Venkatesan M, Fong A, Sell P J
University Hospitals of Leicester, Infirmary Square, Leicester LE1 5WW, UK.
J Bone Joint Surg Br. 2012 Aug;94(8):1097-100. doi: 10.1302/0301-620X.94B8.29397.
The aim of this study was first, to determine whether CT scans undertaken to identify serious injury to the viscera were of use in detecting clinically unrecognised fractures of the thoracolumbar vertebrae, and second, to identify patients at risk of 'missed injury'. We retrospectively analysed CT scans of the chest and abdomen performed for blunt injury to the torso in 303 patients. These proved to be positive for thoracic and intra-abdominal injuries in only 2% and 1.3% of cases, respectively. However, 51 (16.8%) showed a fracture of the thoracolumbar vertebrae and these constituted our subset for study. There were eight women and 43 men with mean age of 45.2 years (15 to 94). There were 29 (57%) stable and 22 (43%) unstable fractures. Only 17 fractures (33.3%) had been anticipated after clinical examination. Of the 22 unstable fractures, 11 (50%) were anticipated. Thus, within the whole group of 303 patients, an unstable spinal injury was missed in 11 patients (3.6%); no harm resulted as they were all protected until the spine had been cleared. A subset analysis revealed that patients with a high Injury Severity Score, a low Glasgow Coma Scale and haemodynamic instability were most likely to have a significant fracture in the absence of positive clinical findings. This is the group at greatest risk. Clinical examination alone cannot detect significant fractures of the thoracolumbar spine. It should be combined with CT imaging to reduce the risk of missed injury.
本研究的目的，其一，是确定为识别内脏严重损伤而进行的CT扫描是否有助于检测临床未识别的胸腰椎骨折；其二，是识别有“漏诊损伤”风险的患者。我们回顾性分析了303例因躯干钝性损伤而进行的胸部和腹部CT扫描。结果显示，这些扫描仅在2%的病例中发现胸部损伤阳性，在1.3%的病例中发现腹腔内损伤阳性。然而，51例（16.8%）显示有胸腰椎骨折，这些构成了我们的研究子集。其中有8名女性和43名男性，平均年龄45.2岁（15至94岁）。有29例（57%）为稳定性骨折，22例（43%）为不稳定性骨折。临床检查后仅预计到17例骨折（33.3%）。在22例不稳定性骨折中，预计到11例（50%）。因此，在303例患者的整个群体中，11例患者（3.6%）漏诊了不稳定脊柱损伤；由于在脊柱检查排除之前他们都得到了保护，所以没有造成伤害。子集分析显示，损伤严重程度评分高、格拉斯哥昏迷量表评分低和血流动力学不稳定的患者在无阳性临床发现时最有可能发生严重骨折。这是风险最大的一组人群。仅靠临床检查无法检测出胸腰椎的严重骨折。应将其与CT成像相结合，以降低漏诊损伤的风险。
