內(nèi)科學(xué)教學(xué)課件：Tuberculosis of bone and joint

Tuberculosisof

boneandjointGeneralSkeletaltuberculosisisstillacommonorthopaedicprobleminChinaandinmanyotherdevelopingcountriesoftheworld.Inanindividualtheskeletallesionisalocalmanifestationofasystemicinfection,thesourceoftenbeingalesioninthelung.Skeletaltuberculosisisachronicdiseaserunningitscourseforoneoreventwoyears.Thischronicmorbiditycreatesothersocioeconomicproblemsinsociety.Incidence

Theincidenceoftuberculosiscasesisincreasingworldwide.Theincidenceofskeletaltuberculosisisveryhighinchildren,adolescentsandyoungadults.

Thehighestincidenceof30%occursintheyoungadultsanditisuncommoninoldage.Causativeorganism:

thehumantypeoftuberclebacillusPathology

The‘tubercle’isthemicroscopicpathologicallesion

AcentralnecrosissurroundedbyEpithelioidcells,

GiantcellsandRoundcells

Progress

Clinicalfeatures

Clinicallytheonsetoftuberculosisinanyboneorjointisinsidious.Intheearlystagesthereareconstitionalsymptomslikelossofweightlossofappetiteandlowgradeeveningtemperature.Thelocalisingsymptomsandsignsthenappearintheaffectedpart.Investigations

Blood:ESR，CRPMantouxtestinchildrenSputumexamination

Biopsy

Aspirationofabscess:Aspirationofthinpusfromcoldabscessoftenconfirmsthediagnosis.

RadiographRadiographofthechestAnteroposteriorandlateralviewsCTMRIImagingfindings

Softtissueswelling,jointeffusionDecreasebonedensity,corticalthinningandenlargementofmedullarycanalBonedensityisdecreasedbothproximallyanddistally

Cartilagedestructionleadstojointspacenarrowing

Metaphyseallesionsmaydevelopsingleormultilocularcysticchanges,perhapswithcentralcalcificationJointspacenarrowingTh7-8TBL5-S1TBGibbusSinusMangemant

Generaltreatment:ImprovenutritionTreatmentEarlyskeletaltuberculosiswillusuallyrespondwelltoappropriateantibiotictreatmentNutritionalsupportRestandimmobilizationarevaluableadjunctsMedicaltreatmentChemotherapyofosteoarticulartuberculosisreliesonsystemicadministrationofdrugsInvitrosensitivitytestingguidetodrugsusedCombinationsdrugsarerecommendedtoprescribed(atleasttwoorthree)MedicaltreatmentChemotherapyofosteoarticulartuberculosisreliesonsystemicadministrationofdrugsInvitrosensitivitytestingguidetodrugsusedCombinationsdrugsarerecommendedtoprescribed(atleasttwoorthree)Isoniazid,Rifampin,pyrazinaide,andEthambutolarecurrentlythemostwidelyuseddrugsPeriodicityoftreatmentisrequiredaboutof6-9monthsSurgicaltreatmentTheaimofsurgeryinskeletaltuberculosisisclearanceofthelesionwhereverpossibleandthepreservationoffunctionofthejoint.BiopsyisoftenrequiredtoestablishthediagnosisandobtainorganismsforcultureandsensitivitystudiesAbscessesshouldbedrainedsurgicallybeforedrainageoccursspontaneouslycreatingariskofsuperinfectionSynovectomymayspeedrecoveryandhelppreservefunctionofinvolvedjointsandtendonsheathsEffectivechemotherapygreatlyreducethearthrodesisofinvolvedjointsSignificantdestructivelesionsofthevertebralcolumnhavebeenmanagedsuccessfullywithchemotherapysurgeryFusionismorepredictablethanwith

chemotherapyTheriskofprogressivekyphosisisdecreasedThetimerequiredforrecoveryissignificantlyshortenedQuiescenceofthelesion

1.General:Disappearanceoftoxaemiawithimprovementinappetiteandweight.2.Local:Absenceoflocalwarmth,tender-nessandmusclespasm.3.Radiological:Evidenceofclarityofthemarginandsclerosisofthelesion.4.Laboratory:

ConsistentlylowESR.Followup

Thepatientisre-examinedperiodicallyforanyclinicalevidenceofpain,musclespasm,tendernessandlossofweight.AradiographistakenandESRdoneatthesametime.Ifthelesionremainsquiescentforoneyearaftercompletionofchemotherapythepatientistakenasclinicallycured.TUBERCULOSISOFTHESPINE

Tuberculosisofthespineforms50-60percentofthetotalincidenceofskeletaltuberculosis.

