ACR 适宜性标准（之三）-可疑脊柱外伤[1] / 开普饭

Edited by Spine Truth Editorial Team脊柱甘露语林®学术·疾病与健康科普·助学·公益行之2000天，第1407篇作者：周全博士摘要abstract颈椎和胸腰椎损伤是创伤患者治疗中常见的问题，在急诊就诊的钝性创伤患者中，颈椎损伤发生率为3%~4%，胸腰段骨折发生率为4%至7%。颈椎血管损伤和胸腰椎损伤的筛查标准与颈椎损伤筛查标准相比，有效性和可接受性相对差。损伤模式和机制的复杂性使得决定什么时候进行影像检查和什么类型的检查具有挑战性。

于脊柱创伤的初始评估，CT优于X射线照片。CT血管造影和MR血管造影均可用于评估颈部血管损伤。评估脊柱创伤中的神经损伤时MRI优于CT脊髓造影。当担心韧带损伤或筛查反应迟钝患者颈椎不稳定时，MRI通常是合适的。

Figure 1 CCR High-Risk Factors for Cervical Spine Injury

Figure 2 CCR Low-Risk Factors for Cervical Spine Injury[2]

Figure 3 the Canadian C-spine rule for radiography[2]

Figure 4 NEXUS 颈椎影像检查标准Variant 1. Age greater than or equal to 16 years and less than 65 years. Suspectedacute blunt cervical spine trauma; imaging not indicated by NEXUS or CCRclinical criteria. Patient meets low-risk criteria. Initial imaging. 年龄大于或等于16岁但不足65岁。怀疑急性钝性颈椎损伤；影像学不符合为NEXUS或CCR的临床标准。病人符合低风险标准。初步影像检查。ProcedureAppropriateness CategoryRelative Radiation LevelArteriography cervicocerebral头颈部动脉造影Usually Not Appropriate通常不合适☢☢☢CT cervical spine with IV contrast颈椎CT静脉造影剂对比增强Usually Not Appropriate通常不合适☢☢☢CT cervical spine without and with IV contrast颈椎CT平扫增强Usually Not Appropriate通常不合适☢☢☢CT cervical spine without IV contrast颈椎CT平扫Usually Not Appropriate通常不合适☢☢☢CT myelography cervical spineCT颈椎脊髓造影Usually Not Appropriate通常不合适☢☢☢☢CTA head and neck with IV contrast头颈部CTA增强Usually Not Appropriate通常不合适☢☢☢MRA neck without and with IV contrast颈部MRA无、有对比增强Usually Not Appropriate通常不合适OMRA neck without IV contrast颈部MRA平扫Usually Not Appropriate通常不合适OMRI cervical spine without and with IV contrast颈椎MRI平扫增强Usually Not Appropriate通常不合适OMRI cervical spine without IV contrast颈椎MRI平扫Usually Not Appropriate通常不合适ORadiography cervical spine颈椎X线Usually Not Appropriate通常不合适☢☢Variant 1：根据CCR标准，所有65岁以上的钝性创伤患者都应考虑颈椎影像学检查。对于怀疑急性钝性颈椎外伤的患者(≥16岁和<65岁)，当影像学不符合Nexus或CCR的临床标准，且符合低风险标准（见上图CCR低危标准）时，不推荐进行影像学检查。Variant 2. Age greater than or equal to16 years. Suspected acute cervical spine blunt trauma. Imaging indicated byNEXUS or CCR clinical criteria. Initial imaging. 年龄大于或等于16岁。怀疑急性颈椎钝性伤。影像学表现符合NEXUS或CCR的临床标准。初步检查。ProcedureAppropriateness CategoryRelative Radiation LevelCT cervical spine without IV contrast颈椎CT无静脉对比增强Usually Appropriate通常适用☢☢☢Radiography cervical spine颈椎X线May Be Appropriate可能适用☢☢Arteriography cervicocerebral头颈部动脉造影Usually Not Appropriate通常不合适☢☢☢CT cervical spine with IV contrast颈椎CT静脉造影剂对比增强Usually Not Appropriate通常不合适☢☢☢CT cervical spine without and with IV contrast颈椎CT平扫增强Usually Not Appropriate通常不合适☢☢☢CT myelography cervical spineCT颈椎脊髓造影Usually Not Appropriate通常不合适☢☢☢☢CTA head and neck with IV contrast头颈部CTA增强Usually Not Appropriate通常不合适☢☢☢MRA neck without and with IV contrast颈部MRA平扫增强Usually Not Appropriate通常不合适OMRA neck without IV contrast颈部MRA平扫无对比增强Usually Not Appropriate通常不合适OMRI cervical spine without and with IV contrast颈椎MRI无、有对比增强Usually Not Appropriate通常不合适OMRI cervical spine without IV contrast颈椎MRI平扫Usually Not Appropriate通常不合适OVariant 2：颈椎CT平扫通常适用于≥16岁，怀疑急性钝性颈椎外伤患者的初次影像学检查，其影像学指标为Nexus或CCR临床标准。