Spinal tuberculosis
Introduction
Introduction to spinal tuberculosis Spinal tuberculosis is caused by vertebral lesions caused by circulatory disorders and tuberculosis infection. The affected spine showed bone destruction and necrosis. There were cheese-like changes and abscess formation. The vertebral body collapsed due to lesions and weight bearing, causing the curvature of the spine to form a curvature, the spinous process was uplifted, and there was a hump deformity on the back. The thoracic tuberculosis was particularly obvious. Spinal tuberculosis accounts for about half of the total number of bone and joint tuberculosis, with the largest number of children and adolescents, all of which can be affected. The lumbar vertebrae are more common, the thoracic vertebrae is second, and the thoracolumbar segment is the third. The cervical vertebrae and the atlas are less common. Among them, vertebral tuberculosis accounts for about 99%, and vertebral tube tuberculosis accounts for about 1%. Patients with fatigue, loss of appetite, low fever in the afternoon, night sweats and weight loss and other symptoms of systemic poisoning. Occasionally, a few cases of acute exacerbation of acute exacerbation of relaxation-type hyperthermia, body temperature of about 39 ° C, many misdiagnosis of severe cold or other acute infection. basic knowledge The proportion of illness: 0.005% Susceptible people: more common in children and adolescents Mode of infection: non-infectious Complications: empyema paraplegia autonomic dysfunction somatosensory disorder dyskinesia
Cause
Spinal tuberculosis
Causes of spinal tuberculosis (80%):
Spinal tuberculosis is the secondary disease, the primary disease is tuberculosis, digestive tract tuberculosis or lymphatic tuberculosis, etc., caused by bone circulation and joint tuberculosis.
Prevention
Spinal tuberculosis prevention
prevention:
1. Actively control infections in other parts of the body.
2. BCG vaccination:
Vaccination with BCG has a significant effect on the prevention of hematogenous disseminated tuberculosis in infants and children with cellular insufficiency, miliary tuberculosis and tuberculous meningitis. Strict implementation of the BCG vaccination system has a positive effect on reducing tuberculosis and extrapulmonary tuberculosis in infants and children.
3. Tuberculosis patient contact prevention:
Pulmonary tuberculosis patients should follow the doctor's advice regularly, and the infection is generally reduced by 95% after 2 weeks of regular treatment. Contact with tuberculosis patients can go to the tuberculosis prescription unit for examination to rule out the possibility of illness. At the same time, do the following precautions:
Do a thorough disinfection. According to the characteristics of cold, heat and dry heat resistance of tubercle bacilli, boiled dishes, towels, clothes, handkerchiefs, masks and other items used by patients for 10 to 15 minutes; for books, quilts, chemical fiber clothing, etc. Cooked items can be exposed to sunlight for 4 to 6 hours or UV light for two hours. In addition, it can also be used for disinfection of disinfectant such as Sushui. The room where the patient lives can be sterilized by ultraviolet light.
Temporarily open the window to ventilate and keep the indoor air fresh. According to statistics, ventilation is ventilated every ten minutes, and after 4 to 5 times, 99% of Mycobacterium tuberculosis in the air can be blown off.
Cultivate good hygiene habits, such as the implementation of the system of food, the special equipment for washing utensils, washing hands frequently, changing clothes frequently, and disinfecting regularly.
4. Drug prevention:
Strong positive tuberculin test (+ + + +), contact with open tuberculosis patients, silicosis patients, hemodialysis patients with renal disease, diabetic patients, long-term use of adrenal cortical hormone patients, in order to eliminate the more active dormant tuberculosis, available Isoniazid oral (1 mg/kg for adults and 10 mg/kg for children) for 1 year to reduce the chance of tuberculosis recurrence.
The purpose of drug prevention:
The purpose of drug prevention is mainly to prevent the occurrence of tuberculosis by taking preventive medications for those who have been infected with tuberculosis and have a high incidence of disease. Because healthy people are not necessarily ill after being infected with tuberculosis, whether the disease is mainly affected by two factors: the size of the virulence of the infected tuberculosis and the strength of the body's resistance. Tuberculosis is highly toxic and low in resistance, and tuberculosis is prone to occur. On the contrary, it is not onset, but it may occur when the body's resistance is significantly reduced. The probability of developing tuberculosis in the lifetime of tuberculosis is about 10%.
