Is focused magnetic resonance imaging adequate for treatment decision making in acute traumatic thoracic and lumbar spine fractures seen on whole spine computed tomography?

PURPOSE

To assess whether a focused magnetic resonance imaging (MRI) limited to the region of known acute traumatic thoracic or lumbar fracture(s) would miss any clinically significant injuries that would change patient management.

Motor and bladder dysfunctions in patients with vertebral fractures at the thoracolumbar junction

Objective  

To present the motor deficits and type of neurogenic bladder dysfunction (NBD) in patients with vertebral fractures at thoracolumbar junction.     

经椎弓根减压固定和植重组异体骨治疗脊柱脊髓损伤

目的 :探讨严重脊柱脊髓损伤经一侧椎弓根和椎体后缘复位减压 ,经椎弓根植重组异体骨和椎弓根钉固定的可行性及效果。方法 :经一侧椎弓根和椎体后缘复位或截骨减压 ,用特制环锯套管经椎弓根植重组异体骨 ,以X线片和CT片分类分型 ,评估手术前后骨折复位减压和植重组异体骨融合效果 ;按Frank分类标准评估脊髓损伤和恢复程度。结果 :除A级病人外 ,其他病人脊髓神经功能均进步 1～ 2级 ,无感染和断钉病人 ,脊柱后凸角度矫正后再丢失平均 3° ;部分病人术后早期对重组异体骨有反应 ,但几周后可消失。结论 :经一侧椎弓根椎体后缘复位或截骨减压 ,同样可达到较理想脊髓减压效果 ,经椎弓根植重组异体骨和椎弓根钉固定简单、安全、有效。     

胸腰椎骨折椎管狭窄与神经功能的关系

对106例连续性胸腰椎爆裂骨折进行回顾性研究,探讨椎管狭窄与神经功能的关系。按自行设计的改良Frankel法将神经功能分六级,将椎管分脊髓圆锥段和马尾神经段,用直线回归相关法分析椎管狭窄与神经损伤程度之间的关系,用等级相关法分析椎管狭窄与发生神经损伤可能性之间的关系。结果表明:无论在脊髓圆锥段或马尾神经段,椎管狭窄与神经损伤程度、损伤可能性之间均存在相关性(r或r_s=0.38～0.90,P<0.05),且脊髓圆锥段的相关程度较高;相同程度椎骨狭窄致神经危害性在脊髓圆锥段较大。发生神经损伤的最小椎管狭窄在脊髓圆锥段为38％,在马尾神经段为63％(?)认为胸腰椎骨折椎管狭窄是神经损伤的主要因素,X-CT扫描可较好地预测神经损伤程度和损伤可能性。     

Cycling and spinal trauma: A worrying trend in referrals to a national spine centre

Introduction

Cycling has seen a large increase in popularity worldwide over the last number of years. This has been linked to an increase in the number of road traffic accidents involving cyclists. Participation in cycling as part of competitive sport and endurance events has seen particular growth.

老年人外伤性脊柱骨折的临床特点

目的:分析老年人外伤性脊柱骨折的临床特点,提高老年人外伤性脊柱骨折的预防及救治水平。方法:2002年1月～2011年12月我院收治老年人外伤性脊柱骨折患者271例,其中男129例,女142例,年龄60～89岁,平均68.8岁,分析其年龄与性别分布情况、骨折原因、骨折节段、创伤严重度评分(injury severity scores,ISS)、脊髓损伤程度ASIA分级、多发性脊柱骨折及合并伤发生率。结果 :年龄分布主要集中在60～69岁,占60.1%(163/271)。摔伤是主要致伤原因,占44.6%(121/271)。男性高处坠落伤及重物砸伤比例较女性患者高,女性患者摔伤比例较男性高,差异有统计学意义(P<0.05)。426个损伤节段中胸椎及腰椎占80.8%(344/426),其中胸腰段(T11～L2)占53.3%(227/426)。男性患者较女性患者有较高的颈椎骨折比例、脊髓损伤发生率、合并症发生率和创伤严重度评分(ISS),差异有统计学意义(P<0.05)。女性患者较男性患者有较高的胸椎及胸腰段椎体骨折比例,差异有统计学意义(P<0.05)。男性患者多发性脊柱骨折最常见原因为高处坠落伤,女性患者为摔伤。脊髓损伤按ASIA分级,A级、B级、C级、D级分别占7.0%(19/271)、1.8%(5/271)、4.8%(13/271)和18.1%(49/271)。男性患者脊髓损伤分级A级占13.2%(17/129),女性患者为0.8%(2/237),两者差异有统计学意义(P<0.05)。结论:老年人外伤性脊柱骨折的致伤原因、多发性脊柱骨折原因、骨折节段、脊髓损伤分级等方面存在明显的性别差异,应根据其性别差异特点对老年人外伤性脊柱骨折进行防治。     

Thoracolumbar burst fractures with a neurological deficit treated with posterior decompression and interlaminar fusion

Introduction  

To our knowledge, thoracolumbar burst fractures with a neurological deficit treated with posterior decompression and interlaminar fusion have never been reported. Our study was to assess the outcome of posterior decompression and interlaminar fusion in treating thoracolumbar burst fractures with a neurological deficit.     

