骨結核英文七年制

Septiclesion?Tumor?IntroductionIntroduction

EpidemiologyandEtiology(流行病學及病因學)

Pathology(病理)DiagnosisandDifferentialDiagnosis(診斷與鑒別診斷)

ProphylaxisandTreatment(預防與治療)

TuberculosisofbonesandjointsGenerallytobeachronicinflammatoryandinfectiousdiseasecausedbyMyobacterium

tuberculosis.Extrapulmonarysecondarydiseases Approximately95%casesoftuberculosisofbonesandjointsareduetopulmonarytuberculosis,butpulmonarytuberculosisisevidentinonlyhalfthepatientswithskeletalinvolvement.EpidemiologyEpidemiologyIngeneral,mostpatientswiththisdiseaseareintheageof30orbelowatdiagnosisindevelopingcountries

Thesusceptiblepopulation

withthisdisease

isintheelderlyindevelopedcountries.Bothsexesareequallyaffected.EpidemiologyTuberculosisofspineisthemostcommonsite,thenextinorderoffrequencybeingtheknee,hip,ankle,sacroiliac,shoulder,andwristjoints.LocationIncidenceInSummaryTuberculosisofbonesandjointsisagranulomatousinflammationcausedbyMyobacteriumtuberculosis.About5%oftuberculosisismusculoskeletal.

最常見的肺外繼發(fā)性結核Tuberculosisofspineisthemostcommonsite,thenextinorderoffrequencybeingtheknee,hip,ankle,sacroiliac,shoulder,andwristjoints.

脊柱結核最常見

EtiologyPathogen(致病菌)

Acid-fastbacilliMycobacteriumtuberculosisHumantuberclebacilli

（人型結核桿菌）commonBovinetuberclebacilli(牛型結核桿菌)rareThefluorescentstainingofacid-fastbacilli

EtiologyOnMarch24,1882,RobertKochannouncedhisdiscoveryofthetuberclebacillus.HediscoveredastainingtechniquethatenabledhimtoseeMycobacteriumtuberculosis.

（結核桿菌）

Dr.RobertKochEtiologyTransmissionRoutesHematogenousdissemination

（血液傳播）tolongbonesandvertebraeDirectspreadtobonefromadjacenttuberculouslymphadenitis

（結核性淋巴腺炎）Singleormulticentric（單發(fā)或多中心），particularlyinAIDSPredilectionforsynovium

（偏好滑膜）-higheroxygenpressurePathology(病理)Initialpathologicalchangesaretuberculous

osteomyelitis

(結核性骨髓炎,單純骨結核)andsynovialtuberculosis(滑膜結核)。Thearticularcartilagesremainintactatthisstage.Thelesionwillbehealedthroughpropertreatmentintime,andjointfunctionwillbereservedthoroughlyorpartially.Iftheoriginalfocusremainsactiveanduntreated,thelesionwillexacerbate,involvedbone,cartilageandsynovia,developingtotuberculouspanarthritis（全關節(jié)結核）.PathologyBasicPathologyChanges:

Exudation

滲出

Deterioration

變質

Proliferation增殖SimpleSeletal

TBTBoftheCancellousBone

centrallesion

PeripherallesionTheanteriorlesion

Theparadiscallesion

TBoftheCorticalBoneTBoftheMetaphysisPathology(SimpleSekeltal

TB)TBoftheCancellousBone

Centraltypepoorbloodsupplymainpathologicalchangesincludeskeletalerosionandnecrosisformingsequestruaandcavities.calcaneusPathology(SimpleSkeletal

TB)TBoftheCancellousBone

Peripheraltypeabundantbloodsupplylocalbonedefectwithoutformingsequestrum

Pathology(SimpleSkeletal

TB)TBoftheCorticalBone

Localizeddestroywithoutformingsequestrumonion-likeproliferation;thequantityofnewboneformationofperiosteumisdeterminedbytheage.Pathology(SimpleSkeletal