Complication
Spinal tuberculosis complications Complications, empyema, paraplegia, autonomic dysfunction, somatosensory disorder, dyskinesia
This thoracic paraspinal swelling can be accompanied by empyema after piercing the pleura.
The most common complications of spinal tuberculosis complicated with paraplegia:
(1) Precursors before spinal paralysis:
1. Feeling disorder: If the patient complains of a belt-like tightening feeling from the back to the chest or the abdomen, or the feeling of ants crawling, numbness, and cold stimulation.
2, movement disorders: consciously walk awkward, do not listen to the move when the footsteps, the lower limbs stiff, hard, trembling, or soft and weak, easy to fall.
3, sphincter dysfunction: mainly the bladder and rectal sphincter disorders, manifested as weakness, incontinence and so on.
4, autonomic dysfunction: such as the performance of the diseased vertebral body under the skin dry, no sweat, low skin temperature, the hand touches the normal vertebral body or the nerves governed by the diseased vertebrae up and down, the left and right range has a hot and cold feeling .
(2) About 10% of the vertebrae combined with paraplegia should be implemented with prevention. The main measure is to insist on no burden on the active period of spinal tuberculosis, and insist on bed rest and anti-spasmodic treatment. If paraplegia has occurred, it should be actively treated early, and most of them can achieve good recovery. If the timing is lost, the consequences are serious. If there are some sputum, generally more non-surgical treatment, according to paraplegia care, absolutely bedridden, anti-tuberculosis drug treatment, improve the general condition, and strive for the best recovery; if no recovery after 1 to 2 months, surgery should be relieved as soon as possible If paraplegia develops quickly, or even completely paraplegic, surgery should be performed as soon as possible, and should not wait. In cervical spondylosis with paraplegia, or cold abscess, surgery should be performed early, incision in the anterior side of the neck, between the anterior aspect of the sternocleidomastoid and the internal jugular vein of the common carotid artery (or before the carotid sheath) Enter, expose and remove the lesion, and treat both sides as necessary. In the thoracic spine surgery, the rib transverse process is used to remove the lesions, or the anterior and posterior anterior lateral decompression and decompression are performed, and the paraplegia is restored. After the general condition is improved, the spinal fusion is performed to stabilize the spine.
Symptom
Spinal tuberculosis symptoms Common symptoms Vertebral tuberculosis Lumbar spine pain Spinal and limb malformations Appetite loss Spinal vestige weight loss Powerless night sweats Low heat limb or trunk posture abnormalities
Spinal tuberculosis is a chronic osteoarticular lesion with slow onset and slow progression, and early symptoms can often be ignored. Some are misdiagnosed as chronic strain, rheumatism, etc. and long-term symptomatic treatment. Very few onset of illness, easy to be confused with acute suppurative inflammation.
1. Systemic symptoms:
Patients with fatigue, loss of appetite, low fever in the afternoon, night sweats and weight loss and other symptoms of systemic poisoning. Occasionally, a few cases of acute exacerbation of acute exacerbation of relaxation-type hyperthermia, body temperature of about 39 ° C, many misdiagnosis of severe cold or other acute infection.
2. Local symptoms:
(1) Pain
The affected area has a dull pain. In the early stage, the progress of the disease gradually worsened. After exerting fatigue, the activity was aggravated. When the car was shaken, coughed, sneezing, it was aggravated. After bed rest, it was relieved. The pain at night is aggravated. If sudden symptoms worsen, most of the vertebral compression or lesions involve the nerve roots. The pain can be radiated along the spinal nerves. The upper cervical vertebrae radiate to the occipital and lower cervical vertebrae to the shoulders or arms. The thoracic vertebrae radiate along the intercostal nerves. The lower abdomen is often misdiagnosed as cholecystitis, pancreatitis, appendicitis, etc. The lower thoracic vertebrae 11-12 can be radiated along the lower inferior nerve to the lower back or buttocks. For this X-ray examination, only the lumbar vertebrae are taken, so the lower thoracic lesions are often missed. Lumbar lesions radiate along the lumbar plexus to the front of the thigh, and even involve the posterior side of the leg, which is easily misdiagnosed as disc herniation.
