改良胸腰段脊柱骨折AO分型可靠性与一致性的临床观察

发布时间：2018-06-28 18:53

本文选题：胸腰段脊柱骨折分型 + Denis分型　；参考：《西南医科大学》2017年硕士论文

【摘要】：研究背景胸腰段骨折是脊柱骨折中最常见的类型,基于简单、实用、准确、全面、可重复、可评估损伤程度、可指导治疗及可预见预后的原则,目前尚未有一种被普遍接受和采用的分类方法。国内外目前常用的胸腰段脊柱骨折分类主要有Denis分型、AO分型(即Magerl系统)、SLC评分系统、TLICS评分分类系统。各个分类由于受当时生物力学的理解与影像学技术的局限,各具优缺点,对其分类提出了更高的要求。随着医学技术的进步和影像学的发展,国内外公认:应根据骨折的受伤机制、骨折的形态,骨折后脊柱的稳定性及神经功能状态来决定。1983年Denis根据其生物力学试验将脊柱分为前、中、后三柱,认为单纯前、后柱损伤不影响脊柱稳定性,提出同时累及中柱的脊柱骨折是不稳定的骨折,但Denis分型只对412例胸腰椎骨折患者做出分析,而且仅有53例做了CT扫描,分型中没有涉及椎间盘损伤的问题。1994年Magerl等通过分析10年中1445例胸腰段脊柱骨折的X线片、CT片,按照骨折形态与严重的伤害程度从A型到C型及其对应的1至3亚型的AO分型,并进一步细分为53种亚型,尽管AO分型(即Magerl系统)充分考虑骨折的形态,一定程度考虑了损伤的严重性、骨折的稳定性与神经受损的危险性,但缺乏MRI影像评估,其太过复杂,未评估神经的功能状态及对治疗的指导意义,且未涉及椎间盘及终板的损伤的评估。Mc Cormack等1994年,通过研究短节段椎弓根螺钉固定胸腰椎脊柱骨折失败的原因后提出了SLC评分系统(share loading scoring system),这种评分系统可作为脊柱外科医生选择前、后手术入路治疗提供了依据,但是该分类方法没有涉及韧带损伤,未评估神经的功能状态,也没有涉及损伤机制,出于这个原因,它不能用来决定手术适应症。TLICS系统评分(Thoracolumbar injury classification and severity score)是2005年由Vaccaro等提出胸腰段脊柱骨折损伤的TLISS评分系统(Thoracolumbar injury severity score)基础上由美国脊柱创伤研究会改进的评分系统,该分类系统根据神经的功能状态、PLC(Posterior ligamentous complex)的完整性及骨折的形态进行分类,但对PLC完整性的MRI诊断提出了质疑,对指导治疗存在文化与地区间的差异性,因此尚不能被广泛采用。2013年AO为提出一种有效、更能指导外科治疗和广泛接受的一种分型,改良胸腰段脊柱骨折AO分型(简称改良的AO分型),它根据骨折的形态与神经功能评分。对其可靠性与一致性在不同国家进行对比观察是必要的,以求最终将用于指导临床。研究目的临床观察改良AO分型的可靠性与一致性,探讨改良AO分型的优缺点。研究方法选择我院2011.01-2016.12期间125例临床及影像学资料(X线片、CT、3DCT、MRI)完整的胸腰段骨折患者,将该125例患者的资料提供给本科室2名骨科医生(2名主治医师,分别为医生1和医生2),分别采用Denis分型、AO分型、SLC评分系统、TLICS评分分类系统及改良AO分型系统五种方法进行脊柱骨折分类和评分。1个月后进行重复分类和评分,采用加权Cohen′s Kappa系数评价观察者的可靠性和一致性。研究结果Denis分型医生1和医生2的kappa值分别为0.734、0.692,所以同一观察者两次一致性为0.713;Denis分型两观察者间一致性第一次和第二次分别为0.618,0.711,所以两观察者间的一致性为0.6645。AO分型医生1和医生2的kappa值分别为0.635、0.621,所以同一观察者两次一致性为0.628;AO分型两观察者间一致性第一次和第二次分别为0.545、0.626,所以两观察者间的一致性为0.5855;改良AO分型系统医生1和医生2的kappa值分别为0.852、0.834,所以同一观察者两次一致性为0.842;改良AO分型系统分型两观察者间一致性第一次和第二次分别0.834、0.823,所以两观察者间的一致性为0.8285;SLC评分医生1和医生2的kappa值分别为0.725、0.734,所以同一观察者两次一致性0.7245;SLC评分观察者间一致性第一次和第二次分别为0.714、0.681。所以两观察者间的一致性为0.6975;TLICS评分医生1和医生2的kappa值分别为:0.743、0.790,所以两观察者间的一致性为0.7665;TLICS评分两观察者间一致性第一次和第二次分别为0.750、0.772。所以两观察者间的一致性为0.761。五种胸腰段骨折分类方法比较,改良AO分型系统方法的可靠性和一致性最高,TLICS分类方法次之,AO分型方法较差,前者更具临床实用价值。研究结论改良AO分型系统结合了AO和TLICS的优点,除了形态学描述,该系统还考虑了神经学状态和患者实际情况,具有较高的可重复性与一致性,这对于外科治疗决策较为实用。但该分型尚未涉及椎间盘与终板的损伤程度及对预后的影响。
[Abstract]:Background the thoracolumbar fracture is the most common type of spinal fracture. It is based on the simple, practical, accurate, comprehensive, repeatable, evaluation of the degree of injury, the principle of guiding the treatment and predictable prognosis. At present, there has not been a widely accepted and adopted classification method. The main classification of thoracolumbar spine fractures at home and abroad is Denis. Classification, AO classification (Magerl system), SLC scoring system, and TLICS classification system. Each classification has its advantages and disadvantages due to the limitations of biomechanics and imaging techniques at that time. It has higher requirements for its classification. With the progress of medical technology and the development of imaging, it is recognized at home and abroad that the injury mechanism should be based on the fracture. The shape of the fracture, the stability of the spinal column after the fracture and the state of the nerve function decided.1983 Denis to divide the spine into the anterior, middle, and the three columns according to its biomechanical test. It is considered that the posterior column injury does not affect the stability of the spine. It is suggested that the spinal fractures involving the middle column are unstable fractures, but the Denis classification is only 412 cases of the thoracolumbar bone. An analysis of the patients was made, and only 53 cases were scanned with CT. The problem of intervertebral disc injury was not involved in the typing.1994 Magerl, etc. through the analysis of the X-ray films of 1445 cases of the thoracolumbar spine fracture in 10 years, the CT slices, according to the fracture morphology and the serious injury degree from the A to the C and the 1 to 3 subtypes of the AO, and further subdivided into 53 The type of subtype, although the AO typing (Magerl system) fully considers the fracture morphology, considers the severity of the injury, the stability of the fracture, and the risk of nerve damage, but it lacks a MRI image assessment. It is too complicated to assess the functional state of the nerve and the guiding significance of the treatment, and does not relate to the assessment of the injury of the intervertebral disc and the end plate. .Mc Cormack and other 