Gonzalez R P, Fried P O, Bukhalo M, Holevar M R, Falimirski M E
University of South Alabama Medical Center, Mobile 36617-2293, USA.
J Am Coll Surg. 1999 Aug;189(2):152-7. doi: 10.1016/s1072-7515(99)00065-4.
The purpose of this study was to evaluate the hypothesis that awake and alert blunt trauma patients with Glasgow Coma Scores of 14 or 15 (regardless of blood ethanol level or other injuries sustained) can be effectively evaluated with clinical examination without radiographic evaluation of the cervical spine.
During a 32-month period at an urban Level 1 Trauma Center, 2,176 consecutive blunt trauma patients who presented with Glasgow Coma Scores of 14 or 15 were prospectively evaluated by trauma resident housestaff. Housestaff performed physical examinations of the neck and questioned the patients for the presence of neck pain. Following study form documentation of the cervical neck examination, a lateral cervical spine x-ray was performed. Further studies such as swimmer's view and CAT scan were performed if the lateral x-ray could not completely evaluate C1 to C7. These further studies were considered part of the lateral cervical spine (c-spine) x-ray screen. Attending radiologists performed final x-ray interpretations.
The study consisted of 2,176 patients, 33 (1.6%) of whom were diagnosed with cervical spine injury. Of the 33 patients with cervical spine injury, 3 had negative clinical examinations (sensitivity, 91%). Lateral c-spine x-ray screen was negative in 1 of these 3 patients. The 2 patients with negative c-spine clinical examination but positive lateral c-spine x-ray screens were diagnosed with C2 spinous process fracture and C6-C7 body fractures. Thirteen patients with negative lateral c-spine screens (sensitivity, 61%) were diagnosed with cervical spine injury. We evaluated 463 patients with blood ethanol levels greater than 100 mg/dL, and 6 (1.3%) were diagnosed with c-spine injury. No injuries were missed on clinical examination in this subgroup with elevated blood ethanol levels.
本研究的目的是评估以下假设：格拉斯哥昏迷评分为14或15分的清醒且警觉的钝性创伤患者（无论血液乙醇水平或其他损伤情况如何），无需进行颈椎的影像学评估，仅通过临床检查即可得到有效评估。
在一家城市一级创伤中心的32个月期间，2176例连续的格拉斯哥昏迷评分为14或15分的钝性创伤患者由创伤住院医师进行前瞻性评估。住院医师对患者颈部进行体格检查，并询问患者是否存在颈部疼痛。在按照研究表格记录颈椎检查情况后，进行颈椎侧位X线检查。如果侧位X线不能完全评估C1至C7，则进行进一步检查，如游泳者位片和计算机断层扫描。这些进一步检查被视为颈椎侧位X线筛查的一部分。放射科主治医生进行最终的X线解读。
该研究包括2176例患者，其中33例（1.6%）被诊断为颈椎损伤。在这33例颈椎损伤患者中，3例临床检查结果为阴性（敏感性为91%）。这3例患者中有1例颈椎侧位X线筛查结果为阴性。2例颈椎临床检查结果为阴性但颈椎侧位X线筛查结果为阳性的患者被诊断为C2棘突骨折和C6 - C7椎体骨折。13例颈椎侧位筛查结果为阴性的患者（敏感性为61%）被诊断为颈椎损伤。我们评估了463例血液乙醇水平大于100mg/dL的患者，其中6例（1.3%）被诊断为颈椎损伤。在这个血液乙醇水平升高的亚组中，临床检查未漏诊任何损伤。
1）对清醒且警觉的钝性创伤患者进行颈部临床检查能够可靠地排除严重颈椎损伤。增加颈椎侧位X线检查并不能提高临床检查对严重颈椎损伤诊断的敏感性。2）乙醇水平升高并非将临床检查用作颈椎损伤筛查工具的禁忌证。由格拉斯哥昏迷评分确定的意识水平是决定颈椎损伤筛查方法的更有效标准。