(2) Limited activity
The soft tissue around the lesion is stimulated by inflammation, pain, protective contracture, and affecting spinal activity. Cervical vertebrae and lumbar vertebrae have large mobility and are easy to detect. The spine mainly has three directions of flexion and extension, lateral bending and rotation. There is no special fixed position for the patient to actively flex, stretch, and bend, and if it is limited, it can often be seen at a glance. If the child does not cooperate, it can be placed on the back, and hip and knee flexion can often be found; if the hip is passively stretched, pain can occur; let the child prone, hold the two hands in one hand and lift it up, showing immediate pain and can See the waist plate shape. That is, the prone back test is positive.
(3) abnormal posture
Patients often have specific posture abnormalities, different parts, and different postures. Cervical tuberculosis patients often have a torticollis, anterior tilt, neck shortening and hands holding the lower jaw position. Thoracic and lumbar vertebrae, lumbar vertebrae, and lumbosacral tuberculosis patients have a chest-chest posture when standing or walking. When sitting, they prefer to use the chair to reduce the pressure on the affected vertebral body. Normal people can bend over and pick up things. They can't bend over because of illness, but they bend their hips and bend their knees. They hold their knees and pick up the other things on the ground. They call it a positive test.
(4) Spinal deformity
Mainly caused by the invasion and destruction of Mycobacterium tuberculosis caused by morphological changes in the vertebral body. The cervical vertebrae and lumbar vertebrae can have physiological protrusion disappeared. The thoracic vertebrae and thoracolumbar segments are more common after convex and deformed, mostly angular kyphosis, touched by hand. Touch it. Scoliosis is not common and is not serious. The kyphosis of the spine is limited by the characteristics of spinal tuberculosis.
(5) tenderness and snoring pain
Early lesions are deeper and more limited, so local tenderness can be inconspicuous. Longitudinal slamming can be used to check: the patient is sitting straight, the doctor holds the patient's chest with one hand, and the fist is slammed longitudinally with one hand. At this time, the patient often has a diseased vertebra. dull pain. When the local deformity is backward, the kyphosis is pressed by hand, which can cause significant pain.
(6) cold abscess and sinus formation
Often the earliest signs of patient visits, 70% to 80% of spinal tuberculosis complicated with cold abscess at the time of presentation, often mistaken for abscesses as tumors. Deep paravertebral abscesses need to be shown by X-ray CT or MRI. Circumferential vertebral lesions may cause dysphagia or respiratory dysfunction in the posterior pharyngeal wall abscess; middle and lower cervical abscesses appear in the anterior or posterior cervical triangle; thoracic tuberculosis vertebral body presents a tensionous fusiform or columnar abscess along the intercostal nerve The vascular bundle is injected into the chest and back, and even penetrates into the lungs, chest, rare perforated esophagus and thoracic aorta; the abscess of the thoracolumbar spine and lumbar vertebrae can flow down the side or both sides of the psoas fascia or its parenchyma Note the posterior peritoneum, even into the fixed organs such as the colon, do not seek to go up to the armpit, groin, buttocks or legs; the sacral pus often gathers in front of the humerus or along the piriformis through the ischial hole Near the greater trochanter of the femur. Abscesses can be injected into the body surface along the muscle fascial space or neurovascular bundle. After treatment, it can absorb itself or form a sinus by itself. When the sinus is infected, the condition will be aggravated, the treatment is difficult, and the prognosis is poor. It should be avoided as much as possible.
(7) spinal cord compression
Tuberculous inflammation spread to the spinal canal or vertebral body deformity compression spinal cord, spinal cord injury symptoms, spinal tuberculosis, especially cervical and thoracic tuberculosis cone above patients should pay attention to the presence of spinal cord compression, limb dysfunction, in order to early detection of spinal cord compression disease. If the inflammation control is not ideal, it directly affects the subarachnoid space, causing tuberculous meningitis, and the prognosis is extremely poor. Spinal tuberculosis with spinal cord injury is the worst type of prognosis.