1994, the SLC scoring system (share loading scoring system) was proposed by studying the causes of the failure of the short segment pedicle screw fixation fracture of the thoracolumbar spine. This scoring system can be used as a basis for the treatment of spinal surgeons before and after surgical approach, but this classification method does not involve ligament damage. The functional state of the nerve was not assessed, nor was it involved in the injury mechanism. For this reason, it could not be used to determine the.TLICS system score (Thoracolumbar injury classification and severity score) is a TLISS scoring system (Thoracolumbar injury severity) for the thoracolumbar spinal fractures in 2005, such as Vaccaro. E) based on the improved scoring system of the American Spine Trauma Institute, the classification system classifies the integrity of the PLC (Posterior ligamentous complex) and fracture morphology according to the functional state of the nerve, but doubts the MRI diagnosis of the integrity of the PLC, and is not yet able to guide the difference between the culture and the region for the treatment of the treatment. .2013 AO is widely used to propose an effective, more effective and widely accepted type of classification to improve the AO type of the thoracolumbar spine fracture (the modified AO typing). It is based on the fracture morphology and neural function score. It is necessary to compare the reliability and consistency of the fracture in different countries in order to eventually use it. To observe the reliability and consistency of the modified AO typing and explore the advantages and disadvantages of the modified AO typing. The research method selected 125 patients with complete thoracolumbar fractures in clinical and imaging data (x ray, CT, 3DCT, MRI) during 2011.01-2016.12 of our hospital, and provided the data of the 125 patients to 2 Department of orthopedics doctors in the undergraduate room. 2 doctors (2 doctors, doctors 1 and doctor 2) were divided into five methods, including Denis typing, AO typing, SLC scoring system, TLICS scoring system and improved AO typing system for the classification and score of spinal fractures after.1 months, and the reliability and consistency of the observers were evaluated by weighted Cohen 's Kappa coefficient. Results the kappa value of Denis type 1 and doctor 2 was 0.734,0.692, so the two conformance of the same observer was 0.713; the conformance of the two observer in the Denis type two was 0.618,0.711 respectively, so the consistency among the two observers was the 0.635,0.621 of the 0.6645.AO type 1 and the kappa value of the doctor 2, respectively. The two conformance of the same observer was 0.628; the consistency of the AO type two observer was 0.545,0.626, so the consistency between the two observers was 0.5855; the kappa value of the improved AO typing system doctor 1 and the doctor 2 was 0.852,0.834, so the same observer was 0.842, and the improved AO classification system was divided. The consistency between the first and second times of the two observers was 0.834,0.823, so the consistency between the two observers was 0.8285; the kappa value of doctor 1 and the doctor 2 was 0.725,0.734, respectively, so the same observer was two conformance 0.7245, and the first and second times of the SLC score were 0.714,0.681. and two observation, respectively. The consistency between the TLICS scores was 0.6975; the kappa value of doctor 1 and doctor 2 was 0.743,0.790, so the consistency between the two observers was 0.7665; the TLICS score two observed the consistency of the first and second times respectively 0.750,0.772., so the consistency among the two observers was the comparison of the classification of the five thoracolumbar fractures, and the improved AO The reliability and consistency of the classification system method is the highest, the TLICS classification method is the second, the AO classification method is poor, the former has the clinical practical value. The improved AO classification system combines the advantages of AO and TLICS. Besides the morphological description, the system also considers the neurology state and the patient's actual situation, and has high repeatability and one. This is useful for surgical decision making, but this classification has not yet involved the degree of injury and prognosis of intervertebral disc and endplate.
【学位授予单位】：西南医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.3

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