Classification of thoracic and lumbar spine fractures: problems of reproducibility

Reproducibility of fracture classification systems in general has been a matter of controversy. The reproducibility of spinal fracture classifications has not been sufficiently studied. We studied the inter-observer and intra-observer reproducibility of the Magerl (AO) classification using radiograms, CTs and MRIs of 53 patients. We compared this classification with the older and simpler Denis classification. Five observers classified the fractures, first using the radiograms and CTs and, 6 weeks later, with radiograms and MRIs. Three of the observers repeated the readings after 3 months. Three observers also classified the fractures according to Denis. Agreement was measured using Cohen's kappa test. The type (A, B, C) classification of the AO system was fairly reproducible with CTs. With MRI this was only moderate. Group subclassification of the types yielded higher kappa values, corresponding to substantial agreement. The agreement was, in general, better with the Denis classification, but the variance was higher due to the difficulty of finding proper categories for some injury patterns. Although the AO classification allows proper registration of all kinds of injury, the reproducibility, especially at the type level, is problematic. Use of MRI and better definition of the distinctive properties of the three different types may enhance the reproducibility of the scheme.     

Timing of thoracolomber spine stabilization in trauma patients; impact on neurological outcome and clinical course. A real prospective (rct) randomized controlled study

OBJECTIVE: Optimal timing of stabilization for spinal injuries is discussed controversially. The goal of this study is to investigate the neurological recovery and its influencing factors in thoracolumbar spine fractures after surgical decompression and stabilization within 8 h of spinal cord injury versus surgery which is performed between 3 and 15 days. METHODS: Twenty-seven patients undergoing thoracolumbar stabilization with neurological deficit for an acute thoracolumbar spinal injury at the level of Th8-L2 vertebra at Selcuk University between March 2004 and December 2006 were recorded. Patients with neurological deficity and medically stable for surgery underwent immediate stabilization within 8 h defined as group I (n = 12) and patients underwent operation in 3-15 days after thoracolumbar injury were defined as group II (n = 15). Patients were assessed for neurologic deficit and improvement as defined by the scoring system of American spinal injury association (ASIA). RESULTS: In spite of comparable demographic data, patients in group I had a significantly shorter overall hospital and intensive care unit stay and had lesser systemic complications such as pneumonia and also exhibited better neurological improvement than group II (p < 0.05). CONCLUSION: Early surgery may improve neurological recovery and decrease hospitalization time and also additional systemic complications in patients with thoracolomber spinal cord injuries. Thus early stabilization of thoracolumbar spine fractures within 8 h after trauma appears to be favorable.     

MRI在胸腰段损伤AO分类评估中的价值

目的 :评估MRI在胸腰段损伤AO分类评估中的价值。方法:回顾分析2010年1月~2013年12月收治的80例胸腰段损伤患者,所有患者均有X线片、CT和MRI检查资料。分析患者骨折数目及骨折节段;根据AO系统评定患者分类为A型压缩损伤、B型牵张损伤、C型旋转损伤,后方韧带复合体(PLC)的状态为无损伤、不确定损伤、完全损伤。第一次评估使用X线片和CT数据(CT组);6周后重复评定,同时加入MRI数据(CT+MRI组)。使用Wilson的置信区间方法分析比较联合MRI后AO分类改变的比例。结果 :CT组检查发现128处胸腰段骨折,其中A型损伤98处,B型损伤24处,C型损伤6处;CT+MRI组发现23处新骨折,共151处骨折,其中A型损伤91处,B型损伤54处,C型损伤6处。与CT组比较,CT+MRI组AO分类出现改变的患者共17例(21.3%),95%的置信区间为(0.14,0.31);无改变63例(78.7%),95%的置信区间为(0.68,0.86)。在AO分类出现改变的患者中,15例(18.75%)由A型改变为B型,95%的置信区间为(0.11,0.27);2例(2.5%)由B型改变为A型,95%的置信区间为(0.01,0.08)。CT评估PLC状态,无损伤58例,不确定损伤1例,完全损伤21例;CT联合MRI评估PLC状态,无损伤45例,不确定损伤2例,完全损伤33例。CT和MRI联用,PLC损伤分级无改变63例(78.7%),95%的置信区间为(0.67,0.88);PLC损伤分级发生改变17例(21.3%),95%的置信区间为(0.13,0.33)。结论:联合MRI比仅用CT能够检出更多的骨与韧带损伤,MRI检查可能改变胸腰段损伤患者的AO分类,检出的PLC是分类发生改变的重要原因。     

