多发伤中胸腰椎骨折误诊漏诊原因分析

目的：分析多发伤病例胸腰椎骨折的误诊漏诊原因。方法：通过对147例多发伤合并胸腰椎骨折临床资源的回顾性分析，研究误诊漏诊的原因。结果：28例胸腰椎骨折被误诊漏诊，占19％。原因包括病情危重、读片失误和病情较稳定但未行X线检查。结论：对于多发伤患者应进行详细全面的脊柱物理检查，有阳性发现时应行X线检查，对于所有胸腰椎骨折或怀疑有胸腰椎骨折患者均应行CT扫描检查。     

胸腰椎爆裂性骨折的诊断

本文对114例120处胸腰椎爆裂性骨折进行回顾性分析。所有病例均摄胸腰椎X线片,94例行CT扫描,74例行MRI检查。结果共有27处骨折被误诊,占22.5％。作者认为,X线片常不能准确反映爆裂性骨折的病理特征,对于胸腰椎骨折应常规行CT扫描,必要时应同时行MRI检查,诊断中应注意将爆裂性骨折与压缩性骨折相鉴别。     

严重复合伤早期漏诊误诊31例分析

目的:总结严重复合伤漏诊误诊的经验教训。方法:对我院402例复合伤中漏诊误诊31例进行分类分析,找出漏诊误诊的原因。结果:多发骨折合并腹部损伤、颅脑损伤合并其他内出血致失血性休克,极易造成漏诊误诊,本文深入分析了漏诊误诊的原因。本组病例死亡率为29％,早期确诊病例死亡率仅为1.9％。结果:复合伤病情复杂,症状体征互相掩盖,对于这类患者要仔细观察患者的每个症状体征,持续观察,认真分析,尽量避免漏诊误诊,提高抢救成功率。     

CT对无神经症状胸腰椎骨折的形态学观察及临床意义

无神经症状是指没有神经损伤症状和体征的胸腰椎骨折 ,以往仅凭Ｘ线平片诊断此类骨折很容易造成对骨折严重程度估计不足 ,甚至误诊、漏诊。我们通过对 10 7例进行ＣＴ扫描胸腰椎骨折患者的形态学观察 ,认为ＣＴ对无神经症状胸腰椎骨折在诊断、判断病情、治疗方法的选择以及确定手术适应症等方面都有重要的临床价值。1　临床资料1 1　一般资料　本组 10 7例 ,男 74例 ,女 33例 ;年龄 2 1～ 6 6岁 ,平均 37岁 ,致伤原因 :高处坠落伤 6 2例 ,跌扑伤 31例 ,车祸 14例。骨折部位 :胸椎 2 7例 ,胸腰段 33例 ,腰椎 47例。受伤时间最短 30分钟 ,最长…     

交通事故多发伤中闭合性肾损伤11例误诊分析

目的:探讨交通事故多发伤中闭合性肾损伤误诊的原因和对策.方法:对我院近7年收治的交通事故多发伤合并闭合性肾损伤患者的病历资料进行回顾性分析.结果;159例交通事故多发伤合并闭合性肾损伤病例中误诊11例,均系漏诊;误诊时间为3～12d.结论:误诊的主要原因是患者早期症状轻微、缺乏典型表现或多发伤病情危重掩盖了肾损伤局部表现,而临床医生工作不细致、缺乏全局现念或未掌握其有效的诊断手段.强化临床医生的责任心和警惕性、正确选择有效的诊断手段、系统而严密地观察病情、细心检查、全面分析,是防止在交通事故多发伤的诊断中漏诊闭合性肾损伤的有效对策.     

Sextent经皮椎弓根螺钉治疗胸腰椎骨折的临床效果分析

目的：探讨Sextent经皮椎弓根螺钉治疗胸腰椎骨折的临床效果。方法2009年10月至2012年4月,应用Sextent经皮椎弓根螺钉技术治疗胸腰椎骨折10例,男8例,女2例;年龄21～51岁,平均39.2岁。其中单纯行跨伤椎4四枚螺钉6例,伤椎的上下椎及伤椎同时固定2例,跨伤椎固定联合伤椎植骨2例。所有患者术前行X线、CT、MR检查,术后即刻、术后1年、末次随访行X线、CT检查,评估其手术治疗效果。结果10例患者术后1年及末次随访的临床疗效满意,优良率100％（优7例,良3例）。术后即刻、术后1年及末次随访的载荷分享评分、伤椎前缘高度百分比、伤椎后凸Cobb＇s角和椎管堵塞指数等结果均显著优于术前。结论 Sextent系统针对不同胸腰椎骨折应强调个体化,根据不同分型和载荷评分选用不同的治疗方法,避免椎体前高、后凸角的矫正及丢失,所有患者在全麻下应首先行手法复位。采用Sextent经皮椎弓根螺钉治疗胸腰椎骨折能获得较好的临床效果。     

