背景:在美国,脊柱的平民枪伤是越来越常见的伤害。大多数可用的研究集中在遭受高能导弹伤害的军事人群上。由于数量有限,现有的研究集中在整个脊柱上,因此最少的研究集中在平民对腰s脊柱的弹道伤害上。
目的:描述腰骶骨脊柱的弹道损伤,并建立一个模型,根据患者的骨折形态预测神经功能缺损的存在。
方法:回顾性图表回顾患者样本:148例连续患者出现在城市1级创伤中心,脊柱弹道损伤涉及L1-S2级。
方法:使用美国脊髓损伤协会(ASIA)损伤量表进行演示和最终随访时的神经系统状况。
方法:获得IRB批准并进行回顾性图表审查。提取的数据包括患者人口统计,表现和最终随访时的神经系统状况,断口形态,稳定性评估,其他相关伤害,和外科手术。进行比例分析以表征骨折及其相关的神经损伤。进行卡方检验以确定与神经系统损伤相关的骨折特征。使用与神经功能缺损高度相关的骨折特征进行多重后勤回归,以建立预测神经功能缺损的模型。然后用接收器操作曲线对模型进行验证。
结果:在148名患者中,14例患者接受了脊柱手术,最常见的适应症是减压和异物取出。腹内损伤发生率较高(73.6%)。骨折的特点是水平,受影响的椎骨部分,和椎管受累。在演示和最终随访时使用ASIA量表对神经损伤进行分类。椎体骨折特征的赔率显示神经功能缺损与椎弓根骨折高度相关(OR=9.07[4.14-21.54]-95%CI),椎板骨折(OR=6.42[3.16-13.62]-95%CI),小关节骨折(OR=5.95[2.90-12.79]-95%CI),管内骨(OR=12.79[5.98-29.05]-95%CI),和运河内轨迹(OR=1078[4.48-28.98])-95%CI。进行多元逻辑回归以构建神经缺陷的预测模型,该模型显示管内轨迹,椎弓根骨折和小关节骨折与神经功能缺损有关。ROC曲线的面积为0.849[(0.7853至0.9128-95%CI),p<0.0001]证明了良好的模型拟合。
结论:腰骶部脊柱的弹道损伤涉及一个经常多外伤患者的复杂损伤模式。涉及椎弓根的骨折,椎板,小平面与神经损伤高度相关,也是一条跨运河的轨迹。患者骨折形态可用于预测是否存在神经缺陷。
BACKGROUND: Civilian gunshot wounds to the spine are an increasingly common injury in the USA. A majority of the available research is focused on a military population suffering high energy missile injury. Minimal research has focused on civilian ballistic injuries to the lumbosacral spine as the available studies focus on the entire spine due to limited numbers.
OBJECTIVE: Characterize ballistic injuries to the lumbosacral spine and develop a model to predict the presence of neurological deficit based upon a patients presenting fracture morphology.
METHODS: Retrospective chart review.
METHODS: One hundred forty-eight consecutive patients that were presented to an urban level 1 trauma center with ballistic injures to the spine involving the levels L1-S2.
METHODS: Neurological status at presentation and final follow up using the American Spinal Injury Association (ASIA) Impairment Scale.
METHODS: IRB approval was obtained, and retrospective chart review was performed. Extracted data included patient demographics, neurological status on presentation and final follow-up, fracture morphology, assessment of stability, other associated injuries, and surgical procedures performed. Proportional analysis was performed to characterize the fractures and their associated neurological injuries. Chi-square testing was done to identify fracture characteristics associated with neurologic injury. A multiple logistical regression was performed using fracture characteristics highly associated with neurological deficit to develop a model to predict neurologic deficit. The model was then validated with a receiver operator curve.
RESULTS: Of the 148 patients, 14 patients underwent spinal surgery with the most common indication being decompression and foreign body removal. There was a high incidence of intra-abdominal injury (73.6%). Fractures were characterized by level, affected vertebral component, and spinal canal involvement. Neurological injury was classified using the ASIA scale at presentation and final follow up. Odds-ratios of vertebral fracture characteristics showed neurologic deficit was highly associated with pedicle fractures (OR=9.07 [4.14-21.54] - 95% CI), lamina fractures (OR=6.42 [3.16-13.62] - 95% CI), facet fractures (OR=5.95 [2.90-12.79] - 95% CI), intra-canal bone (OR=12.79 [5.98-29.05] - 95% CI), and an intra-canal trajectory (OR=1078 [4.48-28.98]) - 95% CI. Multiple logistic regression was performed to construct a predictive model of neurologic deficit which showed that intra-canal trajectory, pedicle fracture and facet fracture are associated with neurologic deficit. An ROC curve was made with an area of 0.849 ([0.7853 to 0.9128 - 95% CI], p<.0001) demonstrating a good model fit.
CONCLUSIONS: Ballistic injuries to the lumbosacral spine involve complex injury patterns in an often polytraumatized patient. Fractures involving the pedicle, lamina, and facet are highly associated with neurologic injury, as is a trans-canal trajectory. A patients fracture morphology can be used to predict if a neurologic deficit is present.