Itisadiseaseofchildhoodandadolescence,50percentofcaseoccurringintheagegroup1-20years.

Themostcommonlevelofthelesionisinthethoraco-lumbarlevel.PathologyThefocusinthespinemaybefoundinoneofthefollowingsites.1.para-discallesioninthesuvchodralareaofthevertebralbody.2.Centralbodylesioninthecentreofthevertebralbody.3.Anteriortypeintheanteriorsurfaceofthevertebral4.Appendiciallesioninthepedicle,lamina,transverseprocessandspinousprocess.5.Articularlesionintheposteriorintervertebraljoint.ClinicalfeaturesPain：willbelocalisedbythepatienttooneregionofthespine.Rigidity：iscausedbythespasmoftheparaspinalmusclesduetothediseaseinthespine.DeformityTheformationofcoldabscessisaninvariablefeatureoftuberculosisofthespine.Detectionofspinalactivity

COINTESTRetropharyngealabscessParavertebralabscessPsoasabscessColdabscess（1）Paravertebralabscess（2）GravitationabscessThoracicvertebraetuberculosiswithgravityabscessParaplegiaThiscomplicationoccursinabout10percentofthecases.Thehighestincidenceofparaplegiaisinlesionsofthethoracicspine.3.Paraplegiaisclassifedinto2types.

Earlyonsetparaplegiaoccuringduringtheactivestageofthedisease.Lateonsetparaplegiaoccurringinpatientswhoselesionhasreactivatedafterlongyearsofquiescence.CompressionofspinalcordRadiologicalfeatures

Lumbarvertebraeosteoclasia

Deformityankylosis

Lateralcurvature

AbscessX-Ray:playanimportantroleinearlydiagnosisoftuberculosisECT:cananearlydiagnosisCT:canprovidetheexactingimagingofbonenecrosis,fragmentandnecrosistissuesMRI:displayabnormalityimaginginthestageofinflammatoryinfiltrationandhelptomadeanearlydiagnosisMRItoobservespinalcordtobecomecompressionorapomorphosis

MRIscanofspinaltumorConservativeTreatmentCompleterestinbedandimprovehisgeneralhealthAntituberculouschemotherapyPeriodicallyassessed.Whenthelesionisquiescent,thepatientisgivenaspinalbraceandmadeambulant.

Thechemotherapyiscontinueduptoatotalperiodof9months.

SurgicalTreatment

Theindicationsforsurgeryinparaplegiaareasfollows;1.Nosignofrecoveryafter3-4weeksofconservativetreatment.2.Paraplegiagettingworseinspiteofconservativetreatment.3.Spasticparaplegiawithsevereanduncontrollablespasmsofthelegs.Anteriordecompressionandspinalfusion:(Hongkongoperation).Throughastandardthorocotomy,theabscessisevacuatedanddebridementdone.Thediseasedvertebralbodiesareexcised(vertebrectomy)andthecordde-compressed.Autologousbonegrafts

areplacedbetweenthevertebralbodiestopromoteanteriorspinalfusion.Case1PathologyexaminationCase2Case3Case4Case5KyphosisTUBERCULOSISOFTHEHIPJOINT

Nexttothespine,thehipjointisthemostcommonsiteforinvolvementbytuberculosis.PathologyPathologicalchangePurelysynovialtuberculosisPurelybonetuberculosis

Furtherdevelopment

TuberculosefocusBreakthroughtojointcavity

WholetuberculosisofjointCartilagedemagePrimaