Thangarajah Tanujan, O'Donoghue Donal, Pillay Robin
Department of Trauma and Orthopaedic Surgery, Sandwell and West Birmingham Hospitals, West Midlands, UK.
Ann R Coll Surg Engl. 2011 Jan;93(1):76-80. doi: 10.1308/003588411X12851639107278.
The finite resources available to National Health Service institutions require clinicians to order investigations that are not readily available appropriately. This is particularly true for the radiological assessment of patients presenting with features pertaining to acute spinal cord dysfunction. Such cases conventionally require urgent magnetic resonance imaging (MRI) which is sometimes performed 'out-of-hours'. There is evidence to suggest, however, that a high proportion of patients do not have a structural abnormality on MRI to account for their clinical findings, and consequently the majority of scans that are requested urgently are normal. The primary aim of this study was to determine whether any clinical feature(s) could accurately predict the presence of a structural abnormality on MRI. As a secondary objective, the ability of such features to predict the need for spinal surgery was assessed.
A retrospective analysis of consecutive patients who warranted urgent MRI was conducted. Eighty-one patients were eligible for study. The Fisher's test was used for statistical analysis of all data. A P-value of less than 0.05 was considered to be significant.
MRI was performed within 24 h of admission in 16 patients, and of these, seven had surgery within 24-48 h. Only two patients were found to have significant neurological compromise. Despite both a history and examination suggesting otherwise, MRI was normal in 10 patients (12%).
We were unable to elucidate any clinical features that were able to predict the presence of an abnormal MRI. We did find, however, that patients with a combination of both subjective neurological findings and positive neurological signs (P = 0.02), saddle anaesthesia and/or decreased anal tone (P = 0.03) or sciatica (P = 0.02) had pathology on MRI that warranted surgical intervention. The authors recommend that the aforementioned features formulate the basis of guidelines used to request and/or perform MRI urgently since they are highly suggestive of surgical intervention. Conversely, patients who do not exhibit the above examination findings might not require either an urgent or 'out-of-hours' scan, but could potentially be investigated less expediently and/or wait until 'normal working hours'.
国民医疗服务体系机构可用资源有限，这就要求临床医生合理安排那些不易获取的检查项目。对于表现出急性脊髓功能障碍特征的患者进行放射学评估时尤其如此。此类病例通常需要紧急进行磁共振成像（MRI）检查，有时还会在“非工作时间”进行。然而，有证据表明，很大一部分患者的MRI检查结果并未显示出能解释其临床症状的结构异常，因此，大多数紧急要求进行的扫描结果都是正常的。本研究的主要目的是确定是否有任何临床特征能够准确预测MRI检查中结构异常的存在。作为次要目标，评估了这些特征预测脊柱手术需求的能力。
对需要紧急进行MRI检查的连续患者进行回顾性分析。81名患者符合研究条件。所有数据均采用Fisher检验进行统计分析。P值小于0.05被认为具有统计学意义。
16名患者在入院后24小时内进行了MRI检查，其中7名患者在24至48小时内接受了手术。仅发现2名患者有明显的神经功能损害。尽管病史和检查结果显示情况并非如此，但仍有10名患者（12%）的MRI检查结果正常。
我们无法阐明任何能够预测MRI检查结果异常的临床特征。然而，我们确实发现，主观神经学检查结果与阳性神经体征同时出现（P = 0.02）、鞍区感觉缺失和/或肛门括约肌张力降低（P = 0.03）或坐骨神经痛（P = 0.02）的患者，其MRI检查发现的病变需要手术干预。作者建议，上述特征应作为紧急要求和/或进行MRI检查的指导原则基础，因为它们强烈提示需要进行手术干预。相反，未表现出上述检查结果的患者可能既不需要紧急或“非工作时间”扫描，而是可以以不那么紧急的方式进行检查和/或等到“正常工作时间”。
