
e
c
k

e
x
p
l
o
r
a
t
i
o
n

u
n
d
e
r
t
a
k
e
n

w
h
e
n

s
e
p
s
i
s

i
s

s
u
s
p
e
c
t
e
d

o
r

a

v
a
s
c
u
l
a
r

i
n
j
u
r
y

i
s

e
v
i
d
e
n
t
.
1
0
5
G
o
n
z
a
l
e
z

R
P
2
0
0
3
J

T
r
a
u
m
a

5
4
:
6
1
-
4
I
I
C
T

s
c
a
n

d
o
e
s

n
o
t

a
p
p
e
a
r

t
o

c
o
n
t
r
i
b
u
t
e

t
o

t
h
e

d
i
a
g
n
o
s
t
i
c

s
e
n
s
i
t
i
v
i
t
y

o
f

p
h
y
s
i
c
a
l

e
x
a
m
i
n
a
t
i
o
n

f
o
r

t
h
e

d
i
a
g
n
o
s
i
s

o
f

s
u
r
g
i
c
a
l
l
y

s
i
g
n
i
f
i
c
a
n
t

a
i
r
w
a
y

o
r

a
r
t
e
r
i
a
l

i
n
j
u
r
y
.

C
T

d
o
e
s

i
m
p
r
o
v
e

t
h
e

d
i
a
g
n
o
s
t
i
c

s
e
n
s
i
t
i
v
i
t
y

o
f

p
h
y
s
i
c
a
l

e
x
a
m

f
o
r

v
e
n
o
u
s

i
n
j
u
r
y
.
1
0
6
T
h
a
v
e
n
d
r
a
n

A
1
9
7
5
I
n
j
u
r
y

7
:
5
8
-
6
0
I
I
I
W
h
e
n

a
d
e
q
u
a
t
e

e
x
p
o
s
u
r
e

c
a
n
n
o
t

b
e

o
b
t
a
i
n
e
d

b
y

e
x
p
l
o
r
a
t
i
o
n

o
f

t
h
e

n
e
c
k
,

m
e
d
i
a
n

s
t
e
r
n
o
t
o
m
y

o
r

a
n
t
e
r
i
o
r

t
h
o
r
a
c
o
t
o
m
y

i
s

a
d
v
i
s
a
b
l
e
.
P
a
g
e

1
0

o
f

1
3
T
a
b
l
e

1
.

E
v
i
d
e
n
t
i
a
r
y

T
a
b
l
e
1
0
7
W
e
a
v
e
r

F
A
1
9
8
8
A
r
c
h

S
u
r
g

1
2
3
:
1
1
0
6
-
1
1
I
I
A
r
t
e
r
i
a
l

r
e
c
o
n
s
t
r
u
c
t
i
o
n

i
s

t
h
e

o
p
t
i
m
a
l

f
o
r
m

o
f

t
r
e
a
t
m
e
n
t

f
o
r

c
a
r
o
t
i
d

a
r
t
e
r
y

i
n
j
u
r
i
e
s
,

e
v
e
n

w
i
t
h

m
o
d
e
r
a
t
e

t
o

s
e
v
e
r
e

n
e
u
r
o
l
o
g
i
c
a
l

d
e
f
i
c
i
t
s
,

i
n
c
l
u
d
i
n
g

c
o
m
a
.

T
h
e

f
e
a
r

o
f

r
e
v
a
s
c
u
l
a
r
i
z
a
t
i
o
n

w
i
t
h

s
e
v
e
r
e

n
e
u
r
o
l
o
g
i
c
a
l

d
e
f
i
c
i
t
s

a
n
d

t
r
a
n
s
f
o
r
m
i
n
g

a
n

i
s
c
h
e
m
i
c

i
n
f
a
r
c
t

i
n
t
o

a

h
e
m
o
r
r
h
a
g
i
c

o
n
e

w
a
s

n
o
t

s
u
p
p
o
r
t
e
d

b
y

t
h
i
s

d
a
t
a
.

