Tuberculosis of the spine is the most common form of osteoarticular tuberculosis in the body, with vertebral tuberculosis accounting for the majority of cases. The lumbar spine is the most mobile and has the highest incidence of tuberculosis in the entire spine, followed by the thoracic spine, the cervical spine, and the sacral and caudal spine. Tuberculosis of the spine is secondary to tuberculosis of the lung, gastrointestinal tract, or lymphatic tract, which causes tuberculosis of the bones and joints via the blood circulation route.
The disease starts slowly, with symptoms such as low fever, fatigue, lethargy, night sweats, loss of appetite and anemia, and children often have nocturnal cries, dullness or impatience. Pain is often the first symptom, usually mild, which is relieved by rest and aggravated by exertion. In addition to neck pain, cervical spine tuberculosis also shows nerve root irritation such as numbness in the upper limbs, and the pain and numbness are aggravated by coughing and sneezing. The lump can be felt on the lateral side of the neck. Thoracic spinal tuberculosis with back pain symptoms must be noted. The pain of lower thoracic spinal lesions sometimes manifests as lumbosacral pain, and kyphosis is very common until the incidental discovery of a thoracic kyphotic deformity.
When standing and walking, patients with lumbar spinal tuberculosis often use both hands to hold the waist, head and trunk tilt backward, so that the center of gravity is shifted back to minimize the pressure of weight on the lesioned vertebrae, and when patients pick up things from the ground, they cannot bend over, but need to bend the waist and knees and hips to squat in order to pick up things, which is called a positive pick-up test. When examining the child, let him lie prone, the examiner lifts the child’s feet with both hands and gently lifts both lower limbs and the pelvis, if there is a lumbar spine lesion, the lumbar region remains rigid due to muscle spasm, and the physiological pronation disappears. In later stage patients with abscess formation in the lumbaris major muscle, the abscess can be seen or felt in the lumbar triangle, iliac fossa or groin. In lumbar spine tuberculosis, the kyphosis is usually not severe, and mild kyphosis can also be detected by pressing the fingers sequentially from the thoracic vertebrae to the sacrum, along both sides of the sacrospinous muscle. Cold abscesses are associated with secondary infection, high fever, and increased toxemia, and after rupture, a large amount of thin fluid mixed with cheese-like material, and also a small amount of dead bone, often forming chronic sinus tracts that do not heal.
The examination of spinal tuberculosis generally includes
1.X-ray examination.
(1) Bone and joint changes, with bone destruction and spinal space narrowing predominant on X-ray. Generally, there are no positive X-ray signs within 2 months after the onset of the disease. Therefore, repeated radiographs or other examinations are required for suspicious cases. In the central type, the bone destruction is concentrated in the center of the vertebral body and is clearer in lateral views. The vertebral body soon appears to be compressed into a wedge shape, narrowing anteriorly and widening posteriorly. It can also invade the intervertebral discs and involve the adjacent vertebral bodies. In the marginal type, the bone destruction is concentrated at the superior or inferior edge of the vertebral body and soon invades the intervertebral disc, showing destruction of the vertebral endplates and progressive narrowing of the intervertebral space with involvement of the two adjacent vertebral bodies. The bone destruction and wedge compression of the marginal type is less obvious than that of the central type, so the kyphosis is not heavy.
(2) The manifestation of cold abscess is shown on lateral cervical spine radiographs as widening of the anterior soft tissue shadow and anterior displacement of the trachea; widening of the paravertebral soft tissue shadow can be seen on orthopantomographs of the thoracic spine, which can be spherical, spindle-shaped or cylindrical, and is generally not symmetrical. In lumbar orthopantomographs, abscesses of the psoas major muscle may appear as blurring of the shadow of the psoas major muscle on one side, or as widening, fullness, or limited elevation of the psoas major muscle shadow, and the abscess may even flow into the hip and femoral triangle. In chronic cases, multiple calcified shadows are seen.
2.CT examination.
The site of the lesion can be clearly shown, and cavity and dead bone formation can be seen. Even small paravertebral abscesses can be detected during CT examination. ct examination is uniquely valuable in detecting abscesses of the psoas major muscle.
3.MRI (magnetic resonance imaging) examination.
It has early diagnostic value and can show abnormal signals at the stage of inflammatory infiltration, and can also be used to observe the presence of compression and degeneration of the spinal cord. The diagnosis of spinal tuberculosis is generally based on history, clinical manifestations, signs, radiographs, CT, MRI and laboratory tests, but to confirm the diagnosis requires surgical removal of the lesion for microbiological and pathological examination.
Treatment.
1. Non-surgical treatment: The decision to operate is based on the presence or absence of surgical indications. Even for those with surgical indications, 2 to 4 weeks of non-surgical treatment is required as preoperative preparation. Non-surgical treatment includes systemic anti-tuberculosis drug therapy and local braking. Local braking is done with external fixation brace, and bed rest should be given during fixation.
2.Surgical treatment.
(1) Incision and drainage of pus, when a cold abscess is extensively injected causing secondary infection in patients with obvious symptoms of systemic toxicity and cannot tolerate lesion removal, incision and drainage of pus can be done to save life. After the cold abscess is incised, the systemic toxic symptoms can be expected to be controlled, but the incision is extremely difficult to heal. Since the abscess is extremely deep, it is mostly incised at the top of the abscess, and drainage is poor. The abscess cavity can be irrigated daily with 4% isoniazid solution and the sinus opening can be kept open. A section of thick rubber tubing can be inserted to dilate the sinus opening, or a double cannula can be used for drainage, taking care not to allow foreign objects such as skin tubes and cotton balls to fall into the abscess cavity. Incisional drainage of cold abscesses without secondary infection is not advisable. The formed sinus tracts have extensive scar tissue formation, inflammatory infiltration and unclear anatomy, so fistulotomy should not be performed hastily to avoid damage to adjacent blood vessels, nerves or important organs. It is also not recommended to perform stratified puncture and drainage of cold abscesses and injection of anti-tuberculosis drugs.
(2) Focal debridement. Since the 1940s and 1950s, the successful synthesis and extraction of anti-tuberculosis drugs have provided the conditions for the implementation of focal debridement. There are two types of surgery: anterior and posterior. The posterior approach is usually used for thoracic spine tuberculosis. In the case of cervical spine tuberculosis, the lesion removal is mostly performed from the anterior approach and is fixed for 3 to 4 months after surgery, and is removed or continued after review as appropriate.
(3) Posterior spinal fusion Posterior pedicle screw system combined with anterior lesion debridement can enhance spinal stability and enable patients to get out of bed early.
(4) Anterior spinal fusion, lesion removal with bone grafting and anterior internal fixation, to achieve the purpose of spinal stability, in order to facilitate bone grafting and fusion.
(5) Orthopedic surgery is mainly to correct kyphosis.
Prognosis.
Generally, after preoperative and postoperative anti-tuberculosis treatment and surgical lesion removal and internal fixation, bone healing is achieved at the lesion, the patient’s symptoms disappear, and the patient is clinically cured.