脊髓损伤ASIA神经学分类标准在临床应用中存在的问题及原因分析

Problems and solutions associated with the clinical application of the international standards for neurological classification of spinal cord injury

中文关键词:  脊髓损伤  美国脊髓损伤学会  神经学分类残损分级

英文关键词:Spinal cord injury  American spinal injury association  Neurological classification  Impairment scale

中文摘要:

  【摘要】 目的：分析脊髓损伤ASIA神经学分类标准（ＡＳＩＡ标准）在临床应用中存在的问题，探讨解决的方法。方法：收集2010年我院收治的341例脊髓损伤患者的临床资料，首先由中级职称医师统计入院时诊断记录、ASIA残损分级记录表和影像学资料，整理出残损分级、脊髓损伤平面和运动平面作为原始记录。再由高级职称医师组成的AISA标准专家组根据原始记录和病历对每例患者的残损分级、损伤平面和运动平面重新评估，得出审核后评定结果。比较审核前后的评定结果。结果：原始记录178例A级患者经审核后1例定为B级，2例定为C级；43例B级患者经审核后15例定为C级，1例定为A级；34例C级患者经审核后1例定为B级，1例定为D级；45例患者未分级。15例C级被误定为B级是由于原始记录者认为运动平面以下超过3个节段以远有少量运动功能的患者属于B级而非C级。1例B级和2例C级被误定为A级是因评定时仅依据ASIA残损伤分级记录表格中的信息而忽略了体格检查中直肠感觉存在和远端非关键肌运动功能保留的记录。A至B、B至C和D至C的级别误定各1例是因对记录表格中信息的归纳错误所致。原始记录中损伤平面：颈髓139例，胸髓145例，圆锥损伤21例，马尾综合征12例，7例未定平面，审核后均与原始记录一致；17例腰髓损伤经审核后只有1例为腰髓损伤，12例为圆锥综合征，4例为马尾综合征。对ASIA标准中腰髓损伤与圆锥综合征及马尾综合征损伤范围理解不清是将后两者误诊为腰髓损伤的主要原因。22例残损D级中央综合征病例中有18例在原始记录中将运动平面定为颈髓，但查体显示下肢关键肌肌力可达2~5级，是忽略运动平面意义造成的使用不当。结论：应用脊髓损伤ASIA标准时应详细、准确理解其内容，以减少对相同标准的不同理解而产生错误的评估结果。

英文摘要:

  【Abstract】 Objectiveｓ： To find practice-based problems of the application of international standards for neurological classification of ｓｐｉｎａｌ　ｃｏｒｄ　ｉｎｊｕｒｙ(ISNCSCI, ASIA standard), and to search the solutions. Methodｓ： The clinical materials including all medical text records and images of 341 SCI cases（in 2010）, which were classified by using ISNCSCI in the hospital, were obtained. The original injury level, motor level as well as ASIA impairment scale(AIS) of each patient were extracted from the medical text records by junior doctors and reassessed by senior doctors according to the obtained clinical materials. Lastly, for all cases, the oringinally given classification and the reassessment results were compaired and analysed. Resultｓ： Concerning AIS, there were 178 oringinal A patients, 1 and 2 of whom were reassessed as B and C respectively; there were 1 and 15 of 43 oringinal B to A and C; and 2 of 34 oringinal C to 1 B and 1 D. The rest 45 cases were with unknown scale. 15 C were oringinally identified as B because the patients with 1 or 2 levels motor function preserved at more than three levels below the motor level were primarily considered as B, but not C. Misclassifications of 1 B and 2 C to A were caused by simply reviewing the ASIA sheets and ignorence of the notes of non-key muscle power and anal deep sensory in the medical text records. The mistakes of 1 A to B, 1 B to C and 1 D to C could be explained as just counting errors. As for injury level, no inaccuracy was found in 139 cervical cases, 145 thoracic cases, 21 conus medullaris syndrome(CMS) cases, 12 cauda equina syndrome(CES) cases，and 7 unknow level cases. 12 and 4 of oringinal 17 lumbar SCI cases were modified by the senior doctors to be CMS and CES, respectively. This problem was brought by the confusion of neural injury range among L1-5, CMS and CES. In addition, 18 of 22 patients who sustained central cord syndrome had muscles power of grade ２ to　５ in lower extremities, were originally recognized to have motor levels at cervical segments by misunderstanding of the concept of motor level. Conclusionｓ：　A precise and intensive comprehension of the wording in ASIA standard is strongly suggested since it is just the solution to address the abovementioned clinical problems.