TB)TBofthemetaphysis(干骺端結核）

formingsequestrua(死骨片）

(cancellousbone)newboneformationofperiosteum

（骨膜）

(compactbone)Pathology

(TBoftheSynovialmembrane滑膜結核)Earlystage:Hyperaemia充血Synovialhypertrophy腫脹Exudateincreasing滲出增多Pannusformation（血管翳）&Ricebodies米粒體(small,freewhitebodiescomposedofcompactmassesoffibrin,necroticsynovialvilli,orcartilagefragments)Latestage:hyperplasiaofsynovium

滑膜肥厚增生Theriskofjointsinvolveknee,hip,elbowandankle.Pathology(Tuberculous

panarthritis)全關節(jié)結核DuetoSimpleTB

DuetosynovialTBComplicationsofLateStageTBofBonesandJointsAbscess膿腫Pathologicalsubluxation,dislocationorfracture病理性半脫位、脫位或骨折Articulardeformityorstiffness關節(jié)畸形強直Shorteningofextremities肢體短縮

(epiphyseserosion)骨骺受損Paraplegia(spinalcordcompressed)截癱ComplicationsofLateStageTBofbonesandjointsAbscess(ColdAbscess)寒性膿腫Paraspinalabscess椎旁膿腫Gravitationabscess流注膿腫Psoasabscess腰大肌膿腫Lumbertrangleabscess腰三角膿腫OtherabscessParaspinalabscess椎旁膿腫Calcificationoftheparaspinalabscessisessentiallypathognomonicfortuberculosis椎旁膿腫鈣化是結核的基本特征

Normalshadowofpsoasmajor正常腰大肌影Psoasabscess腰大肌膿腫Deepgravitationabscessofgroin

腹股溝深部流注膿腫Articularstiffnessanddeformity

關節(jié)強直畸形LimbShortening肢體短縮

Kyphosis（脊柱后凸）

Paraplegia（截癱）掌握要點骨與關節(jié)結核的發(fā)展階段和分型及其X線特點松質骨結核：中心型壞死型邊緣型溶骨型密質骨結核：層狀骨膜增生，梭型膨大干骺端結核：兼有松質骨和密質骨結核特性滑膜結核：無特殊。僅骨質疏松全關節(jié)結核：早期；晚期骨與關節(jié)結核晚期并發(fā)癥：不同部位的寒性膿腫關節(jié)畸形、強直Diagnosisand

DifferentialDiagnosisDiagnosis

MedicalhistoryInsidiousonset隱匿起病Symptoms:

pain疼痛

lowfever低熱

nightsweats盜汗

anorexia厭食

anemia貧血

weightloss體重減輕

localswelling局限腫脹morbidnightcryingofbabies夜啼contacthistory接觸史DiagnosisClinicalexamination

Systemicandregionallymphnods:singleratherthanmultipleappearanceLocalswellingColdabscess:withoutruborandcalorLocalheatandrednessareusuallyabsent,andtendernessisminimal.

Sinustracts:multiple

appearance,periarticulartendernessandpercussingpainJointfunction:insidethejointoroutsidethejointSystemicsymptoms:mildexceptforchildDiagnosisRadiographicFindings(6-8weeksafter)SkeletalTBTBofthecancellousbone:Centrallesion:bonenecrosisPeripherallesion:bonelysisTBofthecorticalbone:layerperiosteumproliferation&shuttle-likeinflationTBofthemetaphysis:DiagnosisRadiographicFindingsTBofthesynovialmembrane:Theearliestfindingsintheradiogramsareregionalboneatrophy,soft-tissueswelling,andcapsulardistention.Thesechangesareduetosynovitisandarenonspecific.Tuberculouspanarthritis:Theabovechangesarefollowedbyperipheralerosionoftheboneanddestructionofthesubchondralbone,withthejointspacenarrowing.

