Spine TB

OUTLINE

Spinal tuberculosis is a specific bacterial infection of the joints and discs caused by bacilli de kock, abbreviated as BK, localized to the spine.

The disease was first described by the English surgeon Percivall Pott at the end nineteenth century It is also known as Pott's disease (mal de Pott). Therefore, in the West, tuberculosis of the spine is also known as Pott's disease.

Tuberculosis of the spine is a disease tuberculosis severe joint disease, accounting for a high rate in osteoarthritic tuberculosis. In Vietnam, along with other bone tuberculosis, spinal tuberculosis is a fairly common social disease, accounting for about 60%. The disease is often diagnosed and treated late, so there are many serious consequences.

Tuberculosis of the spine usually appears after a few years of primary infection, in our country it is seen after tuberculosis of the lungs, pleura and lymph nodes up to 70%. TB bacteria travel to the spine via the bloodstream.

The disease occurs in adults aged 20-40 years old, accounting for 60%, men and women are equally affected, it is found that spinal tuberculosis often occurs in people who have received organ transplants (kidneys, hearts, ...).

About lesions: TB bacteria often damage the vertebrae and discs at the same time, most commonly two vertebrae on the lower and one in the middle, the back and lumbar region accounted for 90% cases (from back 8 to lumbar). back 2). Lesions are seen only in the anterior part of the spine.

Tuberculosis of the spine is a chronic disease, insidious onset with subtle signs, usually without high fever, about 20% cases of mild fever, not more than 38^oC.

The disease usually begins in childhood, when the skeleton is in a period of growth. Adults can also develop tuberculosis of the spine, which is usually a recurrence of old childhood tuberculosis.

If not treated promptly, spinal tuberculosis in children will progress in a three-stage cycle (initial, full-blown, stable), lasting 3-4 years. When stable, spinal tuberculosis can lie dormant for 3-4 years, sometimes decades, sometimes for a lifetime. When the body loses its resistance, tuberculosis of the spine can return, even though the old disease has been too long. If spinal tuberculosis has complications (cold abscess, paralytic fistula), even in the stable stage, complications may still exist partially or completely. Tuberculosis of the spine in adults, or if treated with adequate anti-tuberculosis drugs, the cycle is very short or the TB infection can be completely cured, rather than just stabilized.

Tuberculosis of the spine, like other tuberculosis of the joints, does not spread from person to person like pulmonary tuberculosis, so patients do not need to be isolated.

Histopathology

The general feature of the lesion is bone destruction by BK. The activation of osteogenesis is very poor and occurs late. Bone tuberculosis includes:

The area of bone decay in which the center is an organization of bean pulp, including tissue, surrounded by a tubercular membrane, has many typical tuberculosis cysts containing live bacilli, which is the active part of the tumor and spreading around. The body's reaction zone around the tubercle fossa has fibrous bone to separate the tubercle and prevent it from spreading.

Tuberculosis bacilli damage mainly in the vertebral body in the disc (anterior part of the vertebrae), rarely in the posterior arch of the vertebrae. Thus, the most common lesions in tuberculosis include one or two vertebral bodies and adjacent discs; However, if the disease is left untreated for a long time, it is also possible to have a tuberculosis cluster consisting of many consecutive vertebrae and discs, especially in children.

STAGES OF Illness

The progression of the disease is divided into three stages:

Start-up phase

1. The main physical sign is pain

• Local pain: pain in the affected spine area, fixed in that position unchanged, pain increases when moving, walking, carrying, decreasing when resting; then gradually increased, pain continued throughout the day and night, using pain relievers with little results.
• Radial pain: due to compression injury to a few branches of nerve roots, pain spreads along the path of the roots and nerves, in the neck spreading to the shoulders and hands, in the back spreading along the intercostal nerve, in lumbar extension down the anterior abdomen or sciatic nerve. Pain is aggravated by coughing, sneezing, and straining.

