Department of Neurosurgery, University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA.
Spine (Phila Pa 1976). 2010 Aug 15;35(18):1721-8. doi: 10.1097/brs.0b013e3181e9acb2.
Meta-analytic costeffectiveness analysis.
Our goal was to compare the results of different management strategies for trauma patients in whom the cervical spine was not clinically evaluable due to impaired consciousness, endotracheal intubation, or painful distracting injuries.
We performed a structured literature review related to cervical spine trauma, radiographic clearance techniques (plain radiography, flexion/extension, CT, and MRI), and complications associated with semirigid collar use.
Meta-analytic techniques were used to pool data from multiple sources to calculate pooled mean estimates of sensitivities and specificities of imaging techniques for cervical spinal clearance, rates of complications from various clearance strategies and from empirical use of semirigid collars. A decision analysis model was used to compare outcomes and costs among these strategies.
Slightly more than 7.5% of patients who are clinically unevaluable have cervical spine injuries, and 42% of these injuries are associated with spinal instability. Sensitivity of plain radiography or fluoroscopy for spinal clearance was 57% (95% CI: 57%-60%). Sensitivities for CT and MRI alone were 83% (82%-84%) and 87% (84%-89%), respectively. Complications associated with collar use ranged from 1.3% (2 days) to 7.1% (10 days) but were usually minor and short-lived. Quadriplegia resulting from spinal instability missed by a clearance test had enormous impacts on longevity, quality of life, and costs. These impacts overshadowed the effects of prolonged collar application, even when the incidence of quadriplegia was extremely low.
As currently used, neuroimaging studies for cervical spinal clearance in clinically unevaluable patients are not cost-effective compared with empirical immobilization in a semirigid collar.
荟萃分析成本效益分析。
我们的目标是比较因意识障碍、气管插管或疼痛性致伤而无法临床评估颈椎的创伤患者的不同管理策略的结果。
我们对颈椎创伤、放射学清除技术（平片、屈伸位、CT 和 MRI）以及与半刚性颈托使用相关的并发症进行了系统的文献回顾。
采用荟萃分析技术，汇总来自多个来源的数据，计算出影像学技术对颈椎清除的敏感性和特异性的汇总平均估计值、各种清除策略和经验性使用半刚性颈托的并发症发生率。使用决策分析模型比较这些策略的结果和成本。
略多于 7.5%的临床无法评估的患者存在颈椎损伤，其中 42%的损伤与脊柱不稳定有关。平片或透视对脊柱清除的敏感性为 57%（95%CI：57%-60%）。单独使用 CT 和 MRI 的敏感性分别为 83%（82%-84%）和 87%（84%-89%）。与颈托使用相关的并发症发生率从 1.3%（2 天）到 7.1%（10 天）不等，但通常较轻且短暂。因清除试验漏诊的脊柱不稳定导致的四肢瘫痪对寿命、生活质量和成本产生了巨大影响。这些影响超过了长时间使用颈托的影响，即使四肢瘫痪的发生率极低。
与经验性使用半刚性颈托固定相比，目前用于临床无法评估的颈椎清除的神经影像学研究并不具有成本效益。
