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ACR适宜性标准之三可疑脊柱外伤
EditedbySpineTruthEditorialTeam
脊柱甘露语林?
学术?疾病与健康科普?助学?公益行
之天，第篇
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。
Figure1CCRHigh-RiskFactorsforCervicalSpineInjury
Figure2CCRLow-RiskFactorsforCervicalSpineInjury[2]
Figure3theCanadianC-spineruleforradiography[2]
Figure4NEXUS颈椎影像检查标准
Variant1.Agegreaterthanorequalto16yearsandlessthan65years.Suspectedacutebluntcervicalspinetrauma;imagingnotindicatedbyNEXUSorCCRclinicalcriteria.Patientmeetslow-riskcriteria.Initialimaging.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。
Procedure
AppropriatenessCategory
RelativeRadiationLevel
Arteriographycervicocerebral
头颈部动脉造影
UsuallyNotAppropriate
通常不合适
???
CTcervicalspinewithIVcontrast
颈椎CT静脉造影剂对比增强
UsuallyNotAppropriate
通常不合适
???
CTcervicalspinewithoutandwithIVcontrast
颈椎CT平扫+增强
UsuallyNotAppropriate
通常不合适
???
CTcervicalspinewithoutIVcontrast
颈椎CT平扫
UsuallyNotAppropriate
通常不合适
???
CTmyelographycervicalspine
CT颈椎脊髓造影
UsuallyNotAppropriate
通常不合适
????
CTAheadandneckwithIVcontrast
头颈部CTA增强
UsuallyNotAppropriate
通常不合适
???
MRAneckwithoutandwithIVcontrast
颈部MRA无、有对比增强
UsuallyNotAppropriate
通常不合适
O
MRAneckwithoutIVcontrast
颈部MRA平扫
UsuallyNotAppropriate
通常不合适
O
MRIcervicalspinewithoutandwithIVcontrast
颈椎MRI平扫+增强
UsuallyNotAppropriate
通常不合适
O
MRIcervicalspinewithoutIVcontrast
颈椎MRI平扫
UsuallyNotAppropriate
通常不合适
O
Radiographycervicalspine
颈椎X线
UsuallyNotAppropriate
通常不合适
??
Variant1：
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。
Variant2.Agegreaterthanorequalto16years.Suspectedacutecervicalspineblunttrauma.ImagingindicatedbyNEXUSorCCRclinicalcriteria.Initialimaging.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。
Procedure
AppropriatenessCategory
RelativeRadiationLevel
CTcervicalspinewithoutIVcontrast
颈椎CT无静脉对比增强
UsuallyAppropriate
通常适用
???
Radiographycervicalspine
颈椎X线
MayBeAppropriate
可能适用
??
Arteriographycervicocerebral
头颈部动脉造影
UsuallyNotAppropriate
通常不合适
???
CTcervicalspinewithIVcontrast
颈椎CT静脉造影剂对比增强
UsuallyNotAppropriate
通常不合适
???
CTcervicalspinewithoutandwithIVcontrast
颈椎CT平扫+增强
UsuallyNotAppropriate
通常不合适
???
CTmyelographycervicalspine
CT颈椎脊髓造影
UsuallyNotAppropriate
通常不合适
????
CTAheadandneckwithIVcontrast
头颈部CTA增强
UsuallyNotAppropriate
通常不合适
???
MRAneckwithoutandwithIVcontrast
颈部MRA平扫+增强
UsuallyNotAppropriate
通常不合适
O
MRAneckwithoutIVcontrast
颈部MRA平扫无对比增强
UsuallyNotAppropriate
通常不合适
O
MRIcervicalspinewithoutandwithIVcontrast
颈椎MRI无、有对比增强
UsuallyNotAppropriate
通常不合适
O
MRIcervicalspinewithoutIVcontrast
颈椎MRI平扫
UsuallyNotAppropriate
通常不合适
O
Variant2：
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。
Variant3.Agegreaterthanorequalto16years.Suspectedacutecervicalspineblunttrauma.Confirmedorsuspectedcervicalspinalcordornerverootinjury,withorwithouttraumaticinjuryidentifiedoncervicalCT.Nextimagingstudy.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。
Procedure
AppropriatenessCategory
RelativeRadiationLevel
MRIneckwithoutIVcontrast
颈椎MRI平扫
UsuallyAppropriate
通常适用
O
CTmyelographycervicalspine
CT颈脊髓造影
MayBeAppropriate
可能适用
????
Arteriographycervicocerebral
头颈部动脉造影
UsuallyNotAppropriate
通常不合适
???
CTAheadandneckwithIVcontrast
头颈部增强CTA
UsuallyNotAppropriate
通常不合适
???