3. Multiple groups:
Spinal tuberculosis accounts for 50% to 75% of all patients with bone and joint tuberculosis. The basic trend of the age of onset of spinal tuberculosis is that the higher the age, the less the incidence, and now with the improvement of the physical fitness of the people and the vaccination of BCG, found that spinal tuberculosis The incidence of the disease has also changed. The main incidences are some marginal areas, elderly people with poor nutrition and immune function. Spinal tuberculosis is the least for children under 10 years old, accounting for 2%, and young people aged 10-29 are about 24%, 30-49 years old. Middle-aged accounts for about 31%, and old people over 50 years old account for about 43%, of which men are slightly more than women, with an average age of 47±17.5 years. Among them, multiple lumbar vertebrae, thoracic vertebrae, thoracolumbar vertebrae, lumbosacral vertebrae and cervical vertebrae Wait. There are two vertebral lesions (3% to 7%), which are separated by disease-free vertebral bodies, called jumping spinal tuberculosis.
Examine
Spinal tuberculosis examination
First, X-ray film
X-ray films are mostly negative in the early stage of the disease. When the vertebral bone is 50% affected after the onset of the disease, the conventional X-ray film can be displayed. Early signs of X-ray film showed an increase in paravertebral shadows, involvement of the anterior inferior vertebral body, narrowing of the intervertebral space, sparse vertebral bone, enlarged paravertebral shadows, and dead bones. If the diameter of the vertebral bone destruction area is <15mm, the lateral position film can not be displayed, and the diameter of the body slice destruction area can be detected at about 8mm. Large and small dead bones can be seen in the cancellous bone or abscess of the vertebral body.
1. Changes in the curvature of the spine: the cervical and lumbar spine are straightened, and the thoracic spine is increased. In severe cases, the cervical and lumbar spine can also flex forward.
2, vertebral body changes: early changes are slight, limited, especially the marginal type, often only see a corner of the vertebral body limited to ground glass-like changes, or density is uneven, it is easy to miss. When the lesions are extensive and the dead bones are formed, the X-rays are typical, showing a large density unevenness, often accompanied by destruction and hardening. The dead bones have no blood supply, high density, and clear surrounding boundaries. When the vertebral body is compressed, the vertebral body becomes narrow and the edges are irregular. Tuberculosis vertebral body cavity, small performance and limited, edge hardening, often dead bone.
3, changes in intervertebral space: the gap narrows or disappears, the edges are irregular, blurred. For central vertebral tuberculosis, the early intervertebral space may also be unchanged.
4, soft tissue around the vertebral body: mostly with the diseased vertebral body as the center, the cervical vertebrae visible soft tissue shadow before the vertebrae, the trachea is pushed forward or biased to one side. Different types of paravertebral abscess shadows can be seen in the thoracic vertebrae. Lumbar vertebrae can be seen to increase the depth of the psoas muscle. Explain that the more pus. Such as soft tissue shadows are not large, but there is significant calcification. It shows that the condition has stabilized.
Second, CT examination
CT examination can detect small bone changes and the extent of abscesses at an early stage, as well as the condition of the intervertebral disc and spinal canal. It is more valuable for parts where conventional X-ray film is not easy to obtain satisfactory images. Combined with the comprehensive analysis of clinical data, such as vertebral enlargement shadow, there are calcifications or small bone fragments, which contribute to the diagnosis of spinal tuberculosis. CT sometimes cannot identify spinal tuberculosis and spinal tumors.
Third, MRI examination
It has the characteristics of high resolution of soft tissue and is superior to CT in brain and spinal cord examination. It can be scanned in the sagittal, axial and coronal planes. Spinal tuberculosis MRI showed that the vertebral bodies, discs and attachments of the lesions were higher than the normal signals corresponding to the normal spine, and the lower ones were lower signals.
Vertebral lesion
The T1-weighted image shows a low signal at the lesion, or a short T1 signal. T2-weighted images of vertebral lesions showed signal enhancement. The image shows that in addition to the signal change of the diseased vertebral body, the contour of the vertebral body destruction, the in-line change of the vertebral body collapse and the enlarged paravertebral image are observed.