2. Examination

• Spine: see a stiff spine that does not stretch when bending, limiting the movements of the spine. The muscle mass on both sides of the spine can be stiff, knocking on the posterior spine area of the lesion is clearly painful.
• Whole body: can see signs of tuberculosis infection, examination of organs found a combined TB lesion on 50% cases (pulmonary tuberculosis, pleura, lymph nodes, ...).

3. X-ray and testing

X-rays: very important to help diagnose:

+ Narrow disc compared to other segments

+ Body vertebrae are jagged, blurred front and upper part

The soft tissue around the vertebrae is slightly darker.

In order to clearly see the lesion, a computed tomography (CT-scan) should be performed.

- Test:

+ Complete blood count: increased lymphocytes

+ Blood sedimentation increased 95% cases

+ Mantoux reaction only (+) in 90% cases

+ Find BK or tissue, specific cells for TB (lymphocytes, semi-hemorrhagic cells, giant cells, pox), by aspirating with a needle next to the spine to conduct the test

+ Found combined TB lesions: chest x-ray, BK in sputum, lymph node biopsy, etc.

Full-blown stage

When not diagnosed and treated specifically, the disease progresses after many months, the damage destroys the vertebrae and discs, forms large cold abscesses, and has spinal deformities and signs tamponade.

Over 80% patients in our country were diagnosed during this period.

1. Clinical

• Fixed, constant pain, a lot of pain at night, with frequent, pronounced root syndrome
• Clinical examination:

+ Lồi đốt sống ra sau: nhìn nghiêng thấy một đốt sống lồi ra phía sau, dùng ngón tay miết nhẹ dọc theo các gai sau từ dưới lên sẽ thấy rõ hiện tượng này.

+ Cold abscess: the abscess pocket has a different location depending on the location of the lesion

• Cervical spine: Abscess pocket extends anteriorly to the posterior pharyngeal wall, visible on pharyngeal examination or descends along the paracervical muscles to the supraclavicular fossa.
• Thoracic spine: abscess pocket posteriorly, rhomboid or pear-shaped on either side, raised just below the skin
• Lumbar spine: abscess pocket just under the skin, petit triangle area or on both sides of the waist, abscess in the pelvic fossa region, inguinal folds, inner thigh base (small trochanteric area, where it is attached to the end). of the dorso-pelvic muscle) or beyond, the tubercular abscess migrates along the femoral artery creating a cold abscess pocket of the popliteal. Cold abscesses are usually tender, painless, and some may rupture, oozing yellowish water and crusts, leaving persistent ulcers and fistulas that do not heal.

Compression syndrome: is the worst consequence of the disease, because the vertebrae and discs are destroyed a lot, displaced, subsided and tend to slide backwards, compressing the spinal cord and the horse's tail. According to the location of the injury, the patient has signs of quadriplegia (in the neck), paralysis of the legs (lumbar spine, upper lumbar), ponytail syndrome (lower lumbar segment). Mild degree from sensory disturbance, muscle weakness to severe spastic paralysis, with round muscle disorder (medullary compression). In our country, over 50% when diagnosed showed signs of compression.

Systemic signs: thinness, much weakness, fever, possible buttock ulcers due to lying down for a long time. Tuberculosis lesions spread to other organs (lungs, lymph nodes, membranes,...).

2. X-rays and tests

• The disc is almost completely destroyed
• The vertebral body is destroyed a lot, especially the anterior part creates a wedge shape (tilt), displaced and slipped posteriorly.
• Cold abscess: on straight film, there is a opacity around the lesion (rhombic or bulbous), which may be uneven, with darker calcifications
• Laboratory tests: Elevated erythrocyte sedimentation rate, paraspinal needle puncture to easily find typical tuberculous lesions, lumbar puncture to diagnose signs of spinal cord compression and meningoencephalitis.