Variant 3.Age greater than or equalto 16 years. Suspected acute cervical spine blunt trauma. Confirmed orsuspected cervical spinal cord or nerve root injury, with or without traumaticinjury identified on cervical CT. Next imaging study. 年龄大于或等于16岁。怀疑急性颈椎钝伤。证实或怀疑颈脊髓或神经根损伤，伴或不伴颈椎CT上证实的创伤。下一步影像检查研究。ProcedureAppropriateness CategoryRelative Radiation LevelMRI neck without IV contrast颈椎MRI平扫Usually Appropriate通常适用OCT myelography cervical spineCT颈脊髓造影May Be Appropriate可能适用☢☢☢☢Arteriography cervicocerebral头颈部动脉造影Usually Not Appropriate通常不合适☢☢☢CTA head and neck with IV contrast头颈部增强CTAUsually Not Appropriate通常不合适☢☢☢MRA neck without and with IV contrast颈部MRA平扫增强Usually Not Appropriate通常不合适OMRA neck without IV contrast颈部MRA平扫Usually Not Appropriate通常不合适OMRI cervical spine without and with IV contrast颈椎MRI平扫增强Usually Not Appropriate通常不合适ORadiography cervical spine颈椎X线Usually Not Appropriate通常不合适☢☢Variant 3：≥16岁，怀疑颈椎急性钝性损伤，经证实或怀疑为颈脊髓或神经根损伤的患者，无论是否经颈CT检查，颈椎MRI平扫均应作为下一步影像学检查。Variant 4. Agegreater than or equal to 16 years. Acute cervical spine injury detected onradiographs. Treatment planning for mechanically unstable spine. 年龄大于或等于16岁。X线片发现急性颈椎损伤。拟制定机械不稳定脊柱的治疗计划。ProcedureAppropriateness CategoryRelative Radiation LevelCT cervical spine without IV contrast颈椎CT平扫Usually Appropriate通常适用☢☢☢MRI neck without IV contrast颈椎MRI平扫Usually Appropriate通常适用OCT cervical spine with IV contrast颈椎增强CTUsually Not Appropriate通常不合适☢☢☢CT cervical spine without and with IV contrast颈椎CT平扫增强Usually Not Appropriate通常不合适☢☢☢CT myelography cervical spineCT颈脊髓造影Usually Not Appropriate通常不合适☢☢☢☢MRI cervical spine without and with IV contrast颈椎MRI平扫增强Usually Not Appropriate通常不合适OVariant 4：无静脉对比增强颈椎CT和无静脉对比增强颈椎MRI通常适用于≥16岁急性颈椎损伤（X线检查发现）和脊柱不稳定制定治疗方案。这些操作是对不稳定脊柱损伤的评估的补充。Variant 5. Age greater than or equal to 16 years. Suspected acute cervical spine blunt trauma. Clinical or imaging findings suggest arterial injury with or without positive cervical spine CT. Next imaging study. 年龄大于或等于16岁。怀疑急性颈椎钝伤。临床或影像发现提示动脉损伤，下一步检查。ProcedureAppropriateness CategoryRelative Radiation LevelCTA head and neck with IV contrast头颈部血管增强CTAUsually Appropriate通常适用☢☢☢MRA neck without and with IV contrast颈部MRA平扫对比增强Usually Appropriate通常适用OArteriography cervicocerebral头颈部动脉造影May Be Appropriate可能适用☢☢☢MRA neck without IV contrast颈部MRA平扫May Be Appropriate可能适用OVariant 5：头颈增强CTA和颈部MRA平扫增强通常是适用于≥16岁怀疑急性钝性颈椎外伤，临床或影像学表现提示动脉损伤患者的下一步影像学检查。这些检查是同等替代方案。Variant 6. Age greater than or equal to 16 years. Suspected acute cervicalspine blunt trauma. Obtunded patient with no traumatic injury identified oncervical spine CT. Next imaging study after CT cervical spine without IVcontrast. 