脊椎结核

　　脊柱结核多继发于肺结核，部分患者可无肺结核症状，肺部感染后通过血液传播可至全身，传播至脊椎引起脊椎感染，脊椎血运多为终末支，椎体间为无血液循环的软骨盘，故脊柱结核以中心型、边缘型多见。实际上人体任何部位的骨骼都可以得结核，脊柱部位的结核大约占到50％，其他的比如膝关节、髋关节等很多关节也都可以得结核。

　　脊椎结核可以并发哪些疾病：

　　1、寒性脓肿的治疗如脓肿过大，宜先用穿刺法吸出脓汁，注入链霉素，以免脓肿破溃和发生继发性感染以及窦道形成。在适当时机应尽早进行病灶清除术和脓肿切除或刮除。

　　2、截瘫的治疗脊椎结椎合并截瘫的约有10％，应贯彻预防为主的方针，主要措施为脊椎结核活动期坚持不负重，坚持卧床和抗痨药物治疗等。如已发生截瘫，应早期积极治疗，大多可以取得良好的恢复。如失去时机，后果是严重的。如已有部分瘫痪，一般多先行非手术治疗，按截瘫护理，绝对卧床，进行抗结核药物治疗，改善全身情况，争取最好的恢复；如1～2月后不见恢复，应尽早手术解除张力，如截瘫发展很快，甚至完全截瘫，应尽快手术，不宜等待。在颈椎结核合并截瘫，或有寒性脓肿，应早行手术，可在颈部前侧作切口，在胸锁乳突肌前侧与颈总动脉颈内静脉之间（或在颈动脉鞘之前）进入，显露和清除病灶，必要时一次处理两侧。在胸椎手术多采用肋骨横突切除病灶清除术，或行椎前外侧前灶清除减压术，待截瘫恢复，一般情况好转后，再作脊椎融合术，使脊椎稳定。

　　除具有一般症状外，尚有以下特点：

　　1、早期有贫血，体重减轻，容易疲乏，背（腰）部疼痛及放散痛，疼痛主要在脊椎病变部位，发病初期不重，随病变发展而加剧，休息后可减轻或暂时消失；不同部位的病变还可引起各种转移痛，承重，行走和脊柱活动时疼痛加剧。

　　2, Muscle spasm and motor disorders, muscle spasm, and limited spinal movement are a kind of protective action of the body. Children may experience pain in the waist after relaxed muscles during deep sleep, resulting in 'night crying'. Cervical tuberculosis patients often support their heads with both hands, lumbar tuberculosis patients have a rigid waist like a board, and when picking up objects, they dare not bend over and flex their hips, knees (positive picking-up test), to prevent pain during back and waist movement.

　　3, In the late stage, there are often back deformities and cold abscesses, and after the abscesses are broken through, complications such as infection and sinus tracts may occur.

　　4, Paraplegia, patients who have not received appropriate treatment in the late stage may have compression of the spinal cord, resulting in partial or complete paralysis, which is a serious complication that endangers patients.

　　It is mainly to prevent tuberculosis infection, neonatal BCG vaccination prevention:

　　1, Preoperative:Psychological communication should be carried out with the patient, introduce the positivity, necessity, and safety of the operation to the patient, eliminate the patient's concerns and fear of the operation; encourage the patient to eat high-calorie, high-protein, and high-fat food to improve the patient's tolerance to the operation; train the patient to perform urination and defecation on the bed to adapt to the postoperative needs; for patients with fever, physical cooling should be given in addition to timely informing the doctor to reduce the patient's physical consumption.

　　2, Postoperative:In the case of extreme physical and mental suffering of the patient, it is necessary to give spiritual comfort and encourage the patient to establish confidence in overcoming the disease, actively cooperate with the doctor's treatment to enable the disease to recover as soon as possible; due to postoperative pain in the wound, the pain increases during coughing, and the patient is unwilling to cough or expectorate, which is easy to cause atelectasis and asphyxia due to poor respiratory tract, so it is necessary to encourage the patient and assist the patient in expectoration to prevent respiratory system complications; for patients with high fever after surgery, physical cooling should be given in addition to medication; for patients with indwelling catheters after surgery, timed urination should be performed, and for patients with drainage tubes, the drainage fluid should be discharged in time to prevent urinary tract infection and wound infection; the patient's bed should be kept clean and tidy, the skin should be kept dry, and if the bed is contaminated, it should be cleaned and replaced in time; to prevent bedsores, the patient should be turned every two hours in the early postoperative period, and while turning, the patient's muscles should be massaged to prevent muscle atrophy. Encourage the patient to move on the bed to prevent joint stiffness. Due to surgical trauma and bed rest, the patient requires a diet of fluid,渣-free, and high-nutrition food. According to the condition, it can gradually be changed to semi-liquid or common food; around one week after surgery, assist the patient to get out of bed for activities, and have a special nurse to care for the patient during the activities to prevent accidents. With the strengthening of exercise and the recovery of the disease, around two weeks after surgery, the patient can move freely in the ward, and around three weeks after surgery, outdoor activities can be performed. The patient is advised to take medication on time and have regular follow-up examinations after discharge.

　　First, X-ray films

　　X-ray films are often negative in the early stages of the disease, and it takes about 6 months after onset for routine X-ray films to show that 50% of the vertebral bone is involved. Early signs of X-ray films are manifested as the expansion of paravertebral shadows, the involvement of the anterior inferior margin of the vertebral body, and the narrowing of the intervertebral spaces, as well as the sparsity of vertebral bone, the expansion of paravertebral shadows, and dead bone, etc. The diameter of the vertebral bone destruction area is

　　1. Changes in the physiological curvature of the spine: The cervical and lumbar spine become straight, and the thoracic spine becomes more kyphotic. In severe cases, the cervical and lumbar spines can also be屈曲 forward.

