Bruner J P, Tulipan N, Dabrowiak M E, Luker K S, Walters K, Burns P, Reed G
Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
Ultrasound Obstet Gynecol. 2004 Nov;24(6):612-7. doi: 10.1002/uog.1781.
To assess the accuracy of obstetric sonography in determining the upper level of myelomeningocele lesions.
This was a retrospective study of 171 consecutive cases of spina bifida repaired in utero. The upper level of the lesion as determined by obstetric sonography was assigned by community physicians prior to referral in the second trimester and by the authors at Vanderbilt University Medical Center during preoperative evaluation. One hundred and eleven cases had levels established by plane-film X-ray or magnetic resonance imaging after delivery and this was regarded as the gold standard.
Of the 171 community examinations, only 29% identified a specific upper level of the lesion; our corresponding examinations specified the lesion level in all cases. Of the 111 cases that had upper levels of the lesion established by post-delivery imaging, corresponding levels were available for comparison from 35 of the community examinations and from 111 of the examinations performed at Vanderbilt. All three assigned levels were available for comparison in 35 cases. In 26% of cases, community-assigned levels agreed exactly with post-delivery levels, while 66% agreed within one level and 80% agreed within two levels. In 38% of cases, levels assigned at Vanderbilt agreed exactly with post-delivery levels, while 78% agreed within one level and 96% agreed within two levels. Upper levels of the lesion assigned at Vanderbilt were significantly more accurate overall compared with those assigned by community physicians (signed rank test [paired comparison], P = 0.048). However, comparison of lesion levels assigned at Vanderbilt in the first 50 vs. the last 61 cases revealed a significant learning effect (Fisher's exact test, P = 0.03). When comparison of lesion levels assigned by community physicians was restricted to the first 50 cases at Vanderbilt, accuracy was similar (n = 13; t-test, P = 0.16; rank sum test, 0.31).
Community physicians were successful in assigning the upper level of the spina bifida lesion only 29% of the time. When successful, the accuracy of these determinations was similar to that of the authors at Vanderbilt. A significant learning effect was demonstrated by improved accuracy over time at Vanderbilt. A concerted continuing medical education effort is indicated to improve the imaging skills of physicians in the accurate diagnosis of the severity of spina bifida in fetuses.
评估产科超声检查在确定脊髓脊膜膨出病变上界方面的准确性。
这是一项对171例连续在子宫内接受脊柱裂修复手术病例的回顾性研究。产科超声检查所确定的病变上界，在孕中期转诊前由社区医生确定，在术前评估时由范德堡大学医学中心的作者确定。111例病例在分娩后通过平片X线或磁共振成像确定了病变上界，这被视为金标准。
在171次社区检查中，只有29%确定了病变的具体上界；我们相应的检查在所有病例中都明确了病变水平。在111例通过分娩后成像确定病变上界的病例中，社区检查中有35例以及范德堡进行的检查中有111例可获得相应水平用于比较。在35例病例中所有三种确定的水平都可用于比较。在26%的病例中，社区确定的水平与分娩后水平完全一致，66%在一个水平范围内一致，80%在两个水平范围内一致。在38%的病例中，范德堡确定的水平与分娩后水平完全一致，78%在一个水平范围内一致，96%在两个水平范围内一致。总体而言，与社区医生确定的病变上界相比，范德堡确定的病变上界显著更准确（符号秩检验[配对比较]，P = 0.048）。然而，比较范德堡前50例与后61例病例中确定的病变水平，显示出显著的学习效应（Fisher精确检验，P = 0.03）。当将社区医生确定的病变水平比较限制在范德堡的前50例病例时，准确性相似（n = 13；t检验，P = 0.16；秩和检验，0.31）。
社区医生仅在29%的时间里成功确定了脊柱裂病变的上界。成功时，这些确定的准确性与范德堡的作者相似。范德堡随着时间推移准确性提高证明了显著的学习效应。需要开展协同的继续医学教育努力，以提高医生在准确诊断胎儿脊柱裂严重程度方面的成像技能。