年龄大于或等于16岁。怀疑急性颈椎钝伤。颈椎CT未证实创伤，下一步检查。ProcedureAppropriateness CategoryRelative Radiation LevelMRI neck without IV contrast颈椎MRI平扫Usually Appropriate通常适用OArteriography cervicocerebral头颈部动脉造影Usually Not Appropriate通常不合适☢☢☢CT myelography cervical spineCT颈脊髓造影Usually Not Appropriate通常不合适☢☢☢☢CTA head and neck with IV contrast头颈部血管增强CTAUsually Not Appropriate通常不合适☢☢☢MRA neck without and with IV contrast颈部MRA平扫增强Usually Not Appropriate通常不合适OMRA neck without IV contrast颈部MRA平扫Usually Not Appropriate通常不合适OMRI cervical spine without and with IV contrast颈椎MRI平扫增强Usually Not Appropriate通常不合适ORadiography cervical spine颈椎X线Usually Not Appropriate通常不合适☢☢Variant6:≥16岁的疑似颈椎急性钝性创伤反应迟钝患者，颈椎CT平扫未发现创伤性损伤,MRI平扫通常适合作为下一步影像检查。Variant 7. Agegreater than or equal to 16 years. Suspected acute cervical spine blunt trauma.Clinical or imaging findings suggest ligamentous injury. Next imaging studyafter CT cervical spine without IV contrast. 年龄大于或等于16岁。疑似急性颈椎钝性创伤。临床或影像学发现提示韧带损伤。无静脉造影剂的颈椎CT下一步影像学研究。ProcedureAppropriateness CategoryRelative Radiation LevelMRI neck without IV contrast颈椎MRI平扫Usually Appropriate通常适用OArteriography cervicocerebral头颈部动脉造影Usually Not Appropriate通常不合适☢☢☢☢CT myelography cervical spineCT颈脊髓造影Usually Not Appropriate通常不合适☢☢☢CTA head and neck with IV contrast头颈部血管增强CTAUsually Not Appropriate通常不合适OMRA neck without and with IV contrast颈部MRA平扫增强Usually Not Appropriate通常不合适OMRA neck without IV contrast颈部MRA平扫Usually Not Appropriate通常不合适OMRI cervical spine without and with IV contrast颈椎MRI平扫增强Usually Not Appropriate通常不合适OMRI cervical spine without and with IV contrast颈椎MRI平扫增强Usually Not Appropriate通常不合适☢☢Variant 7：对于怀疑急性钝性颈椎外伤的患者，≥16岁怀疑颈椎急性钝性损伤，临床或影像学表现提示韧带损伤，MRI颈椎平扫通常适合于颈椎CT后的下一步影像学研究。Variant 8. Agegreater than or equal to 16 years. Suspected acute cervical spine blunt trauma.Follow-up imaging on patient with no unstable injury demonstrated initially,but kept in collar for neck pain. No new neurologic symptoms. Includes whiplashassociated disorders. 年龄大于或等于16岁。怀疑急性颈椎钝伤。对无不稳定损伤患者的随访初步检查，但因颈部疼痛保持颈托固定。没有新的神经症状。包括挥鞭伤相关疾病。ProcedureAppropriateness CategoryRelative Radiation LevelCT cervical spine without IV contrast颈椎CT平扫May Be Appropriate可能适用☢☢☢MRI neck without IV contrast颈椎MRI平扫May Be Appropriate可能适用0Radiography cervical spine颈椎X线May Be Appropriate可能适用☢☢Arteriography cervicocerebral头颈部动脉造影Usually Not Appropriate通常不合适☢☢☢CT cervical spine with IV contrast颈椎增强CTUsually Not Appropriate通常不合适☢☢☢CT cervical spine without and with IV contrast颈椎CT平扫增强Usually Not Appropriate通常不合适☢☢☢CT myelography cervical spineCT颈脊髓造影Usually Not Appropriate通常不合适☢☢☢☢CTA head and neck with IV contrast头颈部血管增强CTAUsually Not Appropriate通常不合适☢☢☢MRA neck without IV contrast颈部MRA平扫Usually Not Appropriate通常不合适0MRA neck without IV contrast颈部MRA平扫Usually Not Appropriate通常不合适0MRI cervical spine without and with IV contrast颈椎MRI平扫增强Usually Not Appropriate通常不合适0Variant 8：对于未发现不稳定损伤的≥16岁患者，因颈痛保持颈托固定，且无新的神经学症状，CT颈椎平扫、MRI颈椎平扫或颈椎X线片可能适合于作为随访影像学检查。