T
h
e

m
a
j
o
r

d
e
t
e
r
m
i
n
a
n
t

o
f

m
o
r
b
i
d
i
t
y

a
n
d

m
o
r
t
a
l
i
t
y

i
s

t
h
e

i
s
c
h
e
m
i
c

i
n
s
u
l
t

a
n
d

n
o
t

r
e
p
e
r
f
u
s
i
o
n

h
e
m
o
r
r
h
a
g
e
.
1
0
8
K
h
o
u
r
y

G
1
9
9
0
E
u
r
o

J

V
a
s
c

S
u
r
g

4
:
6
0
7
-
1
0
I
I
I
C
a
r
o
t
i
d

a
r
t
e
r
y

i
n
j
u
r
y

s
e
e
m
s

t
o

h
a
v
e

a

g
o
o
d

p
r
o
g
n
o
s
i
s

i
f

r
e
p
a
i
r
e
d

p
r
o
m
p
t
l
y

w
i
t
h
i
n

3

h
.
1
0
9
R
a
o

P
M
1
9
9
3
S
u
r
g
e
r
y

1
1
4
:
5
2
7
-
3
1
I
I
F
o
r

s
t
a
b
l
e

p
t
s

w
i
t
h

p
e
n
e
t
r
a
t
i
n
g

n
e
c
k

t
r
a
u
m
a
,

a
n
g
i
o
g
r
a
p
h
y

s
h
o
u
l
d

b
e

d
o
n
e
.

I
n
j
u
r
i
e
s

t
o

c
o
m
m
o
n

a
n
d

i
n
t
e
r
n
a
l

c
a
r
o
t
i
d

a
r
t
e
r
i
e
s

s
h
o
u
l
d

b
e

r
e
p
a
i
r
e
d

i
f

p
o
s
s
i
b
l
e
.

O
t
h
e
r
w
i
s
e

i
f

n
o

p
r
e
o
p

n
e
u
r
o
l
o
g
i
c

d
e
f
i
c
i
t

i
s

p
r
e
s
e
n
t

t
h
e
s
e

v
e
s
s
e
l
s

c
a
n

b
e

l
i
g
a
t
e
d
.
1
1
0
K
u
e
h
n
e

J
P
1
9
9
6
A
r
c
h

S
u
r
g

1
3
1
:
9
4
2
-
7
I
I
I
P
a
t
i
e
n
t
s

w
i
t
h

p
o
s
s
i
b
l
e

p
e
n
e
t
r
a
t
i
n
g

i
n
t
e
r
n
a
l

c
a
r
o
t
i
d

a
r
t
e
r
y

i
n
j
u
r
i
e
s

s
h
o
u
l
d

b
e

m
a
n
a
g
e
d

w
i
t
h

a
n

a
l
g
o
r
i
t
h
m

p
r
e
d
i
c
a
t
e
d

o
n

t
h
e

l
i
b
e
r
a
l

u
s
e

o
f

a
n
g
i
o
g
r
a
p
h
y
,

s
t
a
n
d
a
r
d
i
z
e
d

s
u
r
g
i
c
a
l

r
e
p
a
i
r
,

a
n
d

o
b
s
e
r
v
a
t
i
o
n

o
f

s
e
l
e
c
t
e
d

i
n
j
u
r
i
e
s
.

C
e
r
e
b
r
o
v
a
s
c
u
l
a
r

m
o
r
b
i
d
i
t
y

i
s

m
o
r
e

c
o
m
m
o
n
l
y

c
e
r
e
b
r
a
l

e
d
e
m
a

a
n
d

h
e
r
n
i
a
t
i
o
n
,

n
o
t

h
e
m
o
r
r
h
a
g
i
c

i
n
f
a
r
c
t
i
o
n
.

A
r
t
e
r
i
a
l

r
e
c
o
n
s
t
r
u
c
t
i
o
n

i
s

t
h
e

o
p
t
i
m
a
l

f
o
r
m

o
f

t
r
e
a
t
m
e
n
t

f
o
r

c
a
r
o
t
i
d

a
r
t
e
r
y

i
n
j
u
r
i
e
s
,

e
v
e
n

w
i
t
h

m
o
d
e
r
a
t
e

t
o

s
e
v
e
r
e

n
e
u
r
o
l
o
g
i
c
a
l

d
e
f
i
c
i
t
s
,

i
n
c
l
u
d
i
n
g

c
o
m
a
.

T
h
e

f
e
a
r

o
f

t
r
a
n
s
f
o
r
m
i
n
g

a
n

i
s
c
h
e
m
i
c

i
n
f
a
r
c
t
i
o
n

i
n
t
o

a

h
e
m
o
r
r
h
a
g
i
c

o
n
e

b
y

r
e
v
a
s
c
u
l
a
r
i
z
a
t
i
o
n

a
p
p
e
a
r
s

t
o

b
e

o
v
e
r

e
s
t
i
m
a
t
e
d
.

