Department of Anaesthesia and Intensive Care, Royal Derby Hospital, Uttoxeter Rd, Derby, DE22 3NE, UK.
Intensive Care Med. 2012 May;38(5):752-71. doi: 10.1007/s00134-012-2485-4. Epub 2012 Mar 10.
Controversy exists over how to 'clear' (we mean enable the clinician to safely remove spinal precautions based on imaging and/or clinical examination) the spine of significant unstable injury among clinically unevaluable obtunded blunt trauma patients (OBTPs). This review provides a clinically relevant update of the available evidence since our last review and practice recommendations in 2004.
Medline, Embase. Google Scholar, BestBETs, the trip database, BMJ clinical evidence and the Cochrane library were searched. Bibliographies of relevant studies were reviewed.
Plain radiography has low sensitivity for detecting unstable spinal injuries in OBTPs whereas multidetector-row computerised tomography (MDCT) approaches 100%. Magnetic resonance imaging (MRI) is inferior to MDCT for detecting bony injury but superior for detecting soft tissue injury with a sensitivity approaching 100%, although 40% of such injuries may be stable and 'false positive'. For studies comparing MDCT with MRI for OBTPs; MRI following 'normal' CT may detect up to 7.5% missed injuries with an operative fixation in 0.29% and prolonged collar application in 4.3%. Increasing data is available on the complications associated with prolonged spinal immobilisation among a population where a minority have an actual injury.
Given the variability of screening performance it remains acceptable for clinicians to clear the spine of OBTPs using MDCT alone or MDCT followed by MRI, with implications to either approach. Ongoing research is needed and suggestions are made regarding this. It is essential clinicians and institutions audit their data to determine their likely screening performances in practice.
对于临床上无法评估的意识障碍钝性创伤患者（OBTP）中具有显著不稳定损伤的脊柱如何“清除”（我们的意思是能够根据影像学和/或临床检查安全地去除脊柱固定），存在争议。本综述提供了自我们上次 2004 年回顾和实践建议以来，现有证据的临床相关更新。
在 Medline、Embase、Google Scholar、BestBETs、trip 数据库、BMJ 临床证据和 Cochrane 图书馆中进行了搜索。查阅了相关研究的参考文献。
平片对 OBTP 中不稳定脊柱损伤的敏感性较低，而多层螺旋 CT（MDCT）接近 100%。磁共振成像（MRI）对检测骨损伤不如 MDCT 敏感，但对检测软组织损伤的敏感性接近 100%，尽管其中 40%的损伤可能是稳定的和“假阳性”的。对于比较 MDCT 和 MRI 用于 OBTP 的研究；在“正常”CT 后进行 MRI 可能会检测到多达 7.5%的漏诊损伤，其中 0.29%需要手术固定，4.3%需要延长颈托应用。越来越多的数据可用于研究在实际损伤发生率较低的人群中，长时间脊柱固定相关并发症。
鉴于筛查性能的可变性，临床医生仍然可以接受单独使用 MDCT 或 MDCT 后加用 MRI 来清除 OBTP 的脊柱，这两种方法都有其意义。需要开展进一步的研究，并对此提出建议。临床医生和医疗机构必须审核其数据，以确定其在实践中的可能筛查性能。