Final phase

Untreated or the body is too weak, the disease is getting worse, severe paralysis, death from secondary infections, tuberculosis spreading to other organs, especially meningeal tuberculosis, pericardial and pleural tuberculosis, and death from cachexia

SYMPTOMS

• Tuberculosis, usually localized in the vertebral body, spreads to adjacent discs, destroying and resorbing bone. The vertebrae are weak, but the patient still sits, walks and works, so it is easy fracture, often anterior flexing produces a hunchback deformity. Fracture occurs very slowly, so even after the hunchback deformity is very severe, it rarely compresses the spinal cord, causing paralysis. A lot of hunchback will deform the whole ribcage, especially causing hunchback of the sternum in front, easily mistaken for a disease in the chest area.
• Cold abscesses can penetrate into the canal, causing direct compression of the spinal cord or causing the dura mater, pleura, and even spinal cord to become inflamed (Hodgson et al.). Therefore, the above authors divide the causes of paralysis in spinal tuberculosis into two groups:

+ Exogenous causes: dead bones, cold abscesses, dislocation of the vertebrae with tuberculosis compressing the spinal cord

+ Intrinsic causes: episcleritis, medullary membrane, myelitis living.

Paralysis is sometimes temporary, then restored, sometimes it is permanent. Patients with tuberculosis of the spine are paralyzed, likely to have urinary tract infections, infections of the ulcerative areas of the amputee due to bedridden. Infectious paralysis, together with fistula with chronic cold abscess, was formerly the main cause of high mortality in spinal tuberculosis due to exhaustion and amyloidosis, accounting for 63.4% total deaths. due to bone-joint tuberculosis, compared with the rate of 23.6% of row-joint tuberculosis and 5% of tuberculosis. knee joint.

Pott himself relied on signs of three complications, namely kyphosis, cold abscess and paralysis (Pott's triad) to diagnose spinal tuberculosis in the time when there was no X-ray machine.

DIAGNOSE

Diagnosis of spinal tuberculosis

• The earlier the diagnosis, the better, especially at the initial stage when the lesions are small, the more favorable the treatment, the more likely the disease will be cured, and the easier it will be to restore full function.
• Diagnosis at an early stage: difficult because of vague signs, typical symptoms have not appeared, X-ray images are seen later. Diagnosis is based on the features mentioned above: spinal pain (location of bone-joint tuberculosis) appears in childhood (age of onset of bone-joint tuberculosis). Must be associated with signs of presumptive TB such as the child's spontaneous loss of normal activity, preferring to sit still; have unusual postures such as sitting with both hands on the surface of a chair (lumbar spine) or sitting on chin (cervical spine) to support the spine to prevent pain, the back must be kept straight when sitting down pick up objects on the ground instead of stooping like a healthy child. When examining, pressing on the vertebrae affected by TB will cause pain, as well as tapping from the top of the head will also cause tuberculosis in the diseased area; movement area, tuberculosis muscles (bending, supine, ...) are limited. In this case, try to find the primary tuberculosis: check the spectrum and test the sputum to look for BK; Examination of the urogenital and genital organs and urine testing for K. Modern diagnostic methods, such as magnetic resonance imaging or CT-scan, also help in early detection of small foci of bone tuberculosis. If possible, it is best to do a biopsy to test for anatomical pathology. In case of suspected spinal tuberculosis without verification conditions, a trial treatment can be performed: put the patient in bed motionless completely and monitor the progress, if it is true tuberculosis of the spine, the signs will gradually clear up, so it can still be treated in time.
• Diagnosis in full-blown stage: Systemic signs such as anorexia, weight loss, or night awakenings, pain-related crying and night sweats, and classic signs such as hunchback, cold abscess, and paralysis are all evident. The X-ray images are also typical: stenosis or complete loss of the disc, the vertebral body surface is fragmented and there is a focal point of bone loss of the tube, the image of a cold abscess is blurred, and the diagnosis is relatively easy. , but treatment is difficult because the TB lesions are already large, accompanied by complications, even if all TB infections are gone, there is no complete recovery. In the stable stage, the TB cluster stops progressing, so the patient's pain gradually subsides, he can sit, walk without pain (if he is not paralyzed), his general condition is also improved: he can eat and sleep again, gain weight again. The period of stabilization can be long, sometimes lifelong. There are also times when the spine comes back, or the body collapses. In less favorable cases, complications persist at the stable stage. Differential diagnosis: there are many diseases in the spine that are easily confused with spinal tuberculosis. First of all, it is necessary to make a differential diagnosis with another infectious disease, nonspecific spondyloarthritis, which is also quite common in children. In contrast to spinal tuberculosis, which is a chronic, insidious disease, nonspecific spondyloarthritis is an acute infection with sudden onset, quite aggressive, with high fever, general weakness collapse rapidly, white blood cells increase. Another chronic spinal disease in children is vertebra plala caseation aseptic (non-infectious) with signs of spinal pain and limited range of motion, a chronic, insidious progression that is easily confused with spinal tuberculosis. But there is a typical X-ray picture: the vertebrae are flattened like solid bone, the contrast is stronger than other healthy vertebrae (in contrast to the thinning and loss of bone of bone tuberculosis), the vertebral body border is still regular. , when the disc is completely normal. Other diseases such as juvenile kyphosis (Scheuermann's disease) that are common in puberty or vertebral compression fractures (rare in children) are not infectious, so blood tests are normal. .

Differential diagnosis

Attention should be paid to distinguishing diseases that cause damage to the vertebrae:

• Với viêm đốt sống do vi khuẩn mủ (tụ cầu,…), dấu hiệu nhiễm khuẩn nặng, điều kiện phát bệnh (viêm cơ, mụn nhọt), trên X-quang không có hình áp-xe lạnh.
• With tumor lesions: cancer, metastasis, hemangioma, ... based on systemic signs, X-ray does not show cold abscess. If in doubt, perform aspiration to confirm the diagnosis.
• Most are misdiagnosed at the front lines with intercostal neuralgia, rheumatism, kidney pain, spondylolisthesis, etc.

TREATMENT

• Spinal tuberculosis treatment has two purposes:

+ Cure tuberculosis infection

+ Keep the weak bones destroyed by BK chisel from being further destroyed by walking or working, creating good conditions for bones to recover and reach normal strength to be able to function.

• Using a combination of measures: taking anti-tuberculosis drugs, strengthening the body's resistance; good immobilization, surgery.

Nowadays anti-tuberculosis drugs Specifically, it has completely cured most cases of tuberculosis in general and tuberculosis of the spine in particular, which in the previous period was only capable of temporary stable treatment. Using anti-tuberculosis drugs is also a mandatory condition for safe surgery, especially direct surgery to remove dead and fibrous tissues, which was previously banned because it is easy to spread TB and often causes tuberculosis. high mortality. However, anti-tuberculosis drugs do not kill all TB bacilli, only guaranteeing cure for 90% cases of bone tuberculosis. To avoid drug-resistant TB bacilli in treatment, it is necessary to use a combination of 2-3 anti-TB drugs (for dosage see Tuberculosis, Encyclopedia of Pathology, Volume 1). Using the drug early, right at the initial stage, is effective and the cure rate is high. Tuberculosis at this time is still small, has not formed surrounding fibrous tissue, taking drugs for 6-12 weeks is enough (Anderson, LD). In the full-blown stage, it takes longer, 12 months or longer to use the drug. After each course of 6-8 weeks, the clinical results and clinical films must be checked: if not stable, the drug must be continued. Only when the pathological signs in the TB area are completely gone, the condition returns to normal, the X-ray shows all signs of osteoporosis, the rows of TB are full again, the TB bones are firmly adhered to each other. blood tests (erythrocyte sedimentation rate) returned to normal.

Strengthen the body's resistance. Tuberculosis of the spine is a long-lasting chronic disease that depletes the body; If there is a prolonged cold abscess leak or irreversible paralysis, the deterioration of the organ will become worse. With that condition, anti-tuberculosis drugs will hardly be effective against TB infection. Surgery is even more dangerous. In the era of anti-tuberculosis drugs, it is important to nourish patients with adequate food, rich in protein and vitamins, take care of body hygiene, and rest in open and fresh air to strengthen their resistance. The support of the body is still the basic measure to help prevent spinal tuberculosis. In patients with spinal tuberculosis, campos found that patients with adequate body protein, that is, the ratio of lymphocytes/monocytes with a value of ≥ 5, had a better prognosis than the group of patients with protein deficiency. the above ratio < 5.

