Schoenfeld Andrew J, Bono Christopher M, McGuire Kevin J, Warholic Natalie, Harris Mitchel B
Department of Orthopaedic Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts 02215, USA.
J Trauma. 2010 Jan;68(1):109-13; discussion 113-4. doi: 10.1097/TA.0b013e3181c0b67a.
Ruling out injuries of the cervical spine in obtunded blunt trauma patients is controversial. Although computed tomography (CT) readily demonstrates fractures and malalignment, it provides limited direct evaluation of ligamentous integrity, leading some to advocate a magnetic resonance imaging (MRI) in obtunded patients. Thus, the question remains: does adding an MRI provide useful information that alters treatment when a CT scan reveals no evidence of injury?
Published studies from 2000 to 2008 involving patients undergoing MRI for the purposes of further cervical spine evaluation after a "negative" CT scan were identified via a literature search of online databases. Data from eligible studies were pooled and original scale meta-analyses were performed to calculate overall sensitivity, specificity, positive and negative predictive values, likelihood ratios, and relative risk. The Q-statistic p value was used to evaluate heterogeneity.
Eleven studies met the inclusion criteria, yielding data on 1,550 patients with a negative CT scan after blunt trauma subsequently evaluated with a MRI. The MRI detected abnormalities in 182 patients (12%). Ninety traumatic injuries were identified, including ligamentous injuries (86/182), fractures, and dislocations (4/182). In 96 cases (6% of the cohort), the MRI identified an injury that altered management. Eighty-four patients (5%) required continued collar immobilization and 12 (1%) required surgical stabilization. The Q-statistic p value for heterogeneity was 0.99, indicating the absence of heterogeneity among the individual study populations.
Reliance on CT imaging alone to "clear the cervical spine" after blunt trauma can lead to missed injuries. This study supports a role for the addition of MRI in evaluating patients who are obtunded, or unexaminable, despite a negative CT scan.
对于意识不清的钝性创伤患者，排除颈椎损伤存在争议。尽管计算机断层扫描（CT）能轻易显示骨折和排列不齐，但它对韧带完整性的直接评估有限，这使得一些人主张对意识不清的患者进行磁共振成像（MRI）检查。因此，问题依然存在：当CT扫描未发现损伤证据时，增加MRI检查是否能提供改变治疗方案的有用信息？
通过在线数据库文献检索，确定2000年至2008年发表的涉及在“阴性”CT扫描后接受MRI进一步评估颈椎的患者的研究。汇总符合条件的研究数据并进行原始量表荟萃分析，以计算总体敏感性、特异性、阳性和阴性预测值、似然比和相对风险。Q统计量p值用于评估异质性。
11项研究符合纳入标准，得出了1550例钝性创伤后CT扫描阴性随后接受MRI评估的患者的数据。MRI在182例患者（12%）中检测到异常。共识别出90处创伤性损伤，包括韧带损伤（86/182）、骨折和脱位（4/182）。在96例（占队列的6%）中，MRI识别出改变治疗方案的损伤。84例患者（5%）需要继续使用颈托固定，12例（1%）需要手术固定。异质性的Q统计量p值为0.99，表明各研究人群之间不存在异质性。
钝性创伤后仅依靠CT成像“排除颈椎损伤”可能导致漏诊。本研究支持在评估尽管CT扫描阴性但意识不清或无法检查的患者时增加MRI检查的作用。
