Homnick Adena, Lavery Robert, Nicastro Olivia, Livingston David H, Hauser Carl J
Department of Surgery, Division of Trauma, UMDNJ-New Jersey Medical School, Newark, New Jersey, USA.
J Trauma. 2007 Dec;63(6):1292-5. doi: 10.1097/TA.0b013e31812eed3c.
Historically, thoracolumbar spine transverse process fractures (TVPFx) found on "plain films" of the spine were occasionally associated with occult, mechanically significant vertebral fractures. Thus, "log-roll precautions" have been used pending formal spine evaluation and further imaging. As integrated helical computed tomography (CT) scans of the torso have become routine screening tools in high-energy trauma, TVPFx have been diagnosed with far greater frequency. Yet, where no associated spine injuries are found initially, such isolated TVPFx appear to be benign.
We retrospectively reviewed the diagnosis and management of TVPFx in a large Level I trauma center in the period between 2002 and 2005. Of 314 patients with TVPFx who survived more than 48 hours, 17% had fractures of the weight-bearing columns of the thoracolumbar spine noted on the same CT scan and were excluded from study. The management and outcome of the remaining "isolated" TVPFx were assessed by review of trauma registry and charted data.
The 248 patients included sustained 2.3 +/- 1.5 (SD) TVPFx. They spent 29 hours +/- 32 hours on log-roll precautions while being evaluated by spine consultants and "cleared" before initiating physical therapy. Despite this prolonged immobilization and substantial further investigation, none of the patients with TVPFx judged to be isolated on the basis of screening truncal CT scan proved to have a missed injury of a major vertebral element on further study.
Isolated thoracolumbar TVPFx are found frequently when helical CT scan is used to screen the torso after high-energy injury. TVPFx are usually multiple. They can be markers for visceral injuries, and in this study, 17% were associated with "significant" fractures. TVPFx require careful pain management and benefit by early mobilization. Yet, where no other vertebral fracture is seen on an adequate screening CT scan, investigation may reasonably end. Further imaging and consultations with spine services waste scarce resources, and lead to prolonged log-roll precautions, which delay mobilization and are potentially deleterious to overall patient care.
从历史上看，在脊柱“平片”上发现的胸腰椎横突骨折（TVPFx）偶尔与隐匿性、具有机械意义的椎体骨折相关。因此，在进行正式的脊柱评估和进一步影像学检查之前，一直采用“滚动式护理预防措施”。随着躯干螺旋计算机断层扫描（CT）已成为高能创伤的常规筛查工具，TVPFx的诊断频率大幅提高。然而，在最初未发现相关脊柱损伤的情况下，这种孤立性TVPFx似乎是良性的。
我们回顾性分析了2002年至2005年期间一家大型一级创伤中心TVPFx的诊断和治疗情况。在314例存活超过48小时的TVPFx患者中，17%在同一CT扫描中发现有胸腰椎承重柱骨折，这些患者被排除在研究之外。通过回顾创伤登记和图表数据来评估其余“孤立性”TVPFx的治疗及结果。
纳入研究的248例患者共发生2.3±1.5（标准差）处TVPFx。在脊柱专科医生评估并“排除问题”以开始物理治疗之前，他们在滚动式护理预防措施下度过了29小时±32小时。尽管有这种长时间的固定和大量进一步检查，但根据筛查性躯干CT扫描判断为孤立性TVPFx的患者，在进一步检查中均未发现主要椎体结构的漏诊损伤。
在高能损伤后使用螺旋CT扫描筛查躯干时，经常会发现孤立性胸腰椎TVPFx。TVPFx通常为多发性。它们可能是内脏损伤的标志，在本研究中，17%与“严重”骨折相关。TVPFx需要仔细的疼痛管理，并通过早期活动获益。然而，在充分的筛查CT扫描未发现其他椎体骨折的情况下，检查可以合理结束。进一步的影像学检查和脊柱专科会诊会浪费稀缺资源，并导致长时间的滚动式护理预防措施，这会延迟活动并可能对患者的整体护理产生有害影响。