　　2. Changes in vertebral body: The early changes are mild and localized, especially in the marginal type, often only showing localized opacification or density invertebrate changes in one corner of the vertebral body, or density inhomogeneity, which is easy to miss. When the lesion is extensive and dead bone formation occurs, the X-ray manifestation is typical, showing a large area of inhomogeneous density, often with destruction and hardening coexisting. Dead bone, due to lack of blood supply, has high density and clear boundaries with the surrounding area. When the vertebral body is destroyed and compressed, the vertebral body narrows and the edges are uneven. The空洞 of the tuberculous vertebral body is often small and localized, with hardening edges and often with dead bone.

　　3. Changes in vertebral interspace: The interspace narrows or disappears, and the edges are uneven and blurred. If it is a central type of vertebral tuberculosis, the vertebral interspace may not change in the early stage.

　　4. Soft tissue around the vertebral body: It is mostly centered on the lesion vertebral body. The anterior soft tissue shadow of the cervical vertebrae can be enlarged, and the trachea can be pushed forward or to one side. The thoracic vertebrae can show different types of paravertebral abscess shadows. The lumbar vertebrae can show an enlarged and deepened psoas shadow. This indicates more pus. If the soft tissue shadow is not very large but there is obvious calcification, it indicates that the condition has stabilized.

　　2. CT examination

　　CT examination can detect early subtle skeletal changes and the range of abscesses, and can also show the condition of intervertebral discs and spinal canal. It is more valuable for areas that are difficult to obtain satisfactory images with routine X-ray films. Combined with clinical data for comprehensive analysis, if there are calcification foci or small bone fragments in the expanded shadow of the paravertebral area, it is helpful for the diagnosis of spinal tuberculosis. CT sometimes still cannot differentiate between spinal tuberculosis and vertebral tumors.

　　3. MRI examination

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

　　1. Vertebral body lesion: The T1-weighted image shows low signal at the site of the lesion, or there may be short T1 signal. The T2-weighted image of vertebral body lesions shows signal enhancement. The image shows that in addition to the signal change, the outline of vertebral body destruction, vertebral body collapse, and expanded paravertebral imaging can be seen in the vertebral bodies with lesions.

　　2. Paravertebral abscess: The paravertebral abscess of spinal tuberculosis shows low signal in the T1-weighted image and higher signal in the T2-weighted image. The coronal view can outline the contour and range of the paravertebral abscess or bilateral psoas abscess.

　　3. Changes in intervertebral disc: The narrowing of the intervertebral disc in the X-ray film of spinal tuberculosis is one of the early signs. The T1-weighted image of MRI shows a narrow disc with low signal. Normally, the nucleus pulposus has transverse fine gaps in the T2-weighted image. When there is inflammation, these fine gaps disappear, and disc inflammation can be detected early.

　　4. Laboratory examination

　　1. Blood routine examination

　　The changes are not obvious, but there may be an increase in lymphocytes. If there is a concurrent infection, the total white blood cell count and neutrophils increase. In patients with a long course of disease, the red blood cells and hemoglobin may decrease.

　　2. Erythrocyte Sedimentation Rate

　　Erythrocyte sedimentation rate increases in the active phase, usually between 30~50mm/h, and if it increases significantly, it indicates that the disease is active or there is a large amount of pus. In the stationary and cured stage, it gradually decreases to normal. If it increases again, it indicates the possibility of recurrence, which is not specific.

　　3. Tuberculosis Bacterium Culture

　　Generally, pus, dead bone, and tuberculous granulation tissue are cultured, with a positive rate of about 50%, which has diagnostic value. However, the culture time is long and the positive rate is not high. Tuberculin skin test (PPD test) is a specific allergic reaction to tuberculosis, which has definite diagnostic value for tuberculosis infection. PPD is mainly used for the diagnosis of tuberculosis in children and adolescents, and has only a reference value for the diagnosis of tuberculosis in adults. Its positive reaction only indicates that there is tuberculosis infection, but does not necessarily mean the patient is sick. If the test shows a strong positive reaction, it often indicates that there is active tuberculosis in the body. PPD has greater diagnostic value for infants and young children than for adults, because the younger the age, the lower the natural infection rate, and the older the age, the more opportunities for natural infection of tuberculosis, and the more PPD positive people, so the diagnostic significance is smaller.

　　In addition to conventional Western medicine treatment for spinal tuberculosis, attention should also be paid to some aspects of diet: diet should be high in protein and energy, and more liquid and渣-free food should be eaten, such as milk, fruit, etc.

　　Precautions before the treatment of spinal tuberculosis:

　　Firstly, nonsurgical therapy

　　1. Bed rest is necessary to prevent the lesion of the spine from bearing weight, which is a necessary measure to prevent the development of the lesion, serious deformity, and paraplegia. Bed rest can be done on a plaster bed or a hard bed.

　　2. Strengthen nutrition and enhance the body's ability to resist diseases.

　　3. Application of Antituberculosis Drugs.

　　4. Gradually increase activities after the lesion has healed, and prevent the spine from bearing too much weight to avoid recurrence of the disease. The sign of lesion healing is the disappearance of local pain and tenderness in the lumbar and sacral region, overall good health, normal body temperature, pulse, and erythrocyte sedimentation rate, and X-ray shows good bone healing.

　　Secondly, treatment of complications

　　1. Treatment of Cold Abscess.

　　2. Treatment of Paraplegia.