Variant 9.Age greater than or equal to 16 years. Blunt trauma meeting criteriafor thoracic and lumbar imaging. Initial imaging. 年龄大于或等于16岁。钝性创伤符合胸腰椎成像检查标准。初步检查。ProcedureAppropriateness CategoryRelative Radiation LevelCT thoracic and lumbar spine without IV contrast胸腰椎CT平扫Usually Appropriate通常适用☢☢☢Radiography thoracic and lumbar spine胸腰椎X线May Be Appropriate可能适用☢☢☢CT myelography thoracic and lumbar spine胸腰椎CT脊髓造影Usually Not Appropriate通常不合适☢☢☢☢CT thoracic and lumbar spine with IV contrast胸腰椎增强CTUsually Not Appropriate通常不合适☢☢☢CT thoracic and lumbar spine without and with IV contrast胸腰椎CT平扫增强Usually Not Appropriate通常不合适☢☢☢☢MRI thoracic and lumbar spine without and with IV contrast胸腰椎MRI平扫增强Usually Not Appropriate通常不合适0MRI thoracic and lumbar spine without IV contrast胸腰椎MRI平扫Usually Not Appropriate通常不合适0Variant 9：胸椎和腰椎CT通常适用于≥16岁符合胸腰椎影像学标准钝性外伤患者的初次影像学检查。胸椎和腰椎CT重建可以同时获得胸部或腹部和骨盆的CT成像，对软组织损伤患者不需要附加辐射暴露。Variant 10. Age greater than or equal to 16 years. Acute thoracic or lumbarspine injury detected on radiographs or noncontrast CT. Neurologicabnormalities. Next imaging study. 年龄大于或等于16岁。平片或CT平扫可发现急性胸椎或腰椎损伤。神经功能异常。下一步检查成像研究。ProcedureAppropriateness CategoryRelative Radiation LevelMRI thoracic and lumbar spine without IV contrast胸腰椎MRI平扫Usually Appropriate通常适用0CT myelography thoracic and lumbar spine胸腰椎CT脊髓造影May Be Appropriate可能适用☢☢☢☢CT thoracic and lumbar spine with IV contrast胸腰椎增强CTUsually Not Appropriate通常不合适☢☢☢CT thoracic and lumbar spine without and with IV contrast胸腰椎CT平扫增强Usually Not Appropriate通常不合适☢☢☢☢MRI thoracic and lumbar spine without and with IV contrast胸腰椎MRI平扫增强Usually Not Appropriate通常不合适0CT脊髓造影可用于评价椎间盘突出或硬膜外血肿所致的外伤性椎管狭窄，并可评估神经节前神经根是否狭窄。与常规CT一样，CT脊髓造影在评估脊髓挫伤、脊髓出血和神经节后神经根损伤方面不如MRI。Variant10：≥16岁的患者在X线或非对比物CT上发现急性胸椎或腰椎损伤，同时有神经异常，胸椎和腰椎MRI平扫通常适合作为下一步影像学检查。参考文献1. BeckmannNM, West OC, Nunez D, Jr., Kirsch CFE, Aulino JM, Broder JS, Cassidy RC,Czuczman GJ, Demertzis JL, Johnson MM, Motamedi K, Reitman C, Shah LM, Than K,Ying-Kou Yung E, Beaman FD, Kransdorf MJ, Bykowski J (2019) ACR AppropriatenessCriteria((R)) Suspected Spine Trauma. Journal of the American College ofRadiology : JACR 16 (5s):S264-s285. doi:10.1016/j.jacr.2019.02.0022.Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, LaupacisA, Schull M, McKnight RD, Verbeek R, Brison R, Cass D, Dreyer J, Eisenhauer MA,Greenberg GH, MacPhail I, Morrison L, Reardon M, Worthington J (2001) TheCanadian C-spine rule for radiography in alert and stable trauma patients. Jama286 (15):1841-1848

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ACR 适宜性标准（之三）-可疑脊柱外伤[1]

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