School of Mechanical Engineering, The University of Adelaide, North Terrace, Adelaide, SA 5000, Australia; Centre for Orthopaedic & Trauma Research, Adelaide Medical School, The University of Adelaide, 30 Frome Rd, Adelaide, SA 5000, Australia; Adelaide Centre for Spinal Research, Adelaide Health and Medical Sciences Building, North Terrace, Adelaide, SA 5000, Australia.
School of Mechanical Engineering, The University of Adelaide, North Terrace, Adelaide, SA 5000, Australia; Centre for Orthopaedic & Trauma Research, Adelaide Medical School, The University of Adelaide, 30 Frome Rd, Adelaide, SA 5000, Australia; Adelaide Centre for Spinal Research, Adelaide Health and Medical Sciences Building, North Terrace, Adelaide, SA 5000, Australia.
Spine J. 2018 Mar;18(3):387-398. doi: 10.1016/j.spinee.2017.07.175. Epub 2017 Jul 21.
Distractive flexion injuries (DFIs) of the subaxial cervical spine are major contributors to spinal cord injury (SCI). Prompt assessment and early intervention of DFIs associated with SCI are crucial to optimize patient outcome; however, neurologic examination of patients with subaxial cervical injury is often difficult, as patients commonly present with reduced levels of consciousness. Therefore, it is important to establish potential associations between injury epidemiology and radiographic features, and neurologic involvement.
The aims of this study were to describe the epidemiology and radiographic features of DFIs presenting to a major Australian tertiary hospital and to identify those factors predictive of SCI. The agreement and repeatability of radiographic measures of DFI severity were also investigated.
STUDY DESIGN/SETTING: This is a combined retrospective case-control and reliability-agreement study.
Two hundred twenty-six patients (median age 40 years [interquartile range = 34]; 72.1% male) who presented with a DFI of the subaxial cervical spine between 2003 and 2013 were reviewed.
The epidemiology and radiographic features of DFI, and risk factors for SCI were identified. Inter- and intraobserver agreement of radiographic measurements was evaluated.
Medical records, radiographs, and computed tomography and magnetic resonance imaging scans were examined, and the presence of SCI was evaluated. Radiographic images were analyzed by two consultant spinal surgeons, and the degree of vertebral translation, facet apposition, spinal canal occlusion, and spinal cord compression were documented. Multivariable logistic regression models identified epidemiology and radiographic features predictive of SCI. Intraclass correlation coefficients (ICCs) examined inter- and intraobserver agreement of radiographic measurements.
The majority of patients (56.2%) sustained a unilateral (51.2%) or a bilateral facet (48.8%) dislocation. The C6-C7 vertebral level was most commonly involved (38.5%). Younger adults were over-represented among motor-vehicle accidents, whereas falls contributed to a majority of DFIs sustained by older adults. Greater vertebral translation, together with lower facet apposition, distinguished facet dislocation from subluxation. Dislocation, bilateral facet injury, reduced Glasgow Coma Scale, spinal canal occlusion, and spinal cord compression were predictive of neurologic deficit. Radiographic measurements demonstrated at least a "moderate" agreement (ICC>0.4), with most demonstrating an "almost perfect" reproducibility.
This large-scale cohort investigation of DFIs in the cervical spine describes radiographic features that distinguish facet dislocation from subluxation, and associates highly reproducible anatomical and clinical indices to the occurrence of concomitant SCI.
下颈椎的分散性前屈损伤（DFIs）是脊髓损伤（SCI）的主要原因。及时评估和早期干预与 SCI 相关的 DFI 对于优化患者的预后至关重要；然而，下颈椎损伤患者的神经检查通常很困难，因为患者通常表现出意识水平降低。因此，确定损伤流行病学与影像学特征和神经受累之间的潜在关联非常重要。
本研究旨在描述在澳大利亚一家主要的三级医院就诊的 DFI 的流行病学和影像学特征，并确定那些预测 SCI 的因素。还研究了 DFI 严重程度的影像学测量的一致性和可重复性。
研究设计/设置：这是一项回顾性病例对照和可靠性一致性研究。
2003 年至 2013 年间，共 226 例（中位年龄 40 岁[四分位距=34]；72.1%为男性）下颈椎 DFI 患者接受了回顾性分析。
确定了 DFI 的流行病学和影像学特征以及 SCI 的危险因素。评估了影像学测量的观察者内和观察者间的一致性。
检查了病历、X 线片、计算机断层扫描和磁共振成像扫描，并评估了 SCI 的存在。两位顾问脊柱外科医生分析了影像学图像，并记录了椎体移位程度、关节突关节贴合、椎管闭塞和脊髓受压程度。多变量逻辑回归模型确定了预测 SCI 的流行病学和影像学特征。采用组内相关系数（ICC）评估了影像学测量的观察者内和观察者间的一致性。
大多数患者（56.2%）发生单侧（51.2%）或双侧关节突关节（48.8%）脱位。C6-C7 椎体水平最常受累（38.5%）。年轻患者中机动车事故较多，而老年人中跌倒导致的 DFI 较多。较大的椎体移位，加上较低的关节突关节贴合，可区分关节突关节脱位和半脱位。脱位、双侧关节突关节损伤、格拉斯哥昏迷量表评分降低、椎管闭塞和脊髓压迫是神经功能缺损的预测因素。影像学测量结果至少具有“中度”一致性（ICC>0.4），大多数结果具有“几乎完美”的可重复性。
本研究对颈椎 DFI 进行了大规模的队列研究，描述了区分关节突关节脱位和半脱位的影像学特征，并将高度可重复的解剖学和临床指标与并发 SCI 的发生联系起来。
