Tuberculosis of the spine accounts for the first of all bone and joint tuberculosis in the body, with tuberculosis of the thoracolumbar spine being the most common. It can occur in all age groups, but is more common in children and adolescents, with more than 80% of patients under 30 years of age. In recent years, the incidence of spinal tuberculosis has been increasing year by year with the increase of patients with HIV and immune system deficiency and the increase of drug-resistant Mycobacterium tuberculosis, and its incidence and mortality rate are higher in underdeveloped areas, and it is the most important cause of non-injury paraplegia.
1. Etiology and pathogenesis
Tuberculosis of the spine is a secondary lesion, about 90% of which is secondary to pulmonary tuberculosis, in addition, lesions of adjacent organs can also spread directly to the spine. Studies have shown that spinal tuberculosis can also develop through venous or lymphatic transmission. When the resistance of the body is strong, the germs are controlled or eliminated; when the resistance of the body is reduced, they can multiply and form foci, and clinical symptoms appear.
2.Clinical manifestations and diagnosis
(1)Clinical manifestations
Tuberculosis is insidious, generally slow onset, systemic symptoms are not obvious, its typical symptoms can be manifested as spinal pain, limited activity, with systemic symptoms, such as low afternoon fever, loss of appetite, emaciation, night sweats, fatigue and weakness, etc. Patients with chronic disease often have kyphosis, nerve damage or sinus tract formation, mostly seen in the thoracic spine, followed by the lumbar
spine and thoracolumbar segment, while the cervical and sacral spine rarely occur.
(2) Imaging
X-ray plain films used to classify spinal tuberculosis into 4 types: marginal, central, subperiosteal and adnexal types.
CT scan is unique in identifying the type of vertebral destruction, the presence or absence of swelling or abscess in the paravertebral soft tissues, the presence or absence of destroyed bone fragments, and the presence or absence of pressure on the dural sac. CT examination can show the degree of destruction of the diseased vertebrae and the relationship with the surrounding tissues, which is more important for guiding clinical treatment.
MRI has more clinical value than CT in the detection of nodular disc destruction, spinal cord and dural sac invasion. MRI is particularly sensitive and accurate in detecting disc destruction or adjacent disc bone destruction, providing an important basis for early diagnosis and detecting lesions when other imaging results are negative. Therefore, MRI is the only method that can detect lesions and determine the extent of lesions at an early stage. Further MRI should be performed for atypical spinal tuberculosis and when it is necessary to determine whether there is a lesion in the spinal canal and to provide necessary assistance before surgery.
3.Treatment
Systemic antituberculosis drug therapy is the fundamental treatment of spinal tuberculosis and should be used throughout the treatment process, while surgical treatment is only an adjunctive therapy at one stage of the treatment process. Orthopedic surgeons should not emphasize surgery over drug therapy.
(1) Systemic supportive therapy and drug therapy
Supportive therapy includes bed rest, adequate sleep, mental comfort, nutritional support, etc. Drug therapy is mainly the appropriate combination of anti-tuberculosis drugs, currently commonly used and better efficacy of anti-tuberculosis drugs are isoniazid, rifampin, streptomycin, para-aminosalicylic acid, ethambutol, kanamycin, etc.. The combination of 2 drugs can increase the efficacy and reduce the resistance of bacteria. The treatment of spinal tuberculosis is a long-term process. Due to the deep lesions and complex anatomy, local administration of drugs is difficult and can only be given through other routes such as the digestive tract, and the application of anti-TB drugs takes longer than other superficial joint tuberculosis. Patients are advised to take the drugs on an empty stomach so as to achieve drug efficacy. Once symptoms such as nausea, vomiting, tinnitus and hearing loss occur, they should be reported to the health care provider so that appropriate measures can be taken or medications can be adjusted.
(2) Surgical treatment
Under the control of systemic supportive therapy and anti-tuberculosis drugs, timely and correct surgical treatment can shorten the course of the disease, prevent or correct deformities, and reduce disability and recurrence. In cases of spinal tuberculosis with obvious dead bone, large cold abscesses that are not easily absorbed, sinus tracts that do not heal over time or paraplegia, surgery becomes the main treatment.
Indications for surgery: the presence of paraspinal abscesses, severe bone destruction and deformity, nerve damage due to spinal cord compression, and intractable infections that are refractory to conservative treatment.
Surgical principles: correct surgical approach and access selection is the basis for the completion of surgery; complete removal of the lesion, anterior decompression of spinal cord compression, and simultaneous anterior bone grafting are the keys to spinal tuberculosis surgery; postoperative cooperation with long-term medication is the guarantee of a good prognosis. The traditional spinal tuberculosis surgical plan is more localized lesion removal and bone graft fusion, but postoperative bed rest is required for 3-6 months, easy to develop lung and urinary system infection, simple bone graft fusion is difficult, pseudo-joint formation and high recurrence rate of tuberculosis (1.3%-5.8%), in recent years, the intervention of internal fixation devices has been greatly developed. The surgical method of excision of tuberculosis lesions and internal fixation treatment has reconstructed the stability of the spine at an early stage, shortened the postoperative bed rest time, reduced the occurrence of complications, and facilitated the recovery of the disease.
4.Health education
Tuberculosis is a contagious disease, and weak people are vulnerable to it. Therefore, in addition to avoiding contact infection, it is more important to pay attention to exercise, diet and life conditioning to promote physical health and strengthen the body’s resistance. Comfortable environment, rest, nutrition and medication are the four major assets for TB recovery.