下颈椎损伤分类评分系统的信效度检验及临床应用

背景：脊柱损伤分类系统对下颈椎损伤的诊治及预后具有重要指导意义,然而临床上缺乏一种能被广泛接受的分类系统。目的：对下颈椎损伤分类评分系统进行可信度分析与有效度检验,并观察其在临床治疗中的应用效果。方法：基于下颈椎损伤分类评分系统治疗75例下颈椎损伤患者,根据该系统评分,11例〈4分的患者选择非手术治疗,6例=4分及58例〉4分的患者选择手术治疗,手术患者依据该系统中损伤形态学不同结合间盘韧带复合体损伤和神经损伤状态选择不同的手术入路。分别采用Cronbach’sα系数与Kappa系数考察内部一致性信度和重测信度;用内容效度指数检验内容效度。结果与论：下颈椎损伤分类评分系统亚类的内部一致性信度均在0.8以上,表明该评分系统具有较好的内部一致性信度。间盘韧带复合体及下颈椎损伤分类评分系统总分的重测信度为中度可信,形态学损伤、神经损伤状态及治疗选择的重测信度均大于0.6为高度可信。下颈椎损伤分类评分系统全部条目平均内容效度指数值为0.936,证明该评分系统各条目较好地指导了下颈椎损伤患者的诊断及治疗。根据该评分系统指导治疗75例下颈椎损伤患者,治疗后无神经损伤加重,并发症发生率较低,ASIA分级得到相应改善。提示下颈椎损伤分类评分系统具有较高的信效度,且应用简便、易于掌握,其在指导下颈椎损伤手术与非手术治疗以及手术入路的选择方面具有重要意义。     

Missed cervical spine fracture: chiropractic implications

OBJECTIVE: To discuss the case of a patient with an anterior compression fracture of the cervical spine, which had been overlooked on initial examination. CLINICAL FEATURES: A 36-year-old man was seen at a chiropractic clinic 1 month after diving into the ocean and hitting his head on the ocean floor. He chipped a tooth but denied loss of consciousness. Initial medical examination in the emergency department did not include radiography, but an anti-inflammatory medication was prescribed. Radiographs taken at the chiropractic clinic 1 month later revealed an anterior compression fracture of the C7 vertebra, with migration of the fragment noted on flexion and extension views. INTERVENTION AND OUTCOME: The patient was referred back to his medical doctor for further evaluation and management.He was instructed to wear a Philadelphia collar for 4 weeks. During this time period, he reported "shooting" pain and tingling from his neck into his arms. The patient reported resolution of his neck and arm symptoms at 2.5 months after injury. Follow-up radiographs at 6 months after injury revealed fusion of the fracture fragment with mild residual deformity. At that time, the patient began a course of chiropractic treatment. CONCLUSION: After head trauma, it is essential to obtain a radiograph of the cervical spine to rule out fracture. Chiropractors should proceed with caution, regardless of any prior medical or ancillary evaluation, before commencing cervical spine manipulation after head and neck trauma.     

The unstable occult cervical spine fracture: a review.

The initial evaluation and management of cervical spine injuries is of critical importance because of the impact of early treatment and management on the patient's eventual outcome. The devastation and cost of missing even one unstable cervical spine fracture is tremendous. The existence of patients with an unsuspected cervical spine fracture who have few, if any, symptoms and/or signs of an injury to the cervical spine is a valid concern and a dilemma for the practicing physician. Thus the principle of the occult unstable cervical spine fracture, which has been established as the standard of care, has major significance and implications. Recently, however, the concept of the occult cervical spine fracture has been challenged. Does the entity of an occult cervical spine fracture exist? If so, how should this affect our indications for obtaining cervical spine radiographs? The author presents the case of an unstable occult cervical spine fracture and a review of the literature.     

