Spinal tuberculosis complicated with sinus tract

　　The causes of sinus tract formation: The majority of patients with this disease have spontaneous rupture of surface abscesses, and sinus tracts form postoperatively, indicating that the timing of surgery was not appropriate, and the focus may still be in the exudative lesion stage.

　　1. The condition is usually severe, with an average of 3.1 affected vertebrae, and complications such as active pulmonary tuberculosis, tuberculosis meningitis, renal tuberculosis, epididymal tuberculosis, hip joint tuberculosis, and sacroiliac joint tuberculosis.

　　2. Additionally, due to the weak resistance of the patients, postoperative infections are easy to occur, and active prevention is required. For patients with drains, complications such as leakage of gas, subcutaneous emphysema, effusion, and dyspnea may occur at the drain site.

　　Patients with this disease may have typical symptoms of tuberculosis, pus may be found flowing from the fistula, X-ray examination may show obvious vertebral destruction, dead bone, caseous material, or flowing abscesses, and 25% of cases with sinus tract secretions positive for Mycobacterium tuberculosis culture, which can be considered as one of the sources of tuberculosis transmission. The diagnosis is not difficult when combined with bacteriological examination.

　　Active treatment of tuberculosis, strengthening physical fitness, preventing the spread of tuberculosis bacteria, is the key to the prevention and treatment of this disease. Secondly, in nursing, attention should also be paid to prevent the occurrence of infection. In addition, due to the long course and recurrent nature of the disease, patients are prone to anxiety and depression, losing confidence in treatment. Medical staff should actively communicate with them, patiently comfort and explain, ensure adequate sleep, carefully and meticulously perform all nursing work, relieve pain in a timely manner, explain the condition, let patients understand the knowledge of the disease, build confidence in treatment, reduce anxiety, alleviate fear, and at the same time, do a good job of family work, cooperate with treatment and nursing.

　　Strengthen nutrition, improve the body's resistance and tissue repair capacity:

　　1. Provide a high-protein, high-calorie, high-vitamin diet, delicious food, to enhance nutrition. Encourage patients to eat more. Such as milk, eggs, lean meat, fish, fresh vegetables, fruits, etc.

　　2. The total daily calorie intake should be between 2000 to 3000 calories.

　　3. Protein should be provided at a rate of 1.5 to 2 grams per kilogram of body weight per day.

　　4. For patients with poor liver and digestive function, the intake of fat should be appropriately restricted to reduce the burden on the gastrointestinal tract and liver.

　　First, the choice of surgical indications and timing

　　If the sinus tract does not heal after 3 to 4 months of reasonable chemotherapy, surgery can be considered under the following conditions:

　　1. Significant vertebral destruction, with dead bone, caseous material, or purulent abscesses.

　　2. Secondary infection of the sinus tract is controlled, the patient does not have fever, and there is little pus locally. Bacterial cultures are negative 2 to 3 times.

　　3. Ensure the patency of the sinus tract.

　　Second, preoperative preparation

　　1. Antituberculosis drugs: Select drugs that are effective against tuberculosis and mixed infections, such as rifampin, ofloxacin, and ciprofloxacin, and formulate a plan. Combination therapy for 2 to 3 months.

　　2. Sinus tract angiography: Clarify the position of the sinus tract, the size of the dead space, and its relationship with the bone lesion and visceral organs, providing reference for surgical design.

　　3. Ensure the patency of the sinus tract and control secondary infection: It is an important link in perioperative management to dilate the sinus tract before surgery or perform sinus tract shortening surgery to ensure the patency of the sinus tract. Local application of drugs for irrigation should be avoided to prevent superficial pyogenic bacteria from entering the deep lesion.

　　4. The whole-body supportive therapy is used to improve the general condition of the patient and enhance resistance.

　　Three, Key Points of Surgery

　　1. The choice of approach: It is better to go extrapleurally for lesions in the thoracic vertebrae, and extraperitoneally for lumbar or lumbosacral vertebrae.

　　2. More thoroughly remove dead bone, granulation tissue, and caseous traits from the bone lesion, and try to eliminate the residual cavity of the sinus tract.

　　3. Complete hemostasis should be performed at the end of the operation.

　　4. Place closed drainage and suture with absorbable suture.

　　5. Use drugs sensitive to suppurative bacteria for about 4 to 6 weeks around the perioperative period to prevent the recurrence of potential suppurative bacteria.

　　Four, Position

　　Determined by the location of the bone lesion and sinus tract.

　　Five, Operation Steps

　　1. Incision: Depending on the location of the bone lesion, refer to the relevant chapters. The sinus tract should be treated with a separate incision, and it is best to excise the skin, subcutaneous tissue, and scrape the sinus tract wall. These soft tissue pathological sections have proven to have tuberculosis in 80% of cases, and they should be resected during surgery.

　　2. Carefully separate and剥离 adjacent tissues or organs such as the peritoneum, intestines, and nerves and blood vessels adjacent to the sinus tract wall, as they are generally tightly adhered. Damage should be avoided, and the dead bone, caseous, granulation tissue, and scar tissue in the sinus tract should be thoroughly removed. Hemostasis should be perfected, and a large amount of saline or antibiotic solution should be used for irrigation. The incision should be sutured with absorbable suture to leave as little dead space as possible, and a pedicled muscle flap may be used to fill the defect if necessary. The lesion should be placed with a silicone tube for negative pressure drainage, and subcutaneous rubber sheet drainage should be used to prevent infection and ensure the success of the surgery.

　　Six, Postoperative Management

　　1. Continue to take anti-tuberculosis medication for about 1 year. According to the preoperative general bacterial culture and drug test, select anti-infection drugs to maintain for 4 to 6 weeks.

　　2. Subcutaneous rubber sheet drainage should be removed within 48 to 72 hours after surgery; the local condition of the lesion drainage tube can be maintained until 72 to 96 hours after surgery.

　　Seven, Prevention of Sinus Tracts

　　According to our data, 70% of sinus tract cases are caused by spontaneous rupture, incision and drainage, and residual reasons after surgery. Active prevention should be carried out:

　　1. Early diagnosis and rationalized treatment should be carried out.

　　2. When the tension of the abscess is high, timely puncture and aspiration of pus should be performed, and repeated procedures may be necessary if required.

　　3. In cases where the surface of cold abscesses is at risk of溃破, timely sealing drainage should be performed.

　　4. In cases where cold abscesses continue to enlarge and systemic toxic symptoms and fever are present, chemotherapy should be performed first and surgery scheduled later to avoid the formation of postoperative sinus tracts.