Diagnosis

Labtestbloodrt.10%pt.whitecellThesedimentationrate:non-pathognomonicfortuberculosisbutaltersearlythanX-ray(male<15mm/h;femal<20mm/h)

Tuberculinskintest:immunocompetentpatients:alwayspostiveimmunocompromisedpatients:33%postiveDiagnosis

LabfindingBacteriologicexamination

(thetuberclebacillusculture)

(3~6weeks)

orhistologicalexaminationofpusorbiopsyspecimen.PositiveRateofCultureforM.tuberculosis

onsmearpus:70%granulomasorcaseation(orcheesy)necrosisarea:43%jointasperationordeadbone:35%PositiveRateofPathologicalexam:70-80%(Langerhansgiantcells)

MRIandPCRuseforearlydiagnosisMethodofJointAspirationforTBDifferentialDiagnosisRheumatoidArthritis:

20~55歲女性，多關節(jié)、小關節(jié)，對稱性。RF因子（+）

AnkylosingSpondylitis:

15~35歲男性，多發(fā)，（脊柱、髖、膝），對稱性，無膿無死骨，HLAb27（+）

Septicarthritis:關節(jié)穿刺

SepticOsteomyelitis:

全身中毒癥狀重。細菌學和病理檢查

BoneTumor:脊柱結核早期侵犯椎間盤，椎間隙狹窄消失急性骨髓炎(以破壞和增生為主）X線見骨質廣泛破壞，大量死骨及大量骨膜新骨形成骨結核（破壞、疏松、萎縮為主）髓腔內溶骨性破壞,無死骨；骨干周圍有廣泛新骨形成慢性骨髓炎破壞與增生并存;骨質硬化；大量死骨、包殼發(fā)生骨結核以破壞、疏松、萎縮為主;很少硬化；死骨少、小(沙粒狀）掌握要點骨與關節(jié)結核的診斷要點：分四步驟：病史與臨床表現(xiàn)結菌素皮膚實驗X線片檢查（胸部和患肢）;MRI細菌學檢查（痰培養(yǎng)、膿腫穿刺液培養(yǎng)）主要鑒別的疾病：結締組織病骨關節(jié)感染性疾病骨腫瘤ProphylaxisandTreatmentEffectiveTBControlTheWHO-recommendedtreatmentstrategyfordetectionandcureofTBisDOTS.TreatmentEarlydiagnosisandtheuseofantituberculousdrugshaveradicallyimprovedtheprognosisoftuberculousarthritis.Othermeasuresadoptedareresttotheaffectedjointinfunctionalposition,tractionwhenneededanddietaryimprovement.Treatmentconsistsofgeneralmedicalmeasures,chemotherapy,localconservativeorthopediccare,andsurgery.CriterionofCure治愈標準全身情況良好，體溫正常，食欲（orexia）良好局部癥狀消失，無疼痛，竇道閉合血沉3次結果正常X線顯示膿腫縮小乃至消失或鈣化，無死骨，病灶邊緣輪廓清晰起床活動已達1年，仍保持上述4項指標Indicationsofoperation手術適應證骨關節(jié)結核有明顯的死骨忽而大膿腫形成竇道流膿經久不愈脊柱結核引起脊髓受壓SpinalTuberculosisClinicalManifestationCervical:NeckPain(mildtosever)NumbnessofarmduetoneuralcompressionObstructingbreathingandswallowingwithPostpharyngealabscessTuberculosisofSpine

ClinicalManifestationThoracic:BackpainGibbousdeformityLumbar:SpecialStandingstancePick-uptest(+)GravitationabscessOsseousdestroyanddecreaseinoneormorediscspacesColdAbscess:Cervical:

Lumbar

ThoracicTuberculosisofSpine

RoentgenographicFindings

PrincipleofTreatmentCastfixationSurgicaltreatmentEvacuationorexcisionofsofttissueabscesses（切開排膿）

Clearanceoffocallesion（病灶清除術）

Osteotomy,Arthrodesisandarthroplasty.

（矯形手術）HipTuberculosisClinicalManifestationHippainLimpAbscessofgroinPE:Figure4testHiphyperextensiontestThomastestHipTuberculosis

RoentgenographicFindingsX-rayCTMRIHipTuberculosisPrincipleofTreatmentChemotherapySkintractiontopreventionformingcontracturehip(bendingdeformity)thenfixwithhipspicafor3months.SimplesynovialTB:Intra-articularinjectionwithanti-tuberclemedicineSynovectomyorcurettageforthecaseswithintra-articulardropsytoreservefemoral