Surgical treatments Spinal tuberculosis includes two groups: surgery directly into the tubercle to remove dead tissue, pus and bacteria; surgical treatment of plastic sequelae. Regarding surgery directly into the TB foci to treat TB infection, the opinions of the authors are very different, even contradictory. Some argue that surgery is completely unnecessary because antituberculosis drugs have the potential to cure TB (Smith TT 1988; Dec Prez K. M, 1988; Ryckewaert A, 1988). The SOSCOT Orthopedic Society Conference in 1974 also concluded that surgery not only does not facilitate healing, but also does not accelerate the healing process. Other authors believe that surgery leads to better curative outcomes, so it is recommended to operate all cases of spinal tuberculosis as soon as it is detected (Hodgson AR). In fact, surgery has a certain place in the treatment regimen for spinal tuberculosis. If the disease is treated early, in the initial stage, anti-tuberculosis drugs and conservative measures can completely cure the infection, then direct TB surgery is the indicated therapy when conservative treatment is available. existence yielded no results. Other surgeries are also needed to address the complications of spinal tuberculosis. It must not be forgotten that only when anti-tuberculosis drugs are used can surgery be effective and safe. In developing countries like Vietnam, because there are not enough anti-TB drugs, the classic treatment regimen for spinal TB is often applied by strengthening the body's resistance combined with long-term immobilization during 3 stages. of the disease cycle. When suffering from spinal tuberculosis, the spines destroyed by BK are weak, so they are not able to bear the pressure when knees, walking, standing. Therefore, the patient feels pain when moving. If you continue to move, the vertebrae will be destroyed and flattened further: TB vertebrae are injured twice, due to tuberculosis and labor disease will be aggravated. The spine is painful, causing spasm of blood vessels in the TB area, poor blood circulation causing hypoxia in the TB area. Recent studies show that peroxide (Perosido Radica CO) helps the body's white blood cells to kill bacteria. Thus, the pain in the TB area reduces the body's resistance to BK In summary, immobilization in the treatment of spinal tuberculosis is both a measure to strengthen the body's resistance and protect the bone tuberculosis area from being infected. aggravated destruction. The period of immobilization must be long not only to clear the TB infection, but also to continue until the bone has recovered and is strong enough to withstand daily activities without pain. The degree of immobilization can vary depending on the situation: absolute immobilization by complete rest, with or without a cast bed at the stage of bone destruction, the victim is in severe pain; immobilize with a cast or orthopedic vest so that the patient can sit and walk at a stable stage of the disease. Only when there are complete signs (clinical and subclinical) and especially complete absence of pain during activity will immobilization stop.

Treatment results are only really effective, not necessarily thanks to the full application of all the above measures, although it is very necessary. The most important thing is early treatment of spinal tuberculosis; Therefore, early diagnosis of spinal tuberculosis is very important. Even in a situation where only classical treatment is possible because there are not enough anti-TB drugs, there is hope for early treatment at the initial stage: specialized hospitals in Vietnam can do all kinds of surgery. treatment of spinal tuberculosis, but the results are not high because the percentage of patients undergoing surgery is low; Moreover, many cases of disease are detected too late, so even with successful surgery, it is difficult to fully recover.

CONCLUDE

Tuberculosis of the spine is a secondary TB disease, so it is completely possible to prevent it if we do well in the primary TB prevention movement by improving people's living standards and doing a good job of vaccinating children against TB. . During the periodical or individual health checkups, especially for children, the physician should be aware of early detection of spinal tuberculosis and pay attention to ensuring adequate anti-TB drugs for the patient to gradually eliminate the disease. this dangerous disease.