MRI在胸腰椎骨折诊疗中的应用价值

目的探讨MRI在胸腰椎骨折诊疗中的应用价值。方法自2008-12—2014-12对360例胸腰椎骨折行MRI检查,对X线、CT检查未发现后柱损伤的病例筛选出15例合并后柱损伤。结果对仅有X线及CT检查未发现后柱损伤经MRI检查发现,根据由美国脊柱创伤研究会提出的针对胸腰椎损伤的分型方法——胸腰椎损伤TLICS评分系统进行评分,明确手术指征并进行手术治疗。结论 MRI在胸腰椎骨折诊治中可以明确地判断有无后柱损伤,避免漏诊,有利于指导治疗。     

多发伤中胸部损伤的CT和X线平片诊断价值分析

目的：探讨多发伤中胸部创伤的X线和CT诊断价值。方法：对46例多发伤中胸部伤患者进行临床、X线平片、CT扫描诊断，对X线平片与CT片进行对比分析。结果：CT表现为肺挫伤39例，肺撕裂伤6例，膈疝4例，X线分别漏、误诊18例、4例和4例，CT漏诊骨折11例。结论：CT能明确胸部创伤病变的部位、性质、程度，敏感性和特异性较X线平片高，能为临床提供更多可靠的诊疗依据，为多发伤中胸部创伤最重要的检查方法之一。     

严重胸腰椎骨折合并椎间盘损伤的手术治疗

目的　探讨胸腰椎骨折合并椎间盘损伤的情况及其对选择手术方式和预后的意义。方法　对 6 1例严重的胸腰椎骨折常规行MRI检查 ,了解合并椎间盘损伤的程度和位置以及椎管占位情况 ,并依此同时结合临床表现、X线片、CT检查结果 ,确定治疗方案。结果　 6 1例中 ,合并有上或下位椎间盘损伤者共 4 1例。单纯伤椎的上位椎间盘损伤 2 6例 ,单纯伤椎的下位椎间盘损伤 11例 ,伤椎的上下位椎间盘同时有损伤 4例。对 4 1例合并椎间盘损伤行前路手术 ,所有患者均获得良好骨融合 ,未出现后凸畸形复发或加重。结论　严重的胸腰椎骨折常合并有椎间盘的损伤 ,其中以上位椎间盘损伤多见。MRI是确定椎间盘损伤的重要手段之一。椎间盘损伤程度应作为选择手术方式的重要参考因素之一。     

胸、腹部复合锐器伤的诊断和治疗

目的 :提高胸腹部锐器伤的诊断和治疗水平。方法 :回顾性分析收治的 59例胸腹部复合锐器伤病人。结果 :行开胸探查 8例 ,死亡 1例 ,剖腹探查 4 0例 ,死亡 3例。保守治疗 1 1例 ,死亡 3例。结论 :胸腹部复合锐器伤伤情复杂 ,易漏诊、误诊 ,病死率高。应遵循抢救、诊断、治疗、严密观察并重的原则。伤口探查 ,胸、腹穿刺 ,CT、超声检查、X线平片对诊断有重要价值。有手术指征病人应立即急诊手术 ,暂时无手术指征病人应严密观察 ,以防有迟发临床表现。     

MRI对胸腰椎爆裂性骨折的诊断价值

本文对５６例胸腰椎爆裂性骨折的ＭＲＩ检查结果进行回顾性分析,以探讨ＭＲＩ的诊断价值,重点观察骨折,韧带及椎间盘损伤、脊髓马尾损害及血肿情况。结果有５３例前、中柱骨折在ＭＲＩ图像上得到明确显示,其椎管狭窄及后凸畸形程度与Ｘ线平片或ＣＴ扫描结果成正相关,有非常显著的统计学意义（Ｐ＜０．０１）,而ＭＲＩ所示韧带损伤多数无法根据Ｘ线平片或ＣＴ扫描结果作出诊断。作者认为,ＭＲＩ对于胸腰椎爆裂性骨折的诊断具有重要价值,必要时应与ＣＴ扫描同时选用。     

