Pulmonary tuberculosis with posterior kyphosis

　　Spinal tuberculosis often occurs secondary to pulmonary tuberculosis, and some patients may not have symptoms of pulmonary tuberculosis. After pulmonary infection, the bacteria can spread throughout the body through the blood, causing spinal infection. The blood supply of the spine is mostly terminal branches, and the intervertebral discs are cartilage discs without blood circulation, so central and marginal types of spinal tuberculosis are more common. In fact, any part of the human skeleton can get tuberculosis, and spinal tuberculosis accounts for about 50% of the cases. Other joints such as the knee and hip can also get tuberculosis. The etiology of this disease is relatively complex, and various factors can cause spinal kyphosis deformity. Factors affecting the postural deformity of the spine include the patient's age, the initial angle of postural deformity, the number of affected vertebrae, the number of vertebrae completely lost during treatment, and the level of the spine where the lesion is located.

　　This disease not only affects the patient's appearance and psychological pressure, but also severe postural deformities after thoracic or thoracolumbar tuberculosis can affect their cardiovascular and pulmonary function, leading to complications of cardiovascular and pulmonary organs, and may even appear more serious complications such as late-onset病灶-cured paraplegia.

　　If the lesion of the fourth or fifth lumbar vertebra damages even one vertebra completely, it has little effect on the postural deformity of the spine, which may be compensated by the original physiological forward curvature of the lumbar spine.

　　If a thoracic or thoracolumbar tuberculosis leads to the complete loss of one or two, three vertebrae, a postural deformity of 30° to 90° will eventually form. In this group, 23 cases (46%) belong to this situation, with postural deformity reaching about 70°. Relevant reports show that the destruction and disappearance of a single vertebra can lead to a postural deformity of 33° in the thoracic spine, 37° in the thoracolumbar spine, and only 24° in the lumbar spine, with significant differences. Severe postural deformities (>100°) seem to be more concentrated in the lower segment of thoracic tuberculosis.

　　The age of the patient at the start of treatment has an important impact on the degree of progressive postural deformity. Patients whose spinal growth and development have been completed usually develop postural deformity within 12 months of treatment, with almost no progressive increase in the following 2 years. In children with growth and development, those with initial postural deformity <40°, the lesion is in the thoracic lumbar or lumbar spine, and the postural deformity can be reduced or unchanged; conversely, those with initial postural deformity >40° will have progressive increase in postural deformity as the child's spine develops.

　　This disease is mainly caused by the transfer of tuberculosis bacteria to the spine, therefore, actively treating tuberculosis and preventing the spread of the bacteria is the key to the prevention and treatment of the disease. In addition, attention should also be paid to appropriate exercise to enhance the opportunity of resistance.

　　One, X-ray film

　　1. In the early stage of the disease, it is mostly negative. According to Lifeso et al. (1985), it is believed that about 6 months after the onset, when 50% of the vertebral bone is involved, routine X-ray films can show the change.

　　2. Early signs of X-ray film in most cases are the expansion of paravertebral shadows, with involvement of the anterior inferior edge of the vertebral body, narrowing of the intervertebral space, and bone sparsity of the vertebral body, with expanded paravertebral shadows and dead bone. The diameter of the vertebral bone destruction area

　　3. In central vertebral tuberculosis, the intervertebral space often shows no obvious change, making it difficult to differentiate from vertebral tumors; while some slowly growing tumors such as thyroid metastatic carcinoma, chordoma, and malignant lymphoma can show varying degrees of intervertebral stenosis, which is very difficult to differentiate from osteolytic vertebral tuberculosis.

　　4. In most cases of vertebral tuberculosis, except for patients with old or impending cure, the expansion of paravertebral shadows is mostly bilateral. However, in vertebral tumors such as osteoclastoma of the vertebral body, chordoma, malignant lymphoma, and renal cell carcinoma metastasis to the spine, unilateral or bilateral expansion of paravertebral shadows can be seen on the anteroposterior X-ray film, especially when limited to one side, attention should be paid to differentiation.