胸腰段脊柱骨折合并创伤性膈疝的诊断与治疗

目的：探讨胸腰段脊柱脊髓伤合并创伤性膈疝的诊断和治疗。方法：回顾性分析我院1985年1月～2004年12月收治的此类伤21例。骨折按Denis分类：爆裂型9例,压缩性骨折2例,骨折脱位10例。神经功能按ASIA分级：A级7例,B级5例,C级6例,D级3例。结果：左侧膈疝18例,右侧膈疝3例。24h内确诊11例,48h内确诊5例,72h内确诊4例,漏诊死亡1例。生存20例,随访6个月～12年,平均4年2个月。神经功能ASIAA级7例中部分感觉功能恢复4例,其余神经功能均较术前改善1—3级。手术并发症中后路脱钩1例,椎弓根钉断裂2例。结论：对胸腰段脊柱脊髓损伤合并创伤性膈疝的患者应全面仔细地体格检查及X线或CT检查。治疗时应优先处理膈疝,如果患者情况许可同期行膈肌修补和脊柱固定手术。     

Damage control surgery for spine trauma

The concept of "damage control" surgery was originally developed for massive abdominal trauma and also successfully applied to the management of lone bone injuries. More recently this has been extended to severely injured patients with spine injuries. This paper provided an overview of how damage control principles can be applied to multitrauma patients with spine injuries, to patients with isolated spine injuries and to spine injuries with and without neurology. The role of neuroimaging in acute spine trauma and controversies in the pharmaceutical approach to spine injuries are discussed. Additional prospective controlled trials are required to delineate the role and timing of damage control surgery in acute spine injury. With improved neuroimaging early spinal damage control surgery will be formally established in the management of spine trauma.     

Conservative management of thoracolumbar and lumbar spine compression and burst fractures: functional and radiographic outcomes in 136 cases treated by closed reduction and casting

Introduction  Both fractures of the lumbar spine and at the thoracolumbar junction are quite common. The treatment of these fracture types is discussed controversially. Some authors advocate surgical treatment even in fractures without neurologic compromise while other series report good results after non-operative treatment. Materials and methods  Between January 1997 and April 2004, 324 patients with spinal fractures were admitted to our institution. Hundred and thirty-six patients with compression and burst type fractures treated by closed reduction and casting were available for follow-up. Their medical records, radiographs and computer tomography scans were reviewed and their functional status was assessed. Results  94 male (69.1%) and 42 female (30.9%) patients with a mean age of 48.6 years (range 17–81) at time of injury were included. The thoracolumbar junction (T11-L1) was affected in 104 patients (76.5%). 23.5% had lumbar fractures. All of the burst type fractures with involvement of the posterior column affection were type A3.3. fractures according to the Magerl classification. Significant correction of radiographic parameters was achieved in the early postreduction period (P < 0.0001). Reduction could not be maintained at the final follow-up but still showed slight improvement compared to the initial presentation. Reduction could be maintained better in the thoracolumbar region than in the lumbar spine. Neurologic function was restored in all patients with unilateral radicular pain but only one patient recovered fully after cauda equina-syndrome. Patients after lumbar spine indicated a higher level of pain when compared to patients with fractures at the thoracolumbar junction. Discussion  Closed reduction and casting is a safe and effective method for treatment of compression and burst type fractures at the thoracolumbar junction and can restore neurologic function in patients with unilateral radicular pain. It is of limited value in lumbar fractures and in burst type fractures with posterior column involvement.     

骨质疏松性脊柱骨折治疗的现状与展望

对于脊柱外科医生来说,骨质疏松的脊柱问题有疼痛性椎体压缩性骨折,骨折后椎体持续不稳,以及由于多发椎体压缩造成的渐进性体态改变和骨质疏松性骨折引起的神经并发症。运用聚甲基丙烯酸甲脂(PMMA)对骨质疏松的椎体进行强化是十分有效的治疗方法之一。虽然在大部分病例中,由于椎体骨折造成的疼痛会在前几周内逐渐缓解,但仍然有相当数量患者持续疼痛并且椎体持续性塌陷。经皮椎体注入骨水泥会使80%～93%的患者产生迅速而持久的疼痛缓解。多个椎体同时注入还能使严重骨质疏松的脊柱成为一个整体,从而更加有效的阻止椎体进一步塌陷和保持体态。在新鲜的骨折中,球囊扩张椎体成型术可以改善脊柱前凸,若实施前凸成型术会更有效。脊椎后凸的矫正范围为8.5°～14°。椎体高度可以恢复90%。当获得稳定性后,为了在严重骨质疏松的骨质上锚住内固定物,将聚甲基丙烯酸甲脂(PMMA)强化和螺钉内固定相结合是目前惟一的方式。     