Diagnosing cervical spine instability: role of the post-computed tomography scan out-of-collar lateral radiograph

BACKGROUND: Cervical spine injuries may have devastating neurological consequences, which makes accurate diagnosis of injury a key part of the trauma evaluation. Imaging plays a significant role in making the diagnosis and guiding management. Current American College of Radiology Appropriateness Criteria guidelines recommend computed tomography (CT) of the cervical spine with multi-planar reformats as the highest-rated imaging examination for patients meeting clinical criteria, without subsequent need for further imaging with a negative scan in a neurologically intact and non-obtunded patient. Although CT is fast and accurate for evaluation of bony injury, it may overlook ligamentous injury. OBJECTIVE AND CASE REPORT: We report a case in which ligamentous instability was demonstrated as subluxation with an out-of-collar lateral radiograph after a CT scan showed no subluxation or fracture in a patient without neurological deficits. Our Radiology Department routinely performs an out-of-collar lateral radiograph after a negative CT scan, and this case suggests that there may be an important role for this practice. CONCLUSION: Magnetic resonance is the optimal study for soft tissue and ligamentous evaluation; however, a simple lateral out-of-collar radiograph after CT clearance, in an otherwise neurologically intact and non-obtunded patient, may be a quick and cost-effective means to assess for instability of the cervical spine.     

The radiographic evaluation of spinal trauma

The authors describe a systematic approach to the radiographic evaluation of spinal trauma, discussing cervical spine anatomy, the mechanism of injury, and classification of injuries, and then discuss several specific injuries of the cervical and thoracolumbar spine and their radiographic evaluation.     

Is the anteroposterior cervical spine radiograph necessary in initial trauma screening?

The usefulness of the anteroposterior (AP) radiograph of the cervical spine in contributing to the diagnosis of cervical spine injuries in the acute trauma patient was examined in a retrospective study. All cases of cervical spine fracture or dislocation seen at a level I trauma center over a 3-year period and at a rehabilitation center over a 10-year period were reviewed. The lateral radiograph, open-mouth odontoid radiograph, and AP radiograph of each case were sequentially examined by a neuroradiologist (blinded to the original diagnosis) to determine the contribution of each view in making a diagnosis of cervical spine injury. Results of these reviews showed that there were no cases of cervical spine injury evident on the AP view without an obvious corresponding abnormality on the lateral or open-mouth view. It was concluded that the AP view could be dropped from the initial screening radiographic study of the cervical spine in the trauma patient. Only an adequate lateral view and open-mouth odontoid view would then be necessary to initially evaluate the cervical spine in the trauma patient, and decisions to obtain further studies could be based safely on only the lateral and open-mouth views.     

颈椎损伤的X线与CT诊断

目的探讨常规X线和CT扫描对颈椎损伤的诊断价值。方法对50例X线和CT诊断为颈椎损伤的病例进行分析。结果本组50例,受损椎体共60个。低位颈椎骨折并（或）脱位27例,寰椎骨折9例,寰枢椎脱位8例,枢椎骨折6例。X线平片显示椎体后缘联线异常24例,CT片根据脊柱三柱结构诊断不稳定骨折28例,椎管0度狭窄22例,1度狭窄17例,2度狭窄8例,3度狭窄3例。外伤性颈椎间盘脱出10例。结论对于颈椎损伤的患者,应常规行X线和CT扫描检查,以利于为临床提供更全面可靠的信息。CT能对颈椎损伤做出较全面、准确的诊断,有利于治疗方案的选择,可作为颈椎损伤临床术前诊断和治疗的影像学检查的首选方法。     

HWS-Trauma im Alter: keine Bagatelle

The case of a dangerous cervical spine injury is presented from the perspective of the family doctor and manual therapist. An elderly patient with a fracture of the dens axis first developed neurological symptoms 4 days after the trauma. The early evaluation of the situation using the criteria of the Canadian C-spine rules could possibly have helped to diagnose the fracture earlier.     

Evaluation and management of acute cervical spine trauma

The evaluation and management of cervical spine injuries is a core component of the practice of emergency medicine. This article focuses on evaluation and management of blunt cervical spine trauma by the emergency physician. Pertinent anatomy of the cervical spine and specific cervical spine fractures are discussed, with an emphasis on unstable injuries and associated spinal cord pathology. The association of vertebral artery injury with cervical spine fracture is addressed, followed by a review of the most recent literature on prehospital care. Initial considerations in the emergency department, including cervical spine stabilization and airway management, are reviewed. The most current recommendations for cervical spine imaging with regard to indications and modalities are covered. Finally, emergency department management and disposition of patients with spinal cord injuries are reviewed.     

Cervical spine injuries in blunt trauma patients requiring emergent endotracheal intubation.