2. Paravertebral abscess
Spinal tuberculosis paraspinal abscess showed a low signal in the T1-weighted image, while the T2-weighted image showed a higher signal. The coronal plane can depict the contour and extent of a paraspinal abscess or bilateral psoas abscess.
3. Intervertebral disc changes
Spinal tuberculosis X-ray film disc narrowing is one of the early signs. The T1-weighted image of the MRI exhibits a low-signal narrowed disc. In the normal nucleus pulposus, there is a transverse gap in the T2-weighted image. When there is inflammation, the fine gap disappears, and the inflammation of the intervertebral disc can be detected early.
The diagnosis of early spinal tuberculosis by MRI is more sensitive than any other imaging examination including ECT. The clinical symptoms appeared for 3 to 6 months. Patients with suspected spinal column tuberculosis had no abnormalities on X-ray films. MRI showed the affected vertebral body and paravertebral soft tissue (abscess). The T1-weighted image was low signal and the T2-weighted image was high signal. Early MRI images of spinal tuberculosis can be divided into three types. 1 vertebral body inflammation; 2 vertebral inflammation combined with abscess; 3 vertebral inflammation, abscess combined with discitis. It is worth mentioning that the affected vertebral body is in the inflammatory phase, and no soft tissue and intervertebral disc signal changes can not be differentiated from vertebral tumors. If necessary, biopsy should be confirmed.
Fourth, laboratory inspection
Blood routine
The change is not obvious, there may be increased lymphocytes. If there is a co-infection, the total number of white blood cells and neutrophils are increased, and the long course of the disease, red blood cells and hemoglobin can be reduced.
ESR
ESR increased in the active period, mostly in 30~50mm/h. If it is obviously elevated, it suggests that the disease activity or a large amount of empyema. The quiescent and healing period gradually decreased to normal, such as rising again indicating the possibility of recurrence, no specificity.
3. Tuberculosis culture
Generally, pus, dead bone, and tuberculosis granulation tissue are cultured, and the positive rate is about 50%, which has qualitative diagnostic value. However, the culture time is long and the positive rate is not high. The tuberculin test (PPD test), a positive reaction is a tuberculosis-specific allergy, which has a positive diagnostic value for tuberculosis infection. PPD is mainly used for the diagnosis of tuberculosis in juveniles and children, and has only a reference value for the diagnosis of adult tuberculosis. The positive reaction only indicates that there is tuberculosis infection, and it is not necessarily sick. If the test is strongly positive, it often indicates that there is active tuberculosis in the body. The diagnostic value of PPD for infants and young children is greater than that of adults, because the younger the age, the natural infection rate The lower the age, the greater the chance of natural infection of tuberculosis, and the more PPD-positive, the less diagnostic significance.
Diagnosis
Diagnosis and diagnosis of spinal tuberculosis
Diagnostic criteria
(1) History of tuberculosis or history of contact with tuberculosis patients.
(2) There are symptoms of tuberculosis such as low-grade fever, night sweats, loss of appetite, weight loss, and fatigue.
(3) Pain, tenderness and sputum pain in the spinal lesions. There may be a posterior horn deformity, limited spinal activity, and a positive sample test.
(4) There may be cold abscess formation. Cervical tuberculosis is often in the posterior pharyngeal wall; thoracic tuberculosis is mostly in the paravertebral; lumbar tuberculosis can be seen in the groin, the medial side, the lumbar triangle or the buttocks in addition to the psoas muscle abscess. If the cold abscess ruptures, it can form a sinus and long-term unhealed.
(5) Spinal tuberculosis combined with paraplegia, incomplete or complete paraplegia below the spinal compression plane.
(6) ESR increased during the active period of tuberculosis.
(7) Positive X-ray of the spine, showing irregular bone destruction of the vertebral body, or collapse of the vertebral body, cavity, formation of dead bone, narrowing or disappearing of the intervertebral space. There is a cold abscess shadow on the paravertebral.
(8) CT examination or MRI examination can show the extent of lesions, intraspinal lesions and spinal cord compression.