MRAneckwithoutandwithIVcontrast
颈部MRA平扫+增强
UsuallyNotAppropriate
通常不合适
O
MRAneckwithoutIVcontrast
颈部MRA平扫
UsuallyNotAppropriate
通常不合适
O
MRIcervicalspinewithoutandwithIVcontrast
颈椎MRI平扫+增强
UsuallyNotAppropriate
通常不合适
O
Radiographycervicalspine
颈椎X线
UsuallyNotAppropriate
通常不合适
??
Variant3：
≥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。
Variant4.Agegreaterthanorequalto16years.Acutecervicalspineinjurydetectedonradiographs.Treatmentplanningformechanicallyunstablespine.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。
Procedure
AppropriatenessCategory
RelativeRadiationLevel
CTcervicalspinewithoutIVcontrast
颈椎CT平扫
UsuallyAppropriate
通常适用
???
MRIneckwithoutIVcontrast
颈椎MRI平扫
UsuallyAppropriate
通常适用
O
CTcervicalspinewithIVcontrast
颈椎增强CT
UsuallyNotAppropriate
通常不合适
???
CTcervicalspinewithoutandwithIVcontrast
颈椎CT平扫+增强
UsuallyNotAppropriate
通常不合适
???
CTmyelographycervicalspine
CT颈脊髓造影
UsuallyNotAppropriate
通常不合适
????
MRIcervicalspinewithoutandwithIVcontrast
颈椎MRI平扫+增强
UsuallyNotAppropriate
通常不合适
O
Variant4：
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。
Variant5.Agegreaterthanorequalto16years.Suspectedacutecervicalspineblunttrauma.ClinicalorimagingfindingssuggestarterialinjurywithorwithoutpositivecervicalspineCT.Nextimagingstudy.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。
Procedure
AppropriatenessCategory
RelativeRadiationLevel
CTAheadandneckwithIVcontrast
头颈部血管增强CTA
UsuallyAppropriate
通常适用
???
MRAneckwithoutandwithIVcontrast
颈部MRA平扫+对比增强
UsuallyAppropriate
通常适用
O
Arteriographycervicocerebral
头颈部动脉造影
MayBeAppropriate
可能适用
???
MRAneckwithoutIVcontrast
颈部MRA平扫
MayBeAppropriate
可能适用
O
Variant5：
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。
Variant6.Agegreaterthanorequalto16years.Suspectedacutecervicalspineblunttrauma.ObtundedpatientwithnotraumaticinjuryidentifiedoncervicalspineCT.NextimagingstudyafterCTcervicalspinewithoutIVcontrast.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。
Procedure
AppropriatenessCategory
RelativeRadiationLevel
MRIneckwithoutIVcontrast
颈椎MRI平扫
UsuallyAppropriate
通常适用
O
Arteriographycervicocerebral
头颈部动脉造影
UsuallyNotAppropriate
通常不合适
???
CTmyelographycervicalspine
CT颈脊髓造影
UsuallyNotAppropriate
通常不合适
????
CTAheadandneckwithIVcontrast
头颈部血管增强CTA
UsuallyNotAppropriate
通常不合适
???
MRAneckwithoutandwithIVcontrast
颈部MRA平扫+增强
UsuallyNotAppropriate
通常不合适
O
MRAneckwithoutIVcontrast
颈部MRA平扫
UsuallyNotAppropriate
通常不合适
O
MRIcervicalspinewithoutandwithIVcontrast
颈椎MRI平扫+增强
UsuallyNotAppropriate
通常不合适
O
Radiographycervicalspine
颈椎X线
UsuallyNotAppropriate
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。
Variant7.Agegreaterthanorequalto16years.Suspectedacutecervicalspineblunttrauma.Clinicalorimagingfindingssuggestligamentousinjury.NextimagingstudyafterCTcervicalspinewithoutIVcontrast.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。
Procedure
AppropriatenessCategory
RelativeRadiationLevel
MRIneckwithoutIVcontrast
颈椎MRI平扫
UsuallyAppropriate
通常适用
O
Arteriographycervicocerebral
头颈部动脉造影
UsuallyNotAppropriate
通常不合适
????
CTmyelographycervicalspine
CT颈脊髓造影
UsuallyNotAppropriate
通常不合适
???
CTAheadandneckwithIVcontrast
头颈部血管增强CTA
UsuallyNotAppropriate
通常不合适
O
MRAneckwithoutandwithIVcontrast
颈部MRA平扫+增强
UsuallyNotAppropriate
通常不合适
O
MRAneckwithoutIVcontrast
颈部MRA平扫
UsuallyNotAppropriate
通常不合适
O
MRIcervicalspinewithoutandwithIVcontrast
颈椎MRI平扫+增强
UsuallyNotAppropriate
通常不合适
O
MRIcervicalspinewithoutandwithIVcontrast
颈椎MRI平扫+增强
UsuallyNotAppropriate
通常不合适
??