Airway management in the blunt trauma patient is complicated by the potential for causing or exacerbating an injury to the cervical cord if an unstable cervical fracture is present. The records of 987 blunt trauma patients who required emergent endotracheal intubation over a 5-year period were retrospectively reviewed to determine the incidence and type of cervical spine injury and the incidence of injury based on airway management. Sixty of the patients (6.1%) had a cervical fracture; 53 were potentially unstable injuries by radiographic criteria. Twenty patients had neurologic deficits prior to intubation. Twenty-six patients with unstable injuries were intubated orally, 25 nasally, and two by cricothyrotomy. One patient developed a neurologic deficit after nasotracheal intubation. Because of a possible selection bias in which severely injured patients were preferentially referred to this trauma center, the true incidence of cervical spine injuries may be lower than the 6.1% we found. The authors conclude that the incidence of serious cervical spine injury in a very severely injured population of blunt trauma patients is relatively low, and that commonly used methods of precautionary airway management rarely lead to neurologic deterioration.     

上颈椎损伤的早期诊断与治疗

目的：探讨上颈椎损伤的早期诊断方法和治疗措施。方法：回顾分析2000年1月至2008年7月间收治住院的上颈椎损伤患者35例临床资料,其中寰椎骨折6例,枢椎骨折24例,无骨折的寰枢关节脱位5例。除3例陈旧性齿状突骨折和2例陈旧性寰枢关节脱位外,其余为新鲜损伤。评价其早期诊治方法及其预后。结果：早期漏诊6例,35例患者X线检查后均需结合CT或MRI检查完善诊断及分型。手术治疗18例,其中5例为齿状突骨折早期保守治疗后改手术治疗,2例为漏诊的陈旧性寰枢关节脱位。非手术治愈16例,其中3例齿状突骨折Ⅲ型畸形愈合。1例复合性损伤患者住院3月后诊断出寰枢关节脱位出院。33例得到4～38个月随访。随访的33例患者中,骨折患者均愈合,4例寰枢关节脱位患者脱位整复,上颈椎稳定性均维持良好,神经功能改善。结论：重视上颈椎损伤患者影像检查方法早期合理的分步选择与充分利用,避免漏诊。治疗上,积极地整复骨折与脱位,尽早恢复上颈椎的稳定性。     

Biomechanics of the cervical spine 4: major injuries.

This review presents considerations regarding major cervical spine injury, including some concepts that are presently undergoing evaluation and clarification. Correlation of certain biomechanical parameters and clinical factors associated with the causation and occurrence of traumatic cervical spine injuries assists in clarifying the pathogenesis and treatment of this diverse group of injuries. Instability of the cervical column based on clinical and mechanistic perspectives as well as the role of ligaments in determining instability is discussed. Patient variables such as pre-existing conditions (degenerative disease) and age that can influence the susceptibility or resistance to injury are reviewed. Radiological considerations of major injuries including dynamic films, CT and MRI are presented in the diagnosis and treatment of cervical trauma. Specific injury patterns of the cervical vertebral column are described including attention to the relative mechanisms of trauma. From a biomechanical perspective, quantification of injury tolerance is discussed in terms of external and human-related variables using laboratory-driven experimental models. This includes force vectors (type, magnitude, direction) responsible for injury causation, as well as potential influences of loading rate, gender, age, and type of injury.     

Interobserver reliability in physical examination of the cervical spine in patients with headache

OBJECTIVE: To assess interobserver reliability of two expert headache neurologists when examining the cervical spine of patients with headache. BACKGROUND: The diagnosis of cervicogenic headache involves the physical examination of the cervical spine. METHODS: Twenty-four patients diagnosed as having migraine, tension-type headache, or cervicogenic headache were included in the study. After interview, each patient's cervical spine was examined in a structured way. Reliability was assessed by Cohen's kappa. RESULTS: Reduced range of motion in the cervical spine showed kappa scores indicating moderate agreement. Provocation of headache revealed moderate-to-substantial agreement. Assessment of zygapophyseal joint pressure pain showed slight-to-fair agreement. The kappa values of the circumscribed characteristic tender points showed agreement ranging from "not better than chance" to "substantial agreement." CONCLUSIONS: Our study showed that the interobserver reliability of expert headache neurologists was satisfactory in the majority of the physical examination tests of the cervical spine in patients with different headache syndromes. However, standardization of the clinical tests in order to improve their reliability is recommended.     