　　Two, CT examination

　　1. It can detect early subtle skeletal changes and the range of abscesses, which is more valuable for areas that are difficult to obtain satisfactory images with routine X-ray films, such as the cervical and upper thoracic spine and the irregular sacrum. Some scholars divide the CT images of spinal tuberculosis into four types: ① Fragmentary type: After vertebral destruction, small fragments are left, with low-density soft tissue shadows around them, often containing scattered small fragments; ② Osteolytic type: There is an osteolytic destructive area at the anterior edge or center of the vertebral body; ③ Subperiosteal type: There are irregular bony destructions at the anterior edge of the vertebral body, and circular or semicircular calcification shadows are often visible in the paravertebral soft tissue; ④ Localized osteolytic destruction type: There is often a hardening zone around the destructive area (Jainr et al., 1993).

　　2. CT examination of spinal tuberculosis commonly shows fragmentary type, while spinal tumors also often have similarities with it, so a comprehensive analysis should be made in combination with clinical data. For example, the presence of calcified foci or small bone fragments in the expanded paravertebral shadow is helpful for the diagnosis of spinal tuberculosis. However, even with this classification, CT sometimes still cannot differentiate spinal tuberculosis from spinal tumors.

　　Three, MRI examination

　　It has the characteristics of high-resolution soft tissue, which is superior to CT in cranial and spinal cord examinations, and can be scanned and imaged in sagittal, axial, and coronal planes. The MRI manifestations of spinal tuberculosis show that the signal intensity of the affected vertebral body, intervertebral disc, and appendages is higher than that of the corresponding normal spinal cord, with higher signal intensity than normal and lower signal intensity than normal.

　　1. Vertebral lesion: In the T1-weighted image, the lesion shows low signal intensity, or it may contain short T1 signal. In the T2-weighted image, the signal intensity is enhanced. The image shows that in addition to the signal change in the affected vertebral body, the outline of vertebral destruction, vertebral collapse with alignment changes, and expanded paravertebral shadows can be seen.

　　2. Paravertebral abscess spinal tuberculosis: In the T1-weighted image, paravertebral abscess shows low signal intensity, while in the T2-weighted image, it presents with higher signal intensity. The coronal view can delineate the outline and range of paravertebral abscess or bilateral psoas abscess.

　　3. Changes in intervertebral disc in spinal tuberculosis X-ray films show disc narrowing as one of the early signs. The T1-weighted image of MRI shows a narrow disc with low signal. The normal nucleus pulposus has transverse fine gaps in the T2-weighted image, which disappear when inflammation is present, and disc inflammation changes can be detected early.

　　MRI is more sensitive than any other imaging examination, including ECT, in the early diagnosis of spinal tuberculosis. For patients with clinical symptoms appearing 3 to 6 months, suspected of having spinal tuberculosis, without any abnormalities in X-ray films, MRI can show involved vertebral bodies and paravertebral soft tissues (abscess), with T1-weighted images showing low signal and T2-weighted images showing high signal. Early MRI images of spinal tuberculosis can be divided into three types: ① vertebral body inflammation; ② vertebral body inflammation with abscess; ③ vertebral body inflammation, abscess, and intervertebral disc inflammation. It is worth mentioning that vertebral bodies involved in the inflammatory stage without soft tissue and intervertebral disc signal changes cannot be distinguished from vertebral body tumors, and biopsy should be performed to confirm when necessary.

　　The diet of patients with kyphosis deformity in spinal tuberculosis should be light, easy to digest, with a high intake of vegetables and fruits, a reasonable dietary balance, and attention to adequate nutrition. In addition, patients should also avoid spicy, greasy, and cold foods.

　　1. For patients with tuberculosis of the thoracic and thoracolumbar spine, when the destruction of the thoracic vertebral bodies is 0.75 or more, and when the lumbar spine loses 1.5 or more vertebral bodies, surgical intervertebral bone grafting is required to prevent progressive deformity.

　　2. Intervertebral bone grafting is an effective measure to prevent and control the occurrence and development of kyphosis deformity. When the mechanical strength of the bone graft is insufficient, especially in the thoracolumbar segment, the bone graft may break or sink into the cancellous bone. When rib grafting exceeds two defecting vertebrae, the bone graft is prone to break or slip. Using fibula can avoid this. There are reports of bone graft failure in 59% of cases. Postoperative radiographs should wait for intervertebral fusion, and when getting out of bed and exercising, a 'brace' should be worn if necessary.

　　3. For children under ten years old with a posterior kyphosis deformity of 40° or more, there is a risk of progressive increase in spinal kyphosis deformity with the growth and development of the spine. Surgical treatment is considered an indication.