放射学检查在颈椎损伤早期诊断价值的研究

评估传统放射学检查方法对颈椎损伤早期诊断价值。对１５２例疑有急性颈椎损伤的成人患者行常规放射学检查即颈椎侧位片、前后位片及枢椎齿状突开口位片检查，并与断层扫描、ＣＴ扫描及ＭＲＩ检查结果进行比较。结果１５２例患者中８７例发生颈椎骨折（占５７．２％）；颈椎侧位片诊断的敏感性、特异性和准确性分别是８４％、７４％和８０％，而颈椎常规放射学诊断的敏感性、特异性和准确性分别为９３％、８０％和８７％。作者认为：颈椎损伤早期应采用颈椎侧位片、前后位片及枢椎齿状突开口位片作为放射学常规检查；对于常规放射学检查或临床表现提示有颈椎损伤者以及根据常规放射学检查难以确定诊断者，应考虑行断层扫描、ＣＴ扫描及ＭＲＩ检查     

An evidenced-based approach to radiographic assessment of cervical spine injuries in the emergency department

The modern approach to suspected cervical spine injuries is highly dependent on appropriate utilization of radiographic studies. Clinical decision rules have been developed for determination of those most likely to benefit from plain film studies, but there is confusion regarding those who should undergo computed tomography (CT) scanning. This case-based review highlights current available evidence and provides a framework to guide emergency medicine providers in the treatment of patients with trauma to the cervical spine.     

Missed cervical spine fracture-dislocations: the importance of clinical and radiographic assessment

OBJECTIVE: To review the case of a patient who suffered a cervical spine fracture-dislocation missed at a hospital emergency department. CLINICAL FEATURES: A 77-year-old man involved in a motor vehicle accident was transported to a local emergency hospital where cervical spine x-ray films taken were reported as demonstrating no evidence of acute injury. The patient visited a chiropractic clinic 6 days later, where x-ray films were again obtained, finding that the patient sustained fractures of C5 and C6, as well as a bilateral facet dislocation at C5/C6. Computed tomography confirmed the fractures, and magnetic resonance imaging findings demonstrated cervical spinal cord compression and posterior spinal cord displacement. INTERVENTION AND OUTCOME: The patient was referred for preoperative medical evaluation. He underwent C5-6 closed reduction and anterior/posterior fusion surgery and was released without complication. Patient follow-up indicated full recovery with minimal neurologic symptoms. CONCLUSION: Cervical spine fracture-dislocations are often missed during standard radiographic examinations in emergency department settings. Chiropractors are encouraged to perform a comprehensive evaluation of patients presenting with cervical trauma even if they have had prior x-ray films reported as normal. Standard x-ray films taken at emergency department facilities are not entirely reliable for detecting or revealing cervical spine fracture-dislocations. This case stresses the importance of careful clinical assessment and imaging procedures on patients who have encountered cervical spine trauma.     

Clearance of the cervical spine in multitrauma patients: The role of advanced imaging

The cervical spine is injured in 3% of major trauma patients. Radiographic clearance for injury must be provided efficiently and accurately. There are numerous choices for clearance that are now in clinical practice: lateral radiograph only, 3-view or 5-view cervical-spine (c-spine) series, flexion-extension radiographs, computed tomography (CT) with multiplanar reformations, and magnetic resonance imaging (MRI). This article reviews the literature on methods of c-spine clearance, and emphasizes the pitfalls of each modality. Although lateral radiographs detect 60% to 80% of c-spine fractures, a significant number of fractures are not visible, even when three views of the spine are obtained. The sensitivity of plain radiographs can be improved by attention to several subtle features, which are discussed. Flexion-extension radiographs in the acute setting have an unacceptably high false-negative and false-positive rate. CT detects 97% to 100% of fractures, but its accuracy in detection of purely ligamentous injuries has not been documented. Furthermore, CT is limited in patients with severe degenerative disease. MRI is highly sensitive in the detection of ligamentous injury, but not all cases of injury may cause instability. MRI is also much less sensitive than CT to fractures of the posterior elements of the spine, and to injuries of the craniocervical junction. The causes of missed cervical spine injury and delayed instability are discussed and shown in this article. An algorithm for the use of advanced imaging is proposed.     