Cervical spine injury biomechanics: Applications for under body blast loadings in military environments

Background

While cervical spine injury biomechanics reviews in motor vehicle and sports environments are available, there is a paucity of studies in military loadings. This article presents an analysis on the biomechanics and applications of cervical spine injury research with an emphasis on human tolerance for underbody blast loadings in the military.

Methods

Following a brief review of published military studies on the occurrence and identification of field trauma, postmortem human subject investigations are described using whole body, intact head–neck complex, osteo-ligamentous cervical spine with head, subaxial cervical column, and isolated segments subjected to differing types of dynamic loadings (electrohydraulic and pendulum impact devices, free-fall drops).

Findings

Spine injuries have shown an increasing trend over the years, explosive devices are one of the primary causal agents and trauma is attributed to vertical loads. Injuries, mechanisms and tolerances are discussed under these loads. Probability-based injury risk curves are included based on loading rate, direction and age.

Interpretation

A unique advantage of human cadaver tests is the ability to obtain fundamental data to delineate injury biomechanics and establish human tolerance and injury criteria. Definitions of tolerances of the spine under vertical loads based on injuries have implications in clinical and biomechanical applications. Primary outputs such as forces and moments can be used to derive secondary variables such as the neck injury criterion. Implications are discussed for designing anthropomorphic test devices that may be used to predict injuries in underbody blast environments and improve the safety of military personnel.     

Cervical spine injury in low-impact blunt trauma

Few data are available regarding the incidence of cervical spine injuries following relatively low-impact blunt trauma. This prospective level II trauma center study of low-impact blunt trauma found a 1.30% incidence of cervical spine injury. Impressive differences were found in such parameters as population characteristics, modes of injury, elapsed times to emergency department evaluation, and Revised Trauma Scores between this study group and those reported in prospective level I high-impact blunt trauma series. Cervical spine injury in low-impact blunt trauma is significant and often presents less than dramatically, thus emphasizing a need for maintaining a high index of suspicion at all times.     

Occipital condyle fracture in a victim of a motor vehicle collision

Occipital condyle fractures are rarely reported in the Emergency Medicine literature. It is unclear whether these fractures are rare or under-diagnosed. Occipital condyle fractures are associated with high-energy blunt trauma with significant cranial-cervical torque or axial loading. We report a case of a female patient with an occipital condyle fracture. The patient only complained of shoulder pain, but was found to have high cervical spine tenderness, after a moderate-speed front-end motor vehicle collision. Initial cervical spine radiographs were non-diagnostic. Computed tomography of the cervical spine demonstrated a non-displaced occipital condyle fracture. Conservative management with a semi-rigid cervical collar was successful in treating this patient's fracture. A review of the literature covers the diagnosis, radiographic findings, and management of this fracture.     

Review article: Indications for thoracolumbar imaging in blunt trauma patients: A review of current literature

Thoracolumbar spine injury is a common complication of blunt multitrauma and up to one third of fractures are associated with spinal cord dysfunction. Delayed fracture diagnosis increases the risk of neurological complications. While validated screening guidelines exist for traumatic c‐spine injury equivalent guidelines for thoracolumbar screening are lacking. We conducted a literature review evaluating studies of thoracolumbar injury in trauma patients to generate indications for thoracolumbar imaging. We performed MEDLINE and Pubmed searches using MeSH terms “Wounds, Nonpenetrating”, “Spinal Fractures”, “Spinal Injuries” and “Diagnostic Errors”, MeSH/subheading terms “Thoracic Vertebrae/injuries” and “Lumbar Vertebrae/injuries” and keyword search terms “thoracolumbar fractures”, “thoracolumbar injuries”, “thoracolumbar trauma”, “missed diagnoses” and “delayed diagnoses”. Limits and inclusion criteria were defined prior to searching. We evaluated 16 articles; 5 prospective observational studies (1 cohort study) and 11 retrospective observational studies. Predictors of TL injury in prospective studies – high‐risk injury mechanism, distracting injury, impaired cognition, symptoms/signs of vertebral fracture and known cervical fracture – were defined and used to construct a decision algorithm, which in a total of 14189 trauma patients from all eligible studies recommended TL screening in 856(99.1%) of 864 patients with TL fractures and would probably have directed TL imaging in the remaining 8 patients. There is limited low level evidence guiding surveillance TL imaging in adult blunt trauma patients. Despite this, we propose and evaluate an algorithm with a high negative predictive value for TL fractures. This should be incorporated into spinal injury assessment protocols.     