Thoracolumbar fractures in patients with multiple injuries: diagnosis and treatment-a review of 147 cases

BACKGROUND: The initial evaluation and treatment of patients with multiple injuries are challenging. However, little is known about thoracolumbar fractures in patients with multiple injuries. We aimed to determine the incidence of missed injuries of the thoracolumbar spine in patients with multiple injuries, to examine the reasons for the delay in diagnosis, and to study the selection of treatment options in the management and timing of surgical intervention. METHODS: One hundred forty-seven consecutive patients with acute thoracolumbar fractures and multiple trauma at the authors' hospital between 1988 and 1997 were retrospectively reviewed. The incidence of missed injuries of the thoracolumbar spine and the reasons for the delay in diagnosis were determined. All these patients were observed for a minimum of 3 years after surgery, except four who died during their hospital stay. RESULTS: Delayed diagnosis of thoracolumbar fractures was made in 28 patients (19%). There was an increased incidence of pulmonary complications (p < 0.01) and increased length of hospital stay (p < 0.05) in patients treated nonoperatively compared with patients treated operatively. Although no significant differences in the recovery rate of neurologic function (p > 0.05) were noted between the groups, the surgical patients had highly significantly less pain compared with the nonoperative patients (p < 0.01). The relationship between the timing of thoracolumbar surgery and complications failed to show statistical significance (p > 0.05). Neither the severity of injury nor the timing of surgery had any significant effect on the recovery rate (p > 0.05). CONCLUSION: Patients with blunt trauma caused by high-energy impact injuries are much more likely to have thoracolumbar fractures even if injuries elsewhere have been noted. Further radiographic studies of the thoracolumbar spine should be performed if there is any question related to a thorough and systematic examination. Choice of treatment options of thoracolumbar fractures in patients with multiple injuries is not different from that in patients with no associated injuries to other systems. Appropriate timing of thoracolumbar fracture fixation in patients with multiple injuries should not be dependent on a rigid protocol.     

Etiology and clinical course of missed spine fractures

A prospective study was designed to document course and outcome. Two hundred fifty-three patients with 274 spinal injuries were reviewed at the time of injury and discharge from hospital, as well as at 1, 2, and 5 years postinjury. Thirty-eight of these patients were identified who had been misdiagnosed at the initial assessment. Fracture location, cause of injury, neurologic deficit, and delay in diagnosis were all documented: 22.9% of cervical injuries, and 4.9% of the thoracolumbar injuries had a delayed diagnosis ranging from less than 1 day to 36 days. The causes of delayed diagnosis were: 1) failure to take X-rays, 2) fractures missed on X-ray, and 3) failure of patients to seek medical attention. Associated factors such as intoxication of the patient, multiple injuries, level of consciousness, or two levels of spinal injury contributed to the delayed diagnosis of these injuries. Certain "at-risk" populations for missed spinal injuries have been identified. In spite of delays in diagnosis, progression of an established neurologic deficit did not appear to occur in our study. However, the development of secondary deficits was significant in the delayed diagnosis group.     

胸腰椎严重骨折的分型与诊治

目的探讨胸、腰椎严重骨折的表述、分类、诊断与手术治疗原则。方法分析本组收治的51例多节段脊椎骨折和脊椎骨折脱位患者,将其归属于严重的脊柱骨折范畴。并对所有病例进行了分类,给出了详细的诊断描述,对于不同类型的患者采取不同的手术策略。结果26例平均随访38个月,Frankel分级改善1级者13例,2级者8例,3级者4例,无改善者l例,未发现有迟发型神经功能障碍者。结论对于胸、腰椎严重骨折我们首先应明确其分型。对于不同的骨折类型结合其术前评估制定不同的手术策略,将对脊柱稳定性及脊髓损伤的恢复起重要作用。     

Early osteosynthesis and prophylactic mechanical ventilation in the multitrauma patient

Prophylactic mechanical ventilation with PEEP of patients with severe injuries prevents or attenuates the clinical manifestations of ARDS. Also, operative stabilization of all major fractures appears to be beneficial in reducing the incidence of ARDS. Primary external or internal fixation of all unstable long-bone fractures combined with prophylactic ventilation is safe and well tolerated, and allows for optimal nursing of the patient. In a group of 58 severely injured patients, treated accordingly to these principles, late death from remote organ failure due to sepsis--which is the main cause of death in multitrauma patients treated with delayed osteosynthesis or conservative fracture treatment--did not occur. Prophylactic mechanical ventilation with PEEP resulted in a significantly lower incidence of ARDS.     