Retroperitoneal injuries: pitfalls in diagnosis and management

Retroperitoneal injury caused by penetrating trauma or associated with progressive shock following blunt trauma is usually recognized promptly and managed appropriately. Isolated retroperitoneal injury from blunt trauma, unless accompanied by major hemorrhage or gross hematuria, is often difficult to diagnose and needed treatment may be delayed. Although clinical examination remains the cornerstone of diagnosis, the high incidence of ethanol abuse and/or concurrent head injury in trauma patients has led to increased use of computed tomography in the diagnosis of abdominal trauma. To determine the effect, if any, of CT examination on the diagnosis and management of retroperitoneal trauma, we reviewed our patient experience. During the 16-month period ending in April 1986, 135 patients sustained 177 retroperitoneal injuries (116 by blunt and 19 by penetrating trauma). There were 26 deaths (19% mortality). There were 90 pelvic fractures and 31 lumbar spine fractures, as well as 21 genitourinary, 12 gastrointestinal, five pancreatic, and eight major vascular injuries. Ten patients had isolated retroperitoneal hematomas. We conclude that (1) patients with retroperitoneal injuries and coexisting intraperitoneal injuries should have early operation; (2) isolated retroperitoneal trauma tends to lead to observation unless CT is used as part of the early assessment; and (3) routine use of CT in patients at risk accurately defines the extent of injury and enhances clinical management.     

Utility of an Initial D-dimer Assay in Screening for Traumatic or Spontaneous Intracranial Hemorrhage

OBJECTIVE: To evaluate the sensitivity of a D-dimer assay as a screening tool for possible traumatic or spontaneous intracranial hemorrhage. If adequately sensitive, the D-dimer assay may potentially permit omission of a more expensive computed tomography (CT) scan of the head when such hemorrhage is clinically suspected. METHODS: Prospective, consecutive, blinded study of patients (age > 16 years) requiring a CT scan of the head for suspected intracranial hemorrhage over a five-month period at a university, Level I trauma center. All study patients had a serum D-dimer assay obtained prior to their CT scans. Sensitivity and specificity, with 95% confidence intervals (95% CIs), of the enzyme-linked immunosorbent assay (ELISA) D-dimer assay for the detection of intracranial hemorrhage were calculated. RESULTS: Of the 319 patients entered in the study, 25 (7.8%) had a CT scan positive for intracranial hemorrhage. Patients with intracranial hemorrhage were more likely to have a positive D-dimer assay (chi-square = 13.075, p < 0.001). The D-dimer assay had 21 true-positive and four false-negative tests, resulting in a sensitivity of 84.0% (95% CI = 63.7% to 95.5%) and a specificity of 55.8% (95% CI = 55.5% to 55.9%). The four false-negative cases included one small intraparenchymal hemorrhage, one small subarachnoid hemorrhage, one moderate-sized intraparenchymal hemorrhage with mid-line shift, and one large subdural hematoma requiring emergent surgery. CONCLUSIONS: Due to the catastrophic nature of missing an intracranial hemorrhage in the emergency department, the D-dimer assay is not adequately sensitive or predictive to use as a screening tool to allow routine omission of head CT scanning.     

Traumatic intracranial hemorrhages in facial fracture patients: review of 2,195 patients

OBJECTIVE: Patients sustaining facial fractures are at risk for accompanying traumatic intracranial hematomas, which are a major cause of morbidity and mortality. Prompt recognition is crucial in improving patient survival and recovery. This study examined which simple clinical signs identify facial fracture patients at risk for intracranial hemorrhage before the performance of computed tomography. DESIGN AND METHODS: Retrospective study of 2,195 patients with facial fractures during a period of 7 years. By means of univariate and multivariate analysis clinical features potentially predictive for (a) intracranial hemorrhage and (b) surgery for intracranial hemorrhage were identified. SETTING: Critical care units of anesthesiology and neurology, general traumatology, and oral and maxillofacial surgery in a level I trauma university hospital. RESULTS: Seizures (OR 22.1) and vomiting/nausea (OR 20.2) were the strongest independent predictors of intracranial bleeding in facial fracture patients. For intracranial hemorrhages requiring surgical intervention closed head injuries (OR 9.75) and cranial vault fractures (OR 5.0) were the most significant risk factors. However, among those patients without vomiting/nausea and without seizures and without closed head injury ( n=1,628), 20 patients (1.2%) suffered intracranial hemorrhage, and six (0.37%) of them required surgical intervention. CONCLUSIONS: Simple clinical symptoms, such as seizures, vomiting/nausea, history of a closed head injury or cranial vault fractures are strong predictors for intracranial hemorrhage in facial fracture patients. The early consideration of such important indicators allows us to detect patients at elevated risk of an intracranial hematoma requiring surgical intervention.     

