急诊科钝性胸腰椎脊柱创伤评估：病史、体格检查及影像学诊断准确性的荟萃分析
Blunt Thoracolumbar-Spine Trauma Evaluation in the Emergency Department: A Meta-Analysis of Diagnostic Accuracy for History, Physical Examination, and Imaging.
作者信息
VandenBerg James, Cullison Kevin, Fowler Susan A, Parsons Matthew S, McAndrew Christopher M, Carpenter Christopher R
机构信息
Department of Emergency Medicine, Detroit Receiving Hospital and University Health Center, Detroit, Michigan; Division of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri.
Division of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri; Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
出版信息
J Emerg Med. 2019 Feb;56(2):153-165. doi: 10.1016/j.jemermed.2018.10.032. Epub 2018 Dec 28.
BACKGROUND
Delayed diagnoses of unstable thoracolumbar spine (TL-spine) fractures can result in neurologic deficits and avoidable pain, so it is important for clinicians to reach prompt diagnostic decisions. There are no validated decision aids for determining which trauma patients warrant TL-spine imaging.
OBJECTIVE
Our aim was to quantify the diagnostic accuracy of the injury mechanism, physical examination, associated injuries, clinical decision aids, and imaging for evaluating blunt TL-spine trauma patients.
METHODS
A search strategy for studies including adult blunt TL-spine trauma using PubMed, Embase, Scopus, CENTRAL, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov was performed. Excluded studies lacked data to construct 2 × 2 tables, were duplicates, were not primary research, did not focus on blunt trauma, examined associated injuries without any utility in identifying TL-spine injuries, only studied cervical-spine fractures, were non-English, had a pediatric setting, or were cadaver/autopsy reports. Risk of bias was assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies. Diagnostic predictors were analyzed with a meta-analysis of sensitivity, specificity, and likelihood ratios.
RESULTS
In blunt trauma patients in the emergency department, the weighted pretest probability of a TL-spine fracture was 15%. The estimates for detection of TL-spine fractures with plain film were: positive likelihood ratio (+LR) = 25.0 (95% confidence interval [CI] 4.1-152.2; I = 94%; p < 0.001) and negative likelihood ratio (-LR) = 0.43 (95% CI 0.32-0.59; I = 84%; p < 0.001), and for computed tomography (CT) were: +LR = 81.1 (95% CI 14.1-467.9; I = 87%; p < 0.001) and -LR = 0.04 (95% CI 0.02-0.08; I = 23%; p = 0.26).
CONCLUSIONS
CT is more accurate than plain films for detecting TL-spine fractures. Injury mechanism, physical examination, and associated injuries alone are not accurate to rule-in or rule-out TL-spine fractures.
背景
胸腰段脊柱（TL 脊柱）不稳定骨折的延迟诊断可导致神经功能缺损和不必要的疼痛，因此临床医生迅速做出诊断决策很重要。目前尚无经过验证的决策辅助工具来确定哪些创伤患者需要进行 TL 脊柱成像检查。
目的
我们的目的是量化损伤机制、体格检查、合并伤、临床决策辅助工具以及影像学检查对评估钝性 TL 脊柱创伤患者的诊断准确性。
方法
采用 PubMed、Embase、Scopus、CENTRAL、Cochrane 系统评价数据库和 ClinicalTrials.gov 对包括成人钝性 TL 脊柱创伤的研究进行检索。排除的数据缺乏构建 2×2 表格的数据、重复研究、非原始研究、未聚焦钝性创伤、检查了对识别 TL 脊柱损伤无任何作用的合并伤、仅研究颈椎骨折、非英文、儿科背景或尸体/尸检报告。使用诊断准确性研究质量评估工具评估偏倚风险。通过对敏感性、特异性和似然比的荟萃分析来分析诊断预测因素。
结果
在急诊科的钝性创伤患者中，TL 脊柱骨折的加权验前概率为 15%。X 线平片检测 TL 脊柱骨折的估计值为：阳性似然比（+LR）=25.0（95%置信区间[CI]4.1 - 152.2；I² = 94%；p < 0.001），阴性似然比（-LR）=0.43（95%CI 0.32 - 0.59；I² = 84%；p < 0.001）；计算机断层扫描（CT）检测的估计值为：+LR = 81.1（95%CI 14.1 - 467.9；I² = 87%；p < 0.001），-LR = 0.04（95%CI 0.02 - 0.08；I² = 23%；p = 0.26）。
结论
CT 在检测 TL 脊柱骨折方面比 X 线平片更准确。仅损伤机制、体格检查和合并伤不足以准确判断 TL 脊柱骨折的排除或纳入。
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