本文選題：胸腰段脊柱骨折分型 + Denis分型��； 參考：《西南醫(yī)科大學(xué)》2017年碩士論文

【摘要】：研究背景胸腰段骨折是脊柱骨折中最常見的類型,基于簡(jiǎn)單、實(shí)用、準(zhǔn)確、全面、可重復(fù)、可評(píng)估損傷程度、可指導(dǎo)治療及可預(yù)見預(yù)后的原則,目前尚未有一種被普遍接受和采用的分類方法。國(guó)內(nèi)外目前常用的胸腰段脊柱骨折分類主要有Denis分型、AO分型(即Magerl系統(tǒng))、SLC評(píng)分系統(tǒng)、TLICS評(píng)分分類系統(tǒng)。各個(gè)分類由于受當(dāng)時(shí)生物力學(xué)的理解與影像學(xué)技術(shù)的局限,各具優(yōu)缺點(diǎn),對(duì)其分類提出了更高的要求。隨著醫(yī)學(xué)技術(shù)的進(jìn)步和影像學(xué)的發(fā)展,國(guó)內(nèi)外公認(rèn):應(yīng)根據(jù)骨折的受傷機(jī)制、骨折的形態(tài),骨折后脊柱的穩(wěn)定性及神經(jīng)功能狀態(tài)來決定。1983年Denis根據(jù)其生物力學(xué)試驗(yàn)將脊柱分為前、中、后三柱,認(rèn)為單純前、后柱損傷不影響脊柱穩(wěn)定性,提出同時(shí)累及中柱的脊柱骨折是不穩(wěn)定的骨折,但Denis分型只對(duì)412例胸腰椎骨折患者做出分析,而且僅有53例做了CT掃描,分型中沒有涉及椎間盤損傷的問題。1994年Magerl等通過分析10年中1445例胸腰段脊柱骨折的X線片、CT片,按照骨折形態(tài)與嚴(yán)重的傷害程度從A型到C型及其對(duì)應(yīng)的1至3亞型的AO分型,并進(jìn)一步細(xì)分為53種亞型,盡管AO分型(即Magerl系統(tǒng))充分考慮骨折的形態(tài),一定程度考慮了損傷的嚴(yán)重性、骨折的穩(wěn)定性與神經(jīng)受損的危險(xiǎn)性,但缺乏MRI影像評(píng)估,其太過復(fù)雜,未評(píng)估神經(jīng)的功能狀態(tài)及對(duì)治療的指導(dǎo)意義,且未涉及椎間盤及終板的損傷的評(píng)估。Mc Cormack等1994年,通過研究短節(jié)段椎弓根螺釘固定胸腰椎脊柱骨折失敗的原因后提出了SLC評(píng)分系統(tǒng)(share loading scoring system),這種評(píng)分系統(tǒng)可作為脊柱外科醫(yī)生選擇前、后手術(shù)入路治療提供了依據(jù),但是該分類方法沒有涉及韌帶損傷,未評(píng)估神經(jīng)的功能狀態(tài),也沒有涉及損傷機(jī)制,出于這個(gè)原因,它不能用來決定手術(shù)適應(yīng)癥。TLICS系統(tǒng)評(píng)分(Thoracolumbar injury classification and severity score)是2005年由Vaccaro等提出胸腰段脊柱骨折損傷的TLISS評(píng)分系統(tǒng)(Thoracolumbar injury severity score)基礎(chǔ)上由美國(guó)脊柱創(chuàng)傷研究會(huì)改進(jìn)的評(píng)分系統(tǒng),該分類系統(tǒng)根據(jù)神經(jīng)的功能狀態(tài)、PLC(Posterior ligamentous complex)的完整性及骨折的形態(tài)進(jìn)行分類,但對(duì)PLC完整性的MRI診斷提出了質(zhì)疑,對(duì)指導(dǎo)治療存在文化與地區(qū)間的差異性,因此尚不能被廣泛采用。2013年AO為提出一種有效、更能指導(dǎo)外科治療和廣泛接受的一種分型,改良胸腰段脊柱骨折AO分型(簡(jiǎn)稱改良的AO分型),它根據(jù)骨折的形態(tài)與神經(jīng)功能評(píng)分。對(duì)其可靠性與一致性在不同國(guó)家進(jìn)行對(duì)比觀察是必要的,以求最終將用于指導(dǎo)臨床。研究目的臨床觀察改良AO分型的可靠性與一致性,探討改良AO分型的優(yōu)缺點(diǎn)。研究方法選擇我院2011.01-2016.12期間125例臨床及影像學(xué)資料(X線片、CT、3DCT、MRI)完整的胸腰段骨折患者,將該125例患者的資料提供給本科室2名骨科醫(yī)生(2名主治醫(yī)師,分別為醫(yī)生1和醫(yī)生2),分別采用Denis分型、AO分型、SLC評(píng)分系統(tǒng)、TLICS評(píng)分分類系統(tǒng)及改良AO分型系統(tǒng)五種方法進(jìn)行脊柱骨折分類和評(píng)分。1個(gè)月后進(jìn)行重復(fù)分類和評(píng)分,采用加權(quán)Cohen′s Kappa系數(shù)評(píng)價(jià)觀察者的可靠性和一致性。研究結(jié)果Denis分型醫(yī)生1和醫(yī)生2的kappa值分別為0.734、0.692,所以同一觀察者兩次一致性為0.713;Denis分型兩觀察者間一致性第一次和第二次分別為0.618,0.711,所以兩觀察者間的一致性為0.6645。AO分型醫(yī)生1和醫(yī)生2的kappa值分別為0.635、0.621,所以同一觀察者兩次一致性為0.628;AO分型兩觀察者間一致性第一次和第二次分別為0.545、0.626,所以兩觀察者間的一致性為0.5855;改良AO分型系統(tǒng)醫(yī)生1和醫(yī)生2的kappa值分別為0.852、0.834,所以同一觀察者兩次一致性為0.842;改良AO分型系統(tǒng)分型兩觀察者間一致性第一次和第二次分別0.834、0.823,所以兩觀察者間的一致性為0.8285;SLC評(píng)分醫(yī)生1和醫(yī)生2的kappa值分別為0.725、0.734,所以同一觀察者兩次一致性0.7245;SLC評(píng)分觀察者間一致性第一次和第二次分別為0.714、0.681。所以兩觀察者間的一致性為0.6975;TLICS評(píng)分醫(yī)生1和醫(yī)生2的kappa值分別為:0.743、0.790,所以兩觀察者間的一致性為0.7665;TLICS評(píng)分兩觀察者間一致性第一次和第二次分別為0.750、0.772。所以兩觀察者間的一致性為0.761。五種胸腰段骨折分類方法比較,改良AO分型系統(tǒng)方法的可靠性和一致性最高,TLICS分類方法次之,AO分型方法較差,前者更具臨床實(shí)用價(jià)值。研究結(jié)論改良AO分型系統(tǒng)結(jié)合了AO和TLICS的優(yōu)點(diǎn),除了形態(tài)學(xué)描述,該系統(tǒng)還考慮了神經(jīng)學(xué)狀態(tài)和患者實(shí)際情況,具有較高的可重復(fù)性與一致性,這對(duì)于外科治療決策較為實(shí)用。但該分型尚未涉及椎間盤與終板的損傷程度及對(duì)預(yù)后的影響。
[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.
【學(xué)位授予單位】：西南醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R687.3

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