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%. basic knowledge The proportion of illness: 0.058% Susceptible people: more common in children and adolescents Mode of infection: non-infectious Complications: autonomic dysfunction tuberculous pleurisy empyema tuberculous meningitis
Cause
Spinal tuberculosis
Causes:
Spinal tuberculosis is often secondary to tuberculosis. Some patients may have no symptoms of tuberculosis. After pulmonary infection, blood can be transmitted to the whole body, and the spinal cord can cause spinal infection. The spinal blood supply is mostly terminal, and there is no blood circulation between the vertebral bodies. Cartilage disc, so the spinal tuberculosis is more common in the center type and the edge type. In fact, tuberculosis can be obtained from bones in any part of the body, and tuberculosis in the spine is about 50%. Other joints such as knee joints and hip joints can also get tuberculosis.
Pathogenesis:
Vertebral lesions due to circulatory disorders and tuberculosis infection, bone destruction and necrosis, cheese-like changes and abscess formation, vertebral body collapse due to lesions and weight bearing, causing curvature of the spine, spinous process bulge, hump deformity on the back, thoracic vertebrae Tuberculosis is particularly evident. Due to the collapse of the vertebral body, the formation of dead bone, granulation tissue and abscess, the spinal cord can be paralyzed by compression, which occurs in the cervical and thoracic vertebrae. Bone destruction, cold abscess formed under the anterior longitudinal ligament of the spine, can pass through the ligament to the anterior fascial space of the spine, and can spread to the site far away from the lesion due to gravity.
Prevention
Spinal tuberculosis prevention
As the saying goes, "three-point treatment, seven-point care", in clinical work, for patients with spinal tuberculosis surgery, high-quality big care plays an extremely important role in the rehabilitation of the disease.
Before the operation, psychological communication should be carried out with the patient to introduce the patient's enthusiasm, necessity and safety to eliminate the patient's ideological concerns and fear of surgery; encourage patients to eat high-calorie, high-protein, high-fat diet to improve The patient's surgical tolerance; training the patient to urinate in the bed to meet the postoperative needs; for the fever patient, while the doctor is informed in time, the patient is physically cooled and the patient's physical exertion is reduced.
After the operation, in the case of extreme pain in the patient's body and mind, it is necessary to promptly give spiritual comfort and encourage the patient to establish confidence in overcoming the disease, and actively cooperate with the doctor to improve the disease; due to postoperative pain in the patient, the pain is increased during coughing. The patient is reluctant to cough and is not willing to cough. It is easy to cause hypostatic pneumonia and suffocation due to poor airway. Therefore, patients should be encouraged and assisted in sputum drainage to prevent respiratory complications. For postoperative patients with high fever, Physical cooling should be given at the same time as drug treatment; patients with postoperative indwelling catheter should be urinated regularly, and patients with drainage tube should discharge drainage fluid in time to prevent urinary retrograde infection and wound infection; postoperative patient bed should be kept Clean and tidy, the skin should be kept dry. If the bed is contaminated, the bed unit should be cleaned up in time; to prevent the occurrence of hemorrhoids, turn around once every two hours after the operation, and massage the muscles to prevent muscle atrophy while turning over. Encourage patients to move on the bed to prevent joint stiffness. Postoperative patients are required to give fluid, slag-free, and highly nutritious diet due to surgical trauma and bed rest. According to the condition, it can be gradually changed to semi-flow or general food; after a week or so, the patient is assisted to get out of bed, and the patient should be treated with special personnel to prevent accidents. With the strengthening of exercise and the recovery of the disease, two weeks after surgery Left and right, you can work independently in the ward, and you can have outdoor activities about three weeks after surgery. The patient was discharged from the hospital and the patient was regularly reviewed on time.
Complication
Spinal tuberculosis complications Complications, autonomic dysfunction, tuberculous pleurisy, empyema, tuberculous meningitis
Spinal tuberculosis complicated with paraplegia is the most common complication.
(1) Precursors before spinal paralysis:
1. Sensory disorder: If the patient complains of a tight-fitting sensation from the back to the chest or the abdomen, or the feeling of ants crawling, numbness, and cold stimulation.
2. Movement disorder: consciously walk awkwardly, do not listen when you move your footsteps, stiffen your lower extremities, hard, trembling, or weak, easy to fall.
3. Sphincter dysfunction: mainly the bladder and rectal sphincter disorders, manifested as weakness, incontinence and so on.