O
c
c
l
u
s
i
v
e

i
n
j
u
r
i
e
s

i
n

w
h
i
c
h

d
i
a
g
n
o
s
t
i
c

a
n
g
i
o
g
r
a
p
h
y

d
e
m
o
s
t
r
a
t
e
s

d
i
s
t
a
l

v
e
s
s
e
l

i
n
v
o
l
v
e
m
e
n
t

o
r

t
h
a
t

c
a
n
n
o
t

b
e

r
e
p
a
i
r
e
d
,

l
i
g
a
t
i
o
n

i
s

a
c
c
e
p
t
a
b
l
e
.

S
m
a
l
l

i
n
j
u
r
i
e
s

t
o

t
h
e

c
o
m
m
o
n

o
r

i
n
t
e
r
n
a
l

c
a
r
o
t
i
d

a
r
t
e
r
i
e
s

w
i
t
h

m
i
n
i
m
a
l

i
n
t
i
m
a
l

i
r
r
e
g
u
l
a
r
i
t
i
e
s

o
r

s
m
a
l
l

p
s
e
u
d
o
a
n
e
u
r
y
s
m
s

c
a
n

b
e

e
x
p
e
c
t
a
n
t
l
y

m
a
n
a
g
e
d

b
y

s
e
r
i
a
l

a
n
g
i
o
g
r
a
p
h
y
.

1
1
1
M
i
t
t
a
l

V
K
2
0
0
0
J

C
a
r
d
i
o
v
a
s
c

S
u
r
g

4
1
:
4
2
3
-
3
1
I
I
I
G
r
a
d
i
n
g

s
y
s
t
e
m

m
a
y

h
e
l
p

i
m
p
r
o
v
e

t
h
e

u
n
d
e
r
s
t
a
n
d
a
b
i
l
i
t
y

o
f

l
i
t
e
r
a
t
u
r
e

r
e
g
a
r
d
i
n
g

t
h
e
s
e

i
n
j
u
r
i
e
s

a
n
d

h
e
l
p

s
t
a
n
d
a
r
d
i
z
e

m
a
n
a
g
e
m
e
n
t
.
1
1
2
D
i
a
z
-
D
a
z
a

O
2
0
0
3
C
a
r
d
i
o
v
a
s
c

I
n
t
e
r
v
e
n
t

R
a
d
i
o
l

2
6
:
2
1
3
-
2
1
I
I
I
A
n
g
i
o
g
r
a
p
h
i
c

t
e
c
h
n
i
q
u
e
s

a
r
e

s
u
c
c
e
s
s
f
u
l

f
o
r

p
e
n
e
t
r
a
t
i
n
g

v
a
s
c
u
l
a
r

i
n
j
u
r
i
e
s

o
f

t
h
e

h
e
a
d

a
n
d

n
e
c
k
.
1
1
3
D
e
b
r
u
n

G
1
9
7
9
R
a
d
i
o
l
o
g
y

1
3
0
:
1
4
1
-
7
I
I
I
S
m
a
l
l

c
a
s
e

s
e
r
i
e
s

d
e
s
c
r
i
b
i
n
g

a
n

e
n
d
o
v
a
s
c
u
l
a
r

t
e
c
h
n
i
q
u
e

f
o
r

t
r
e
a
t
m
e
n
t

o
f

c
a
r
o
t
i
d

c
a
v
e
r
n
o
u
s

s
i
n
u
s

a
n
d

v
e
r
t
e
b
r
a
l

f
i
s
t
u
l
a
e
1
1
4
H
a
l
b
a
c
h

V
V
1
9
8
8
A
m

J

R
o
e
n
t
g
e
n
o
l

1
5
0
:
4
0
5
-
1
2
I
I
I
T
r
a
n
s
v
a
s
c
u
l
a
r

t
e
c
h
n
i
q
u
e

f
o
r

r
e
p
a
i
r

o
f

v
e
r
t
e
b
r
a
l

a
r
t
e
r
i
o
v
e
n
o
u
s

f
i
s
t
u
l
a
s

i
s

o
k
P
a
g
e

1
1

o
f

1
3
T
a
b
l
e

1
.

E
v
i
d
e
n
t
i
a
r
y

T
a
b
l
e
1
1
5
G
o
l
u
e
k
e

P
1
9
8
7
J

T
r
a
u
m
a

2
7
:
8
5
6
-
6
5
I
I
I
A
n
g
i
o
g
r
a
p
h
y

i
s

g
o
o
d
.

