Delayed Recognition of Thoracic and Lumbar Vertebral Compression Fractures in Minor Accident Cases
Delayed Recognition of Thoracic and Lumbar Vertebral Compression Fractures in Minor Accident Cases
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DOI：
10.7759/cureus.1050
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发表时间：
2017-02-01
影响因子：
1.2
通讯作者：
Jacobson, Robert E.
中科院分区：
文献类型：
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作者：
Hatgis, Jesse;Granville, Michelle;Jacobson, Robert E.
老年人的骨质疏松性椎体压缩骨折(VCFs)通常是在轻微跌倒或创伤后被诊断出来的；然而，这些患者中的大多数以前已经接受过骨质疏松评估，或者在跌倒时已经接受了某种形式的骨质疏松药物治疗。虽然意外是VCFs的已知原因，但这些骨折往往没有得到诊断。在回顾一组在轻微跌倒或车祸后出现的抱怨全身脊柱疼痛的患者时，我们发现了一小部分以前未诊断出VCFs的患者。这些骨折也是之前未被发现的骨质疏松症过程的初步迹象。最初的诊断、治疗和治疗通常集中在其他脊柱节段(主要是腰椎)，直到VCF和骨质疏松症都被确定。本报告旨在提高对骨质疏松症VCFs诊断的认识，并探讨提高诊断水平的步骤。这些患者在初步评估后被诊断为VCFs，原因是保守治疗后持续疼痛或主诉疼痛超出原始受伤区域(即典型的腰椎)。在这一点上，采取了更详细的病史，包括任何过去的骨质疏松症治疗，或以前的跌倒或受伤，以排除先前存在的骨折的可能性。对疼痛区域进行更集中的检查，包括对磁共振成像(MRI)或计算机断层扫描(CT)确定的骨折部位进行敲击。如果可能，要求进行骨骼扫描，将急性和亚急性创伤性骨折与陈旧性/慢性骨折分开。此外，我们调查了另外两家类似的疼痛/事故诊所，他们在24个月内发现了类似数量和人口的VCFs患者，以比较他们识别出的VCFs的数量。在24个月的时间里，大约2700名患者中有10人在轻微事故中发生了急性胸或腰部VCFs，以前没有被诊断为骨质疏松症。由于2700名患者中约有30%发生了新的意外，800名新患者中有10名(1.25%)被发现患有VCFs，而没有已知的骨质疏松症病史。在同一时期，另外两家接受调查的疼痛/事故诊所的患者数量和人数相似；然而，在诊所检查类似数量的患者时，每个诊所只诊断出两到三个VCFs。在另外两个诊所，被诊断为新的VCFs的患者的比例要低得多(0.3%)。意识到骨质疏松VCFs的可能性是检测它们的第一步。这项研究揭示了在轻微创伤病例中存在忽视骨质疏松VCFs的微小但真实的风险。必要时，在受持续性疼痛影响的脊柱节段重复或获得更高质量的成像。胸腰椎交界处(即T12和L1椎体)尤其容易发生VCFs。在轻微事故后延迟识别这些VCFs和患者潜在的骨质疏松症可能是一个大问题，因为患者接受负责纠正和防止进一步脊柱畸形和疼痛的适当内科或手术治疗的关键时间已经缩短。
Osteoporotic vertebral compression fractures (VCFs) in the elderly are commonly diagnosed after a minor fall or trauma; however, the majority of these patients have either been previously evaluated for osteoporosis or are already under some form of medical treatment for osteoporosis at the time of the fall. Although accidents are a known cause of VCFs, these fractures are too often undiagnosed. In reviewing a group of patients seen after minor falls or automobile accidents who were complaining of general spine pain, we found a smaller subgroup with previously undiagnosed VCFs. These fractures were also the initial signs of a previously unrecognized osteoporotic process. Initial diagnosis, treatment, and therapy were usually focused on other spinal segments (i.e. mainly the lumbar spine) until both the VCF and the osteoporosis were identified. The purpose of this report is to raise awareness and discuss the steps for improved diagnosis of osteoporotic VCFs.A retrospective analysis was conducted on a large group of patients from one pain/accident clinic in a 24 month period. These patients were diagnosed with VCFs subsequent to the initial evaluation due to either persistent pain after conservative therapy or complaints of pain beyond the original injured area (i.e. typically the lumbar spine). At this point, a more detailed history was taken, including any past treatment for osteoporosis, or previous falls or injury to exclude the possibility of pre-existing fractures. A more focused examination of the painful area was completed, consisting of percussion at the fracture site identified on magnetic resonance imaging (MRI) or computed tomography (CT) scan. If possible, a bone scan was ordered to separate acute and subacute traumatic fractures from old/chronic fractures. Additionally, we surveyed two other similar pain/accident clinics who saw a comparable number and population of patients diagnosed with VCFs within a 24 month period to make a comparison of the number of VCFs they identified.Ten out of approximately 2700 patients seen over a 24 month period sustained acute thoracic or lumbar VCFs during a minor accident and were not previously diagnosed with osteoporosis. Since approximately 30% of the 2,700 patients had new accidents, 10 out of 800 new patients (1.25%) were found to have VCFs without a known history of osteoporosis. Two other surveyed pain/accident, clinics saw a similar number and population of patients in the same time period; however, each only diagnosed two or three VCFs while examining a similar number of patients in the clinic. In these two other clinics, a much lower percentage (0.3%) of patients were diagnosed with new VCFs.Awareness of the possibility of osteoporotic VCFs is the first step in detecting them. This study reveals the presence of a small but real risk of overlooking osteoporotic VCFs in minor trauma cases. When necessary, repeat or obtain better quality imaging in spinal segments affected by persistent pain. The thoracolumbar junction (i.e. T12 & L1 vertebrae) is especially at risk for sustaining VCFs. The delayed recognition of these VCFs and the patient's underlying osteoporosis after minor accident cases could present a major problem, as the critical time for patients to receive the proper medical or surgical treatments responsible for correcting and preventing further spinal deformity and pain has been reduced.