Variant7：
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。
Variant8.Agegreaterthanorequalto16years.Suspectedacutecervicalspineblunttrauma.Follow-upimagingonpatientwithnounstableinjurydemonstratedinitially,butkeptincollarforneckpain.Nonewneurologicsymptoms.Includeswhiplashassociateddisorders.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。
Procedure
AppropriatenessCategory
RelativeRadiationLevel
CTcervicalspinewithoutIVcontrast
颈椎CT平扫
MayBeAppropriate
可能适用
???
MRIneckwithoutIVcontrast
颈椎MRI平扫
MayBeAppropriate
可能适用
0
Radiographycervicalspine
颈椎X线
MayBeAppropriate
可能适用
??
Arteriographycervicocerebral
头颈部动脉造影
UsuallyNotAppropriate
通常不合适
???
CTcervicalspinewithIVcontrast
颈椎增强CT
UsuallyNotAppropriate
通常不合适
???
CTcervicalspinewithoutandwithIVcontrast
颈椎CT平扫+增强
UsuallyNotAppropriate
通常不合适
???
CTmyelographycervicalspine
CT颈脊髓造影
UsuallyNotAppropriate
通常不合适
????
CTAheadandneckwithIVcontrast
头颈部血管增强CTA
UsuallyNotAppropriate
通常不合适
???
MRAneckwithoutIVcontrast
颈部MRA平扫
UsuallyNotAppropriate
通常不合适
0
MRAneckwithoutIVcontrast
颈部MRA平扫
UsuallyNotAppropriate
通常不合适
0
MRIcervicalspinewithoutandwithIVcontrast
颈椎MRI平扫+增强
UsuallyNotAppropriate
通常不合适
0
Variant8：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。
Variant9.Agegreaterthanorequalto16years.Blunttraumameetingcriteriaforthoracicandlumbarimaging.Initialimaging.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。
Procedure
AppropriatenessCategory
RelativeRadiationLevel
CTthoracicandlumbarspinewithoutIVcontrast
胸腰椎CT平扫
UsuallyAppropriate
通常适用
???
Radiographythoracicandlumbarspine
胸腰椎X线
MayBeAppropriate
可能适用
???
CTmyelographythoracicandlumbarspine
胸腰椎CT脊髓造影
UsuallyNotAppropriate
通常不合适
????
CTthoracicandlumbarspinewithIVcontrast
胸腰椎增强CT
UsuallyNotAppropriate
通常不合适
???
CTthoracicandlumbarspinewithoutandwithIVcontrast
胸腰椎CT平扫+增强
UsuallyNotAppropriate
通常不合适
????
MRIthoracicandlumbarspinewithoutandwithIVcontrast
胸腰椎MRI平扫+增强
UsuallyNotAppropriate
通常不合适
0
MRIthoracicandlumbarspinewithoutIVcontrast
胸腰椎MRI平扫
UsuallyNotAppropriate
通常不合适
0
Variant9：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。
Variant10.Agegreaterthanorequalto16years.AcutethoracicorlumbarspineinjurydetectedonradiographsornoncontrastCT.Neurologicabnormalities.Nextimagingstudy.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。
Procedure
AppropriatenessCategory
RelativeRadiationLevel
MRIthoracicandlumbarspinewithoutIVcontrast
胸腰椎MRI平扫
UsuallyAppropriate
通常适用
0
CTmyelographythoracicandlumbarspine
胸腰椎CT脊髓造影
MayBeAppropriate
可能适用
????
CTthoracicandlumbarspinewithIVcontrast
胸腰椎增强CT
UsuallyNotAppropriate
通常不合适
???
CTthoracicandlumbarspinewithoutandwithIVcontrast
胸腰椎CT平扫+增强
UsuallyNotAppropriate
通常不合适
????
MRIthoracicandlumbarspinewithoutandwithIVcontrast
胸腰椎MRI平扫+增强
UsuallyNotAppropriate
通常不合适
0
CT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,WestOC,NunezD,Jr.,KirschCFE,AulinoJM,BroderJS,CassidyRC,CzuczmanGJ,DemertzisJL,JohnsonMM,MotamediK,ReitmanC,ShahLM,ThanK,Ying-KouYungE,BeamanFD,KransdorfMJ,BykowskiJ()ACRAppropriatenessCriteria((R))SuspectedSpineTrauma.JournaloftheAmericanCollegeofRadiology:JACR16(5s):S-s.doi:10./j.jacr..02.
2.StiellIG,WellsGA,VandemheenKL,ClementCM,LesiukH,DeMaioVJ,LaupacisA,SchullM,McKnightRD,VerbeekR,BrisonR,CassD,DreyerJ,EisenhauerMA,GreenbergGH,MacPhailI,MorrisonL,ReardonM,WorthingtonJ()TheCanadianC-spineruleforradiographyinalertandstabletraumapatients.Jama(15):-
《脊柱甘露语林》：人体低电离辐射拍片法
为善如负重登山志虽已确而力犹恐不及
为恶如乘骏走坂鞭虽不加而足不禁其前
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甘露语林学术