E
m
b
o
l
i
z
a
t
i
o
n

i
s

s
a
f
e

i
f

t
h
e
r
e

i
s

a

p
a
t
e
n
t

p
o
s
t
e
r
i
o
r

i
n
f
e
r
i
o
r

c
e
r
e
b
e
l
l
a
r

a
r
t
e
r
y
.

A
n
t
e
r
i
o
r

a
p
p
r
o
a
c
h

t
o

C
1
-
2

i
s

s
a
t
i
s
f
a
c
t
o
r
y
.
1
1
6
A
l
b
u
q
u
e
r
q
u
e

F
C
2
0
0
2
J

T
r
a
u
m
a

5
3
:
5
7
4
-
8
0
I
I
I
E
n
d
o
v
a
s
u
l
a
r

t
e
c
h
n
i
q
u
e
s

a
l
l
o
w

d
e
l
i
n
i
n
e
a
t
i
o
n

o
f

A
V

f
i
s
t
u
l
a
e

f
l
o
w

p
a
t
t
e
r
n
s
.

B
a
l
l
o
o
n

o
c
c
l
u
s
i
o
n

t
e
c
h
n
i
q
u
e
s

o
f
f
e
r

o
t
h
e
r

a
d
v
a
n
t
a
g
e
s

i
n

t
h
e

m
a
n
a
g
e
m
e
n
t

o
f

p
e
n
e
t
r
a
t
i
n
g

v
e
r
t
e
b
r
a
l

a
r
t
e
r
y

i
n
j
u
r
i
e
s
.

P
e
r
m
a
n
e
n
t

b
a
l
l
o
o
n

d
e
p
o
s
i
t
i
o
n

i
s

a
n

e
f
f
e
c
t
i
v
e

m
e
t
h
o
d

o
f

o
c
c
l
u
d
i
n
g

t
h
e

a
n

i
n
j
u
r
e
d

a
r
t
e
r
y

a
t

t
h
e

s
i
t
e

o
f

a

f
i
s
t
u
l
a

o
r

i
n

t
h
e

r
e
g
i
o
n

o
f

s
u
s
p
e
c
t
e
d

a
c
t
i
v
e

h
e
m
o
r
r
h
a
g
e
.

T
e
m
p
o
r
a
r
y

b
a
l
l
o
o
n

o
c
c
l
u
s
i
o
n

m
a
y

a
l
s
o

b
e

u
s
e
d

t
o

d
e
f
i
n
e

t
h
e

l
u
m
e
n

o
f

t
h
e

p
a
r
e
n
t

v
e
s
s
e
l

a
n
d

a
s
a
n
o
t
h
e
r

m
e
a
n
s

o
f

p
r
e
v
e
n
t
i
n
g

c
o
i
l

h
e
r
n
i
a
t
i
o
n

i
n
t
o

t
h
e

n
o
r
m
a
l

a
r
t
e
r
y

d
u
r
i
n
g

e
m
b
o
l
i
z
a
t
i
o
n

f
o
r

c
o
m
p
l
e
x

p
s
e
u
d
o
a
n
e
u
r
y
s
m
s
.
1
1
7
B
e
n
-
M
e
n
a
c
h
e
m

Y
1
9
8
7
A
m

J

N
e
u
r
o
r
a
d

8
:
5
0
1
-
7
I
I
I
V
e
r
t
e
b
r
a
l

e
m
b
o
l
i
z
a
t
i
o
n

i
s

e
a
s
i
e
r
,

f
a
s
t
e
r
,

a
n
d

s
a
f
e
r

t
h
a
n

s
u
r
g
i
c
a
l

l
i
g
a
t
i
o
n

a
n
d

t
h
e
r
e
f
o
r
e

p
r
e
f
e
r
a
b
l
e
.

W
i
t
h

f
e
w

e
x
c
e
p
t
i
o
n
s
,

e
m
b
o
l
i
z
a
t
i
o
n

s
h
o
u
l
d

b
e

c
o
n
s
i
d
e
r
e
d

t
h
e

p
r
e
f
e
r
r
e
d

m
e
t
h
o
d

i
n

t
h
e

m
a
n
a
g
e
m
e
n
t

o
f

v
e
r
t
e
b
r
a
l

a
r
t
e
r
y

t
r
a
u
m
a
.
1
1
8
Y
e
e

L
F
1
9
9
5
J

T
r
a
u
m
a

3
9
:
4
8
0
-
4
I
I
I
A
n
g
i
o
g
r
a
p
h
y

i
s

g
o
o
d
.
1
1
9
D
e
m
e
t
r
i
a
d
e
s

D
1
9
9
6
B
r
i
t
i
s
h

J

S
u
r
g

8
3
:
8
3
-
6
I
I
I
M
o
s
t

v
e
r
t
e
b
r
a
l

a
r
t
e
r
y

i
n
j
u
r
i
e
s

c
a
n

s
a
f
e
l
y

b
e

m
a
n
a
g
e
d

w
i
t
h
o
u
t

a
n

o
p
e
r
a
t
i
o
n

o
r

b
y

a
n
g
i
o
g
r
a
p
h
i
c

e
m
b
o
l
i
z
a
t
i
o
n
.