A pitfall in neck pain: occult odontoid fracture

Type III odontoid fractures of the axis are the second most common injuries of the cervical spine. Most of these result from motor vehicle accidents and falls. Occult odontoid fractures without preceding trauma are rarely reported in the literature and may be difficult to diagnose. We report the case of a healthy patient who had no history of trauma, but sustained sudden pain in the neck and guarding during head movement after sleep. Initial radiographs of the cervical spine including open-mouth, anterior-posterior, and lateral views did not reveal any obvious fractures. Type III odontoid fracture was uneventfully diagnosed via high-quality three-dimensional reconstruction of computed tomography. The possible mechanism was hyperextension of the neck during the change from the supine to the sitting position. Type III odontoid fractures can occur in the absence of major trauma. The usefulness of computed tomography is emphasized and the literature is also reviewed.     

Trauma radiology: Part V. Imaging of acute cervical spine trauma

Cervical spine injury constitutes a major cause of morbidity resulting from trauma. The consequences of a missed "significant" injury can be devastating for the patient and can create potential medical legal consequences for involved physicians. Multiple imaging modalities can be applied to imaging of the cervical spine after trauma, including radiography, computed tomography (CT), myelography, CT myelography and magnetic resonance imaging (MRI). Controversy exists concerning the appropriate number of radiographic views required for the screening assessment of cervical spine injuries. CT clarifies uncertain radiological findings, identifies subtle fractures in patients with neck pain or with neurological deficits but with normal radiographs, determines details of injury, and assists in operative planning. MRI has virtually replaced myelography and CT myelography in evaluating the traumatized cervical spine. MRI is more accurate than CT with intrathecal contrast in delineating epidural pathology, ligament injury, soft-tissue edema, and cord parenchymal injury. Information derived from MRI guides appropriate management and has value in predicting injury outcome. We consider indications for and relative merits of these various diagnostic modalities, and we describe imaging features of major patterns of cervical spine injury.     

Imaging of acute cervical spine trauma.

Over the past 15 years there have been dramatic changes in the approach to imaging acute cervical spine trauma. This article addresses the current thoughts and controversies regarding the most appropriate techniques to evaluate the patient with cervical spine trauma, with an emphasis on the role of computed axial tomography (CT) and magnetic resonance imaging (MRI). The issue of clinical versus radiographic evaluation of low-risk patients is also discussed.     

脊柱爆裂骨折的CT与X线平片诊断对照分析(附105例报告)

目的：进一步提高CT和X线平片对脊柱爆裂骨折诊断价值的认识。方法：收集经CT检查确诊为脊柱爆裂骨折而线平片诊断为单纯压缩性骨折或未见骨折者共105例进行对照分析。结果；因X线平片无典型征象而误诊33例，由于对典型征象缺乏认识而误诊53例，由于投照因素漏诊19例。结论：X线平片对脊柱爆裂骨折的误诊、漏诊率较高，提高认识水平和投照质量可减少误、漏诊，CT能提高脊柱爆裂骨折的诊断准确率并显示椎管的狭窄程度，有利于临床及时正确的处理。     

The cervical spine: radiologist's perspective

This article provides an essential curriculum in cervical spine radiology. It discusses the uses of plain radiographs, MR imaging, computed tomography (CT), and CT myelography, in addition to the methodologies of discography, epidural injections under visualization, and facet and nerve root injections. It explains how radiographic images of the cervical spine can differentiate tumors, inflammation, recent or prior trauma, and the range of discal, arthritic, neural, and vascular cervical pathologies and, just as importantly, when they cannot.     