(9) Mycobacterium tuberculosis culture was positive.
Differential diagnosis
According to the history of chronic progressive disease, typical symptoms and signs, and special examinations, the diagnosis of spinal tuberculosis is not difficult, but sometimes it is easy to be confused with the following diseases, and should be carefully identified.
(A) ankylosing spondylitis: this disease has ankle inflammation, no systemic poisoning symptoms, X-ray examination can not see bone destruction and dead bones, thoracic spine will appear after the chest expansion disorders and other clinical manifestations can help identify.
(B) disc degeneration: age 40 years old, especially manual labor, common in the cervical spine and lumbar vertebrae, showing chronic pain in the affected area or associated nerve root radiation pain. X-ray film intervertebral stenosis, the edge of adjacent vertebral body is dense, or there is lip-like hyperplasia, no enlarged shadow on the paravertebral, patient's body temperature and erythrocyte sedimentation rate.
(3) Lumbar disc herniation: more common in men aged 20 to 40 years, low back pain and sciatica, increased pain when coughing. Examination showed visible lumbar curvature, physiological lordosis decreased or disappeared, the affected side straight leg elevation test was positive but the patient's erythrocyte sedimentation rate and body temperature were normal. Lumbar vertebrae 4 ~ 5 or lumbar 5 1 vertebral tuberculosis posterior lesions are often confused.
(D) congenital vertebral deformity: more common in 16 to 18 years old, low back pain, appearance or scoliosis and other deformities. X-ray film can be seen in the half-vertebral body, the vertebral body wedge shape changes or the adjacent two vertebral bodies are merged or the ribs and other deformities can be seen at the same time. The pedicles of both sides are transverse and the number of ribs is different. Such congenital malformations should be combined with curative vertebrae. Identification of body tuberculosis.
(5) Spontaneous purulent inflammation: Before the onset, the patient has many skin edema or other septic lesions, and the body temperature is high, the symptoms of poisoning are obvious, the pain in the affected part is obvious, the activity is limited, and the local soft tissue is swollen and tender. X-ray film vertebral body visible bone destruction, narrowing of the intervertebral space, often with dead bone formation, and no abscess formation, should be confirmed by bacteria and histology.
(6) Spontaneous axonal dislocation: often secondary to pharyngeal inflammation. In children under 10 years of age, the child usually holds the lower jaw, has a torticollis, and has limited neck movement. The X-ray film is dislocated forward, and the odontoid is displaced to the lateral or posterior position without bone destruction. Cold-free abscess shadow. A CT scan is helpful for diagnosis.
(7) Flat vertebral body: more common children, showing back pain, kyphosis, limited spinal motion, no systemic symptoms, there are two common causes of this disease: vertebral eosinophilic granuloma and osteochondrosis. X-ray film changes the wedge shape of the vertebrae, and a thin slice can remain. The adjacent intervertebral space is normal, and the slightly enlarged shadow can be seen at the paravertebral. After the lesion is cured, the height of the vertebral body can be restored to different degrees.
(8) Spinal tumors: can be divided into two major categories: primary and metastatic:
1, the primary: common patients under the age of 30, common benign giant cell tumor of bone, osteochondroma, hemangioma; malignant lymphoma, chordoma, Ewing sarcoma.
2, metastatic cancer: more common in patients around 50 years old, common lung cancer, breast cancer, kidney cancer, liver cancer, thyroid cancer, prostate cancer, etc., transferred to the vertebral body or attachment, neuroblastoma is more common in infants under 5 years old .
(9) Chronic low back muscle fasciitis: The patient has low back pain all the year round and is aggravated after exertion. Many patients with lumbar tuberculosis have been diagnosed with psoas fasciitis in the early stage. Although the disease has low back pain and limited function, the patient's health is not affected, there is no fixed tenderness point, and no X-ray examination is performed.
(10) Chronic infections: such as syphilis, brucellosis, typhoid bacillus and other infections, sometimes can cause spinal infection, vertebral destruction, X-ray films are sometimes similar to tuberculosis, need to carefully analyze the medical history, combined with laboratory tests to identify.