S
u
r
g
i
c
a
l

i
n
t
e
r
v
e
n
t
i
o
n

s
h
o
u
l
d

b
e

r
e
s
e
r
v
e
d

f
o
r

p
a
t
i
e
n
t
s

w
i
t
h

s
e
v
e
r
e

b
l
e
e
d
i
n
g

o
r

w
h
e
n

e
m
b
o
l
i
z
a
t
i
o
n

h
a
s

f
a
i
l
e
d
.
1
2
0
R
e
i
d

J
D
1
9
8
8
J

T
r
a
u
m
a

2
8
:
1
0
0
7
-
1
2
I
I
I
V
e
r
t
e
b
r
a
l

a
r
t
e
r
y

i
n
j
u
r
i
e
s

r
a
r
e
l
y

c
a
u
s
e

m
o
r
t
a
l
i
t
y
.

A
s
s
o
c
i
a
t
e
d

i
n
j
u
r
i
e
s

a
r
e

c
o
m
m
o
n
.
1
2
1
S
c
l
a
f
a
n
i

A
P
1
9
9
6
L
a
r
y
n
g
o
s
c
o
p
e

1
0
6
:
1
6
8
-
7
3
I
I
I
A
n
g
i
o
g
r
a
p
h
y

i
s

a

s
a
f
e
,

e
f
f
e
c
t
i
v
e

m
o
d
a
l
i
t
y

i
n

p
a
t
i
e
n
t
s

w
i
t
h

p
e
n
e
t
r
a
t
i
n
g

h
e
a
d

&

n
e
c
k

i
n
j
u
r
i
e
s
.

P
a
t
i
e
n
t
s

w
i
t
h

Z
o
n
e

I
I
I

o
r

f
a
c
i
a
l

w
o
u
n
d
s
,

p
a
r
t
i
c
u
l
a
r
l
y

t
h
o
s
e

w
i
t
h

d
o
c
u
m
e
n
t
e
d

I
C
A
,

I
M
A

o
r

E
C
A

i
n
j
u
r
i
e
s
,

h
a
v
e

a

h
i
g
h
e
r

i
n
c
i
d
e
n
c
e

o
f

m
u
l
t
i
p
l
e

v
a
s
c
u
l
a
r

i
n
j
u
r
i
e
s
.
1
2
2
R
o
b
b
s

J
V
1
9
8
7
S
u
r
g

G
y
n
e
c
o
l

O
b
s
t
e
t

1
6
5
:
3
2
3
-
6
I
I
I
E
i
t
h
e
r

r
e
p
a
i
r

o
r

l
i
g
a
t
i
o
n

o
f

t
h
e

g
r
e
a
t

v
e
i
n
s

i
s

a
c
c
e
p
t
a
b
l
e
.
1
2
3
N
a
i
r

R
2
0
0
0
E
u
r
o

J

V
a
s
c

E
n
d
o
v
a
s
c

S
u
r
g

1
9
:
6
5
-
9
I
I
I
I
t

i
s

s
a
f
e

t
o

l
i
g
a
t
e

v
e
i
n
s

f
o
r

c
e
r
v
i
c
a
l

o
r

m
e
d
i
a
s
t
i
n
a
l

t
r
a
u
m
a

i
f

u
n
s
t
a
b
l
e

o
r

c
o
m
p
l
e
x

r
e
p
a
i
r

r
e
q
u
i
r
e
d
.
1
2
4
A
r
i
s
h
i
t
a

G
I
1
9
8
9
J

T
r
a
u
m
a

2
9
:
3
3
2
-
7
I
I
I
M
a
n
d
a
t
o
r
y

i
m
m
o
b
i
l
i
z
a
t
i
o
n

o
f

a
l
l

c
a
s
u
a
l
t
i
e
s

w
i
t
h

p
e
n
e
t
r
a
t
i
n
g

n
e
c
k

w
o
u
n
d
s

s
u
s
t
a
i
n
e
d

i
n

a
n

e
n
v
i
r
o
n
m
e
n
t

h
a
z
a
r
d
o
u
s

t
o

f
i
r
s
t

a
i
d

p
r
o
v
i
d
e
r
s

h
a
s

a
n

u
n
f
a
v
o
r
a
b
l
e

r
i
s
k
/
b
e
n
e
f
i
t

r
a
t
i
o
.
P
a
g
e

1
2

o
f

1
3
T
a
b
l
e

1
.