多节段非相邻型胸腰椎骨折的手术治疗及分型

目的：探讨多节段非相邻型胸腰椎骨折的手术治疗方式和分型。方法：2005年12月至2008年12月共治疗24例多节段非相邻型胸腰椎骨折患者,其中男16例,女8例;年龄18～63岁,平均36岁。根据ASIA脊髓神经功能损伤分级：A级1例,B级2例,C级2例,D级8例,E级11例。按改进的MNSF分类方法将骨折分为：A型15例,B型9例。骨折范围T6～L4,共累及48个椎体。按ASIA分级评分及影像学资料进行回顾性分析。结果：24例患者均接受手术治疗,无漏诊或延迟诊断。患者术后均获随访,随访时间3～36个月,平均18.3个月。骨折全部获得骨性愈合,骨折椎体高度无明显丢失,无钉棒弯曲、松动或断裂。术前13例脊髓神经损伤患者,术后除1例A级和1例B级无恢复外,其余11例均有1级以上脊髓神经功能恢复,共计A级1例,B级1例,C级1例,D级2例,E级19例。结论：对传统分类方法进行改进以便指导临床治疗,多节段非相邻型胸腰椎骨折的治疗方式应该根据神经损伤情况、骨折稳定性及骨折类型决定。     

Traction bow for acute reduction of fracture and/or dislocation of the thoracic or thoracolumbar spine

Treatment of acute fractures and/or fracture dislocations of the thoracic or thoracolumbar spine has traditionally involved bedrest or the use of traction devices with external hanging weights, until surgical correction can be accomplished. A fiberglass tubular traction bow with continuous adjustable elastic tension has been designed for the application of skeletal traction. When used to treat thoracic or thoracolumbar fractures and/or dislocations, it can maintain distraction forces in an uninterrupted fashion. Ten patients with acute fractures and/or dislocations of the thoracic or thoracolumbar spine were treated with this traction bow. All of the spinal deformities showed dramatic improvement within the first 3 h of treatment. The patients all showed immediate lessening of acute severe pain, and those with incomplete neurologic loss showed improvement of their neurologic function. The patients all tolerated the device well and were able to undergo radiologic examination and, ultimately, spinal fusion while they were stabilized in the traction bow. We believe this device is especially valuable for immediate reduction of spine and care of patients with fractures or fracture dislocations of the thoracolumbar spine.     

CT scanning reduces the risk of missing a fracture of the thoracolumbar spine

The aim of this study was first, to determine whether CT scans undertaken to identify serious injury to the viscera were of use in detecting clinically unrecognised fractures of the thoracolumbar vertebrae, and second, to identify patients at risk of 'missed injury'. We retrospectively analysed CT scans of the chest and abdomen performed for blunt injury to the torso in 303 patients. These proved to be positive for thoracic and intra-abdominal injuries in only 2% and 1.3% of cases, respectively. However, 51 (16.8%) showed a fracture of the thoracolumbar vertebrae and these constituted our subset for study. There were eight women and 43 men with mean age of 45.2 years (15 to 94). There were 29 (57%) stable and 22 (43%) unstable fractures. Only 17 fractures (33.3%) had been anticipated after clinical examination. Of the 22 unstable fractures, 11 (50%) were anticipated. Thus, within the whole group of 303 patients, an unstable spinal injury was missed in 11 patients (3.6%); no harm resulted as they were all protected until the spine had been cleared. A subset analysis revealed that patients with a high Injury Severity Score, a low Glasgow Coma Scale and haemodynamic instability were most likely to have a significant fracture in the absence of positive clinical findings. This is the group at greatest risk. Clinical examination alone cannot detect significant fractures of the thoracolumbar spine. It should be combined with CT imaging to reduce the risk of missed injury.