Best Practice in Diagnostic Imaging after Blunt Force Trauma Injury to the Cervical Spine: A Systematic Review

IntroductionThe aim of this study was to investigate best practice in evidence-based clinical examinations to determine the diagnostic efficacy of plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI) of a cervical spine injury after blunt force trauma.MethodsA systematic review of recent literature was performed, with the intention of analysing only original research articles focusing on at least two imaging modalities or clinical decision guidelines in relation to blunt force trauma injuries involving the cervical spine. The search used the following databases: ProQuest Central, ScienceDirect, and Scopus. A total of 18 studies were identified as suitable for review; these were further supported by relevant secondary studies.ResultsIt was found that the National Emergency X-Radiology Utilization Study and the Canadian C-Spine Rule are both highly sensitive methods for screening patients after cervical spine injuries. CT was shown to have a higher validity than plain radiography and MRI for the detection of a bony cervical spine injury. MRI is recommended for obtunded or unevaluable patients with suspected neurologic deficit.ConclusionsOverall, the literature appears to suggest that individuals with a suspected high risk of injury after examination using clinical decision rules should undergo a cervical CT examination. For patients who are found to have a low risk of injury after clinical decision guidelines, good-quality plain radiography is recommended as sufficient.     

Imaging of the atlas (C1) and axis (C2)

In imaging the atlantoaxial region in injured patients, the initial modality is plain radiography. The lateral C-spine as well as the open-mouth view are essential in this regard. On these views, it is not only important to examine the bony contour but also to look for indirect signs of injury such as prevertebral soft-tissue swelling, air in the prevertebral space, an increased width of the anterior atlantodental interval, and overriding of the C1-C2 joint on one side (the so-called wink sign of atlantoaxial rotatory subluxation). In patients in whom there is a high index of suspicion for occult trauma, but without fractures suggested or adequately visualized on routine films, or in those with severe cranial trauma, further studies should be pursued. CT scan is the modality of choice in optimally imaging the bony contours of the axis and atlas. It has limitations in visualizing transversely oriented fractures such as high dens fractures, transverse fractures of the facet joints (although widening of the facet joint is an indirect indication of facet fracture), or transverse arch fractures. Plain tomography may better demonstrate such transverse fractures but has several disadvantages. Plain tomography is often not as readily available as CT; it requires that the patient be placed in lateral decubitus position to obtain lateral tomograms, which may be contraindicated in such clinical circumstances; and it is not as easy to appreciate three-dimensional relationships on plain tomography as it is on CT. CT clearly defines the location of displaced bone fragments in relationship to the spinal canal as well as often demonstrating disc injuries. Ligamentous injury, though potentially visualized directly on MR imaging, is more commonly addressed with flexion-extension films. Flexion-extension studies should, obviously, be performed only in awake, oriented patients who are without neurologic deficit, and the studies should be done with close physician supervision and stopped at the first onset of pain. MR imaging may be helpful in demonstrating soft-tissue injuries such as hemorrhage, disc herniation, nerve root impingement, and direct spinal cord damage.     

Clinical outcomes of magnetic resonance imaging in blunt cervical trauma

Objectives: To determine whether MRI of the cervical spine resulted in a change in management of patients with blunt trauma and normal plain X‐ray (XR)/CT of the cervical spine. Methods: An explicit chart review was conducted of patients seen at a Level 1 trauma centre over a 1 year period. Clinical details were extracted from the charts of patients with blunt trauma who had a normal plain XR and CT scan of the cervical spine and who underwent cervical spine MRI. A comparison of clinical details was made between those with a normal/abnormal MRI secondary to the acute injury. Results: One hundred and thirty‐four patients met entry criteria. Discharge non‐operative management of the cervical spine was associated with a change in management by the MRI result (P < 0.0001) where MRI of the cervical spine occurred a median of 3 days (interquartile range 0–4.5, range 0–137) after the injury. The MRI occurred before discharge 90% of the time in both groups. Operative management occurred in three patients and was delayed until after first outpatient review in two patients. Conclusions: An abnormal MRI after normal plain XR and CT cervical spine studies resulted in a change in non‐operative management at discharge. Early MRI resulted in one patient receiving surgery before discharge. No unstable injuries were detected by MRI that were not evident on plain XR or CT cervical spine.     

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.     

Intracranial injury following minor head trauma.