E
v
i
d
e
n
t
i
a
r
y

T
a
b
l
e
1
2
5
B
a
r
k
a
n
a

Y
2
0
0
0
I
n
j
u
r
y

3
1
:
3
0
5
-
9
I
I
I
I
n

p
e
n
e
t
r
a
t
i
n
g

i
n
j
u
r
y

t
o

t
h
e

n
e
c
k

w
i
t
h
o
u
t

a

c
l
e
a
r

n
e
u
r
o
l
o
g
i
c
a
l

d
e
f
i
c
i
t
,

t
h
e
r
e

i
s

n
o

p
l
a
c
e

f
o
r

u
s
i
n
g

a

c
o
l
l
a
r

o
r

a
n
y

o
t
h
e
r

d
e
v
i
c
e

f
o
r

n
e
c
k

s
t
a
b
i
l
i
z
a
t
i
o
n
.

N
e
c
k

s
t
a
b
i
l
i
z
a
t
i
o
n

d
e
v
i
c
e
s

s
h
o
u
l
d

b
e

u
s
e
d

w
h
e
n

t
h
e
r
e

i
s

o
v
e
r
t

n
e
u
r
o
l
o
g
i
c
a
l

d
e
f
i
c
i
t

o
r

t
h
e

d
i
a
g
n
o
s
i
s

c
a
n
n
o
t

b
e

m
a
d
e

(
i
.
e
.
,

u
n
c
o
n
s
c
i
o
u
s

v
i
c
t
i
m
)
.

I
t

i
s

o
b
l
i
g
a
t
o
r
y

t
o

e
x
p
o
s
e

t
h
e

n
e
c
k

b
y

r
e
m
o
v
i
n
g

t
h
e

a
n
t
e
r
i
o
r

p
o
r
t
i
o
n

o
f

t
h
e

d
e
v
i
c
e

e
v
e
r
y

f
e
w

m
i
n
u
t
e
s

i
n

t
h
e

i
n
i
t
i
a
l

p
h
a
s
e

o
f

t
r
e
a
t
m
e
n
t
.

N
e
c
k

s
t
a
b
i
l
i
z
a
t
i
o
n

d
e
v
i
c
e
s

m
a
y

b
e

u
s
e
d

f
o
r

t
h
e

u
n
u
s
u
a
l

o
c
c
u
r
r
e
n
c
e

o
f

a

p
e
n
e
t
r
a
t
i
n
g

i
n
j
u
r
y

w
h
i
c
h

i
s

c
o
m
b
i
n
e
d

w
i
t
h

b
l
u
n
t

t
r
a
u
m
a
.

1
2
6
R
h
e
e

P
2
0
0
6
J

T
r
a
u
m
a

6
1
:
1
1
6
6
-
1
1
7
0
N
e
u
r
o
l
o
g
i
c

d
e
f
i
c
i
t
s

f
r
o
m

p
e
n
e
t
r
a
t
i
n
g

a
s
s
a
u
l
t

w
e
r
e

e
s
t
a
b
l
i
s
h
e
d

a
n
d

f
i
n
a
l

a
t

t
h
e

t
i
m
e

o
f

p
r
e
s
e
n
t
a
t
i
o
n
.

C
o
n
c
e
r
n

f
o
r

p
r
o
t
e
c
t
i
n
g

t
h
e

n
e
c
k

s
h
o
u
l
d

n
o
t

h
i
n
d
e
r

t
h
e

e
v
a
l
u
a
t
i
o
n

p
r
o
c
e
s
s

o
r

l
i
f
e

s
a
v
i
n
g

p
r
o
c
e
d
u
r
e
s
.
P
a
g
e

1
3

o
f

1
3

Neck Penetrating Tra

Загружено:

Сведения о документе

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Neck Penetrating Tra

Загружено:

Авторское право:

Доступные форматы

CLINICAL PRACTICE GUIDELINES:

PENETRATING NECK TRAUMA

Вам также может понравиться