20 - Neck and Thoracic Outlet

Abstract

The neck and thoracic outlet contain numerous vital structures in a compact space, so trauma to this region often results in catastrophic hemorrhage, neurological deficit, and death. Consequently, the clinician must approach these patients with a high index of suspicion. The spectrum of vascular injuries ranges from exsanguinating hemorrhage to subtle imaging findings with a seemingly innocuous physical examination that can lead to delayed hemispheric stroke. Vascular injuries to the neck require utilization of multiple imaging modalities, comprehensive planning, and advanced operative skills. A knowledge of anatomy and vascular exposures along with keen surgical judgment are crucial, especially in the unstable patient in whom immediate surgical intervention is required. Improvements in the speed and sensitivity of computed tomography has led to its widespread use in screening patients for inconspicuous injuries. This has led to earlier recognition of blunt cerebrovascular injuries with associated improvements in prognosis. Endovascular treatment of injuries in the neck and thoracic outlet can reduce operative complexity and the morbidity of difficult surgical exposures. Although endovascular skills and technology have improved at a rapid pace, they have not been disseminated to the care of severely injured patients at the same rate. As endovascular capabilities for trauma become more routine, they will dramatically change treatment paradigms and improve outcomes.