One hundred twelve patients presenting with a Glascow Coma Scale (GCS) score greater than or equal to 13 with a history of minor head trauma were prospectively studied to determine if certain historic or physical examination variables would predict which of these patients were at increased risk for intracranial injury. Patients either underwent cranial computed axial tomography (CT) or were followed up by phone at 4 weeks to determine major morbidity or mortality. Thirty-five patients underwent CT scanning of the head and eight demonstrated intracranial injury. Five patients were treated nonoperatively, and three patients had neurosurgical intervention. One patient died following surgery. At the 4-week follow-up no patient was found to have suffered any major morbidity or mortality. Stepwise logistic regression found age over 40 years (P = .05, odds ratio = 6.4, 95% confidence interval 1.0 to 38.8) and complaint of headache (P = .039, odds ratio 8.167, 95% confidence interval 1.074 to 62.09) to be significantly predictive of intracranial injury. All eight patients with positive CTs had a GCS score of 15. The authors conclude that intracranial injury does exist in patients suffering minor head trauma with a GCS score of 13 or above. Age over 40 years and complaint of headache are associated with an increased risk of intracranial injury.     

Neuroimaging of fractureless transforamen magnum penetrating injury of the cerebellum.

An unusual case of penetrating injury to the cerebellum by a foreign body is described. The authors recommend plain radiographs and computed tomography to rule out fractures of the skull vault and base and the upper cervical spine, as well as to ascertain the presence and location of foreign bodies. Magnetic resonance imaging is ideal for the follow-up assessment of brain damage.     

Emergency Physicians' Attitudes toward and Use of Clinical Decision Rules for Radiography

Objectives: 1) To assess Canadian emergency physicians' (EPs') use of and attitudes toward 2 radiographic clinical decision rules that have recently been developed and to identify physician characteristics associated with decision rule use; 2) to determine the use of CT head and cervical spine radiography by EPs and their beliefs about the appropriateness of expert recommendations supporting the routine use of these radiographic procedures; and 3) to determine the potential acceptance of clinical decision rules for CT scan in patients with minor head injury and cervical spine radiography in trauma patients. Methods: A cross-sectional anonymous mail survey of a random sample of 300 members of the Canadian Association of Emergency Physicians using Dillman's Total Design Method for mail surveys. Results: Of 288 eligible physicians, 232 (81%) responded. More than 95% of the respondents stated they currently used the Ottawa Ankle Rules and were willing to consider using the newly developed Ottawa Knee Rule. Physician characteristics related to frequent use of the Ottawa Ankle Rules were younger age, fewer years since graduating from medical school, part time or resident employment status, working in a hospital without a CT scanner, and believing that decision rules are not oversimplified cookbook medicine or too rigid to apply. Eighty-five percent did not agree that all patients with minor head injuries should receive a CT head scan and only 3.5% stated they always refer such patients for CT scan. Similarly, 78.5% of the respondents did not agree that all trauma patients should receive cervical spine radiography and only 13.2% said they always refer such patients for cervical spine radiography. Ninety-seven and 98% stated they would be willing to consider using well-validated decision rules for CT scan of the head and cervical spine radiography, respectively. Fifty-two percent and 67% of the respondents required the proposed CT and C-spine to be 100% sensitive for identifying serious injuries, respectively. Conclusions: Canadian EPs are generally supportive of clinical decision rules and, in particular, have very positive attitudes toward the Ottawa Ankle and Knee Rules. Furthermore, EPs disagree with recommendations for routine use of CT head and cervical spine radiography and strongly support the development of well-validated decision rules for the use of CT head and cervical spine radiography. Most EPs expected the latter rules to be 100% sensitive for acute clinically significant lesions.     

肋软骨骨折的64层螺旋CT诊断价值分析

目的探讨64层螺旋CT在肋软骨骨折诊断中的价值,提高诊断水平。方法回顾性分析28例肋软骨骨折患者的64层螺旋CT三维重组图像,并与X线平片CT直接扫描横断位图像对照。结果28例患者中64层螺旋CT三维重组图像发现肋软骨骨折33处,23例X线平片、9例CT直接横断位图像未显示。结论64层螺旋CT对肋软骨骨折的显示优于普通X线平片及常规CT胸部横断位图像,可望成为检测肋软骨骨折的最佳影像学检查手段。