胸腰段脊柱脊髓损伤后期的MRI研究

目的：观察胸腰段脊柱脊髓损伤后期MRI遥表,咱升性脊髓病变的主要相关因素,方法：选取胸腰段脊仍髓损伤1年以上患者144例的MRI,进行观察,测量工进行统计学处理。结果：本组病例的MRI表现依次有变性、粘连、萎缩、囊变、空洞和外伤性拴系,上升性脊髓病变发生率47．2％,包括变性,萎缩和这洞三种表现。结论：完全性脊髓损伤、脊髓严重受压以及T11、T12骨折的患者更易出现上升性脊髓病变;完全性脊髓损伤、脊髓严重受压的患者更易出现脊髓萎缩。     

后路减压加短节段椎弓根螺钉系统内固定治疗胸腰椎骨折并脊髓损伤

目的探讨脊柱后入路减压加短节段椎弓根螺钉系统内固定治疗胸腰椎骨折并不全瘫的效果。方法对27例胸腰椎骨折进行后路减压、植骨及Dick、RF内固定治疗。结果术后平均随访时间为11个月(6～20个月),脊柱后凸角度(Cobb’s角)由术前的24°平均恢复到10°(5°～15°);伤椎椎体前缘高度由术前35%(10%～60%)平均恢复到90%(80%～100%)。按Frankel脊髓神经功能分级标准D级19例,E级8例。结论后入路减压加短节段椎弓根螺钉系统内固定具有手术操作简单、损伤小、椎管减压充分等优点,有利于脊髓功能的恢复。     

脊柱脊髓损伤合并重型颅脑损伤的早期诊治体会

目的：探讨早期诊治脊柱、脊髓损伤合并重型颅脑损伤病例，降低伤残率、死亡率的有效措施。方法：回顾性分析本院45例患者，及采取的相应诊断治疗措施。结果：临床治愈26例，好转14例，死亡5例。结论：骨科、神经外科和急诊科医生必须给予足够的重视，早期正确检查、及早诊断和有效治疗至关重要，常规行头部和脊柱脊髓影像学检查十分必要，进一步可采取CT三维重建、MRI等检查，提高早期诊断率，对降低伤残与死亡率有着十分重要的临床意义。     

AO spine injury classification system: a revision proposal for the thoracic and lumbar spine

Purpose

The AO Spine Classification Group was established to propose a revised AO spine injury classification system. This paper provides details on the rationale, methodology, and results of the initial stage of the revision process for injuries of the thoracic and lumbar (TL) spine.

Methods

In a structured, iterative process involving five experienced spine trauma surgeons from various parts of the world, consecutive cases with TL injuries were classified independently by members of the classification group, and analyzed for classification reliability using the Kappa coefficient (κ) and for accuracy using latent class analysis. The reasons for disagreements were examined systematically during review meetings. In four successive sessions, the system was revised until consensus and sufficient reproducibility were achieved.

Results

The TL spine injury system is based on three main injury categories adapted from the original Magerl AO concept: A (compression), B (tension band), and C (displacement) type injuries. Type-A injuries include four subtypes (wedge-impaction/split-pincer/incomplete burst/complete burst); B-type injuries are divided between purely osseous and osseo-ligamentous disruptions; and C-type injuries are further categorized into three subtypes (hyperextension/translation/separation). There is no subgroup division. The reliability of injury types (A, B, C) was good (κ = 0.77). The surgeons’ pairwise Kappa ranged from 0.69 to 0.90. Kappa coefficients κ for reliability of injury subtypes ranged from 0.26 to 0.78.

Conclusions

The proposed TL spine injury system is based on clinically relevant parameters. Final evaluation data showed reasonable reliability and accuracy. Further validation of the proposed revised AO Classification requires follow-up evaluation sessions and documentation by more surgeons from different countries and backgrounds and is subject to modification based on clinical parameters during subsequent phases.     

经骶棘肌腰方肌间隙行胸腰段脊柱脊髓损伤侧前方减压术

目的：寻求胸腰段脊柱脊髓损伤侧前方减压的新入路。方法：利用胸腰段的解剖关系设计经骶棘肌腰方肌间隙入路行胸腰段脊柱侧前方减压术。结果：临床应用１２例,手术时间１～１．５ｈ,从皮肤切口到完全显露椎体出血４０～６０ｍｌ。此入路不切断骶棘肌、腰方肌、腰大肌及膈肌,不会伤及胸膜等。随访３～６个月,基本痊愈４例,显著进步３例,进步５例。结论：经骶棘肌腰方肌间隙行胸腰段脊柱侧前前方减压入路简捷,损伤小,出血少。既能充分减压,又能最大限度保持脊柱的稳定性,还可避免加重脊髓损伤、胸膜损伤等并发症。