Delayed Subluxation of an Occult Traumatic Odontoid Fracture in an Elderly Patient

The issue of whether a traumatic but occult cervical spine fracture can exist has generated significant debate in emergency medicine. The profound clinical and legal implications of missing an unstable cervical spine injury are well known to the emergency care provider. An elderly patient who satisfies all of the rigorous criteria for this type of injury is discussed. The patient experienced delayed subluxation of her acute odontoid fracture during a flexion/extension examination completed in the ED, with resultant development of cervical discomfort. Elderly victims of trauma with an appropriate mechanism of injury should be suspected of subtle or occult neck injuries.     

Emergency department intubation of trauma patients with undiagnosed cervical spine injury

Objectives: Some trauma patients have an undiagnosed cervical spine injury but require immediate airway control. This paper reports an emergency department''s (ED) experience with these patients. In particular, is there a worse neurological outcome? Methods: A retrospective study over 6.5 years, based on prospectively collected data from the Royal Perth Hospital trauma registry. Patients with a cervical spine injury were identified and clinical data were abstracted. The primary outcome measure was evidence of exacerbation of cervical spine injury as a result of intubation by ED medical staff. Results: 308 patients (1.9%) of the 15 747 trauma patients were intubated by ED medical staff. Thirty seven (12%) were subsequently verified to have a cervical spine injury, of which 36 were managed with orotracheal intubation. Twenty five (69%) survived to have a meaningful post-intubation neurological examination. Fourteen (56%) of these 25 patients had an unstable cervical spine injury. Ninety per cent of all ED intubations were by ED medical staff. No worsening of neurological outcomes occurred. Conclusions: Every ninth trauma patient that this ED intubates has a cervical spine injury. Intubation by ED medical staff did not worsen neurological outcome. In the controlled setting of an ED staffed by senior practitioners, patients with undiagnosed cervical spine injury can be safely intubated.     

Evaluation of the acute cervical spine: a management algorithm. (Department of Surgery, University of Kentucky, Lexington, KY) J Trauma 2000;49:450–456.

A retrospective review was initiated of all trauma patients evaluated in a Level I trauma center the year before and after implementation of a new cervical spine protocol to determine the incidence of missed cervical injuries. An additional 6 months were reviewed to detect any missed injuries late in the study period. During the 2‐year study period, 4,460 patients presented to the emergency room with some form of cervical spine precautions. Blunt trauma comprised 90% of the study population. According to the protocol, approximately 45% required further cervical radiographs after presentation. In the preprotocol year, 77 of 2,217 (3.4%) patients were diagnosed with cervical spine injuries, 16 of 77 (21%) with multiple level injuries, and 25 of 77 (32%) with neurologic compromise. Three of 2,217 patient had missed cervical spine injuries on their initial evaluations. In the postprotocol year, 84 of 2,243 (3.4%) patients had cervical injuries, 25 of 84 (30%) with multiple levels of injuries and 28 of 84 (28%) with neurologic compromise. No patient evaluated during the protocol year was missed. All statistics between the two groups were not significant. Conclude the current protocol by risk stratifying patients on presentation is effective in assessing patients for cervical spine injuries. Comment by Gabor B. Racz, M.D. This is a retrospective review from a Level I trauma center a year before and after implantation of a cervical spine injury protocol. The comparison of outcomes before and after the protocol was rather similar in that the diagnosis of cervical spine injury in 77 of 2,217 patients, or 3.4% and 84 of 2,243 had cervical injuries again 3.4%. Prior to the initiation of the protocol, the first year had three cervical spine injuries missed, which were diagnosed later secondary to continued neck pain on reevaluation. There were no missed cases after the protocol. The evaluation and examination go hand in hand. More emphasis is placed on the clinical exam and plain multiple view x‐ray films and adherence to limiting the rigid collar to 6 h switching over to soft collar and developing more of a confidence in the clinical exam rather than to concentrate on the more expensive and time consuming radiological diagnostic procedures. The cervical algorithm does work and it is impressive that there were no missed injuries. It is recommended that physicians working in a Level I trauma center should go and review the algorithm in detail. The recommended practice is to rely on plain films first if there is persistent pain flexion and extension films and involvement of appropriate consultants in these patients who must be assumed to have cervical spine injury.