Hauser Carl J, Visvikis George, Hinrichs Clay, Eber Corey D, Cho Kyunghee, Lavery Robert F, Livingston David H
Department of Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, 07103, USA.
J Trauma. 2003 Aug;55(2):228-34; discussion 234-5. doi: 10.1097/01.TA.0000076622.19246.CF.
Concern for thoracolumbar spine (TLS) injuries after major trauma mandates immobilization pending radiographic evaluation. Current protocols use standard posteroanterior and lateral radiographs of the thoracolumbar spine (XR/TLS), but many patients also undergo abdominal or thoracic computed tomographic (CT) scanning. We sought to evaluate whether helical truncal CT scanning performed to evaluate visceral trauma images the spine as well as dedicated XR/TLS.
We prospectively studied 222 consecutive patients sustaining high-risk trauma requiring TLS screening because of clinical findings or altered mentation. The chest, abdomen, and pelvis were imaged with one intravenous contrast infusion. All patients had CT scan of the chest, abdomen, and pelvis (CT/CAP) and XR/TLS. Initial radiologic diagnoses were compared with the discharge diagnosis of acute fractures confirmed by thin-cut CT scan and/or clinical examination of the patient when alert.
Of 222 patients studied, 215 were fully evaluated. Thirty-six (17%) had acute TLS fractures. The accuracy of CT/CAP for TLS fractures was 99% (95% confidence interval [CI], 96-100%). The accuracy of XR/TLS was 87% (95% CI, 82-92%). Sensitivity, specificity, and positive and negative predictive values were better for CT/CAP than for XR/TLS. CT/CAP found acute fractures XR/TLS missed, and correctly classified old fractures XR/TLS read as "possibly" acute. The total XR/TLS misclassification rate was 12.6% (95% CI, 8.4-19%); for CT/CAP it was 1.4% (95% CI, 0.3-3.3%). No fractures were missed by CT/CAP. No unstable fracture was missed by either technique.
CT/CAP diagnoses TLS fractures more accurately than XR/TLS. Neither misses unstable fractures, but CT scanning finds small fractures that benefit by treatment and identifies chronic disease better. CT screening is far faster and shortens time to removal of spine precautions. CT scan-based diagnosis does not result in greater radiation exposure and improves resource use. Screening the TLS on truncal helical CT scanning performed for the evaluation of visceral injuries is more accurate than TLS imaging by standard radiography. CT/CAP should replace plain radiographs in high-risk trauma patients who require screening.
对于严重创伤后胸腰椎脊柱（TLS）损伤的关注要求在进行影像学评估之前进行固定。目前的方案采用胸腰椎脊柱的标准正位和侧位X线片（XR/TLS），但许多患者也会接受腹部或胸部计算机断层扫描（CT）。我们试图评估为评估内脏创伤而进行的螺旋躯干CT扫描对脊柱的成像效果是否与专门的XR/TLS一样好。
我们前瞻性地研究了222例因临床表现或意识改变而需要进行TLS筛查的高危创伤连续患者。通过一次静脉注射造影剂对胸部、腹部和骨盆进行成像。所有患者均接受胸部、腹部和骨盆CT扫描（CT/CAP）以及XR/TLS检查。将初始影像学诊断与出院诊断进行比较，出院诊断为通过薄层CT扫描和/或患者清醒时的临床检查确诊的急性骨折。
在研究的222例患者中，215例得到了全面评估。36例（17%）有急性TLS骨折。CT/CAP对TLS骨折的诊断准确率为99%（95%置信区间[CI]，96 - 100%）。XR/TLS的准确率为87%（95%CI，82 - 92%）。CT/CAP的敏感性、特异性以及阳性和阴性预测值均优于XR/TLS。CT/CAP发现了XR/TLS遗漏的急性骨折，并正确分类了XR/TLS读为“可能”急性的陈旧性骨折。XR/TLS的总错误分类率为12.6%（95%CI，8.4 - 19%）；CT/CAP为1.4%（95%CI，0.3 - 3.3%）。CT/CAP未遗漏任何骨折。两种技术均未遗漏不稳定骨折。
CT/CAP对TLS骨折的诊断比XR/TLS更准确。两种方法均未遗漏不稳定骨折，但CT扫描能发现可通过治疗获益的小骨折，并能更好地识别慢性病。CT筛查速度更快，缩短了去除脊柱防护措施的时间。基于CT扫描的诊断不会导致更大的辐射暴露，且能提高资源利用效率。对因评估内脏损伤而进行的躯干螺旋CT扫描进行TLS筛查比标准X线摄影对TLS的成像更准确。对于需要筛查的高危创伤患者，CT/CAP应取代平片。