4. Autonomic dysfunction: If the skin under the vertebral body is dry, sweat-free, and the skin temperature is low, the upper and lower sides of the nerves that are controlled by the normal vertebral body or the diseased vertebrae have a hot and cold feeling. .
(2) About 10-20% of the vertebrae combined with paraplegia should be implemented. The main measure is to insist on no burden on the spinal tuberculosis activity period, and insist on bed rest and anti-spasmodic medication. 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.
Secondly, tubercle bacilli flow or spread to other parts of the site caused by Mycobacterium tuberculosis infection, such as tuberculous pleurisy, empyema, tuberculous meningitis, etc. is also a common complication.
Symptom
Spinal tuberculosis symptoms Common symptoms Loss of appetite and weight loss of paravertebral anterior soft tissue swelling... Spinal cord compression of the spine destroys the spine degeneration high fever low heat reflection into the night sweats
In addition to the general symptoms, it has the following characteristics:
(1) There is anemia in the early stage, weight loss, easy fatigue, pain in the back (waist) and pain. The pain is mainly in the spinal lesions. It is not heavy at the beginning of the disease, and is aggravated with the development of the lesion. It can be reduced or temporarily disappeared after rest; The lesions in the site can also cause various types of metastatic pain, increased weight during weight bearing, walking and spinal activity.
(2) Muscle spasm and dyskinesia, muscle spasm, and restricted spinal activity are a protective effect of the body. Children suffer from muscle relaxation after asleep, and the waist is slightly moved, causing pain, and nightingale occurs. Supporting the head, lumbar tuberculosis patients with stiff waist as a board, when they pick up things, do not dare to bend over and bend their hips, knees (positive sample test), anti-back pain.
(C) often have a back deformity and cold abscess in the late stage, and the infection and sinus occur after the abscess is worn.
(4) Paraplegia, patients who have not been properly treated, have spinal cord compression in the late stage, and have partial or complete paraplegia, which is a serious complication that jeopardizes the patient.
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.
1. Vertebral lesions: T1-weighted images show 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. Paraspinal abscess: Spinal tuberculosis paraspinal abscess shows a low signal in the T1-weighted image, while the T2-weighted image shows 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
diagnosis
(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
(a) disc degeneration
About 40 years old, especially manual laborers, common in the cervical vertebrae and lumbar vertebrae, showing chronic pain in the affected area or having a subordinate god?? ? line line intervertebral stenosis, the edge of the adjacent vertebral body is dense, or Lip-like hyperplasia changes, there is no enlarged shadow on the paravertebral, and the patient's body temperature and erythrocyte sedimentation rate are normal.
(two) congenital vertebral deformity
More common in 16 to 18 years old, low back pain, appearance or scoliosis and other deformities, X-ray film visible vertebral body, vertebral body wedge shape or adjacent two vertebral body fusion or ribs and other deformities, both sides of the vertebra The transverse roots of the arch and the number of ribs vary. Such congenital malformations should be differentiated from curative vertebral tuberculosis.
(three) lumbar disc herniation
More common in men aged 20 to 40 years, low back pain and sciatica, pain increased when coughing, examination showed 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 vertebra 4 ~ 5 or lumbar vertebrae 51 tuberculosis posterior lesions are often confused.
(4) Overview of ankylosing spondylitis.
(5) Spinal suppurative inflammation
Before the onset, the patient often had skin edema or other septic disease, and the body temperature was high, the symptoms of poisoning were obvious, the pain in the affected part was obvious, the activity was limited, the local soft tissue was swollen and tender, and the X-ray film showed bone destruction. The intervertebral space is narrowed, often with dead bone formation, and no abscess formation. It should be diagnosed by bacteria and histology.
(6) Spontaneous axonal dislocation
Often secondary to pharyngeal inflammation, children under 10 years of age, children often hold the lower jaw, with a torticollis, restricted neck activity, X-ray film ring forward dislocation, odontoid to the lateral or posterior Displacement without bone destruction, no cold abscess shadow, CT examination can help diagnose.
(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 suffering from wedge wedge changes A thin slice can be left, and the adjacent intervertebral space is normal, and the slightly enlarged shadow can be seen on 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. 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 is more common in patients around 50 years old. Common cases include lung cancer, breast cancer, kidney cancer, liver cancer, thyroid cancer, prostate cancer, etc., which are transferred to vertebral bodies or attachments. Neuroblastoma is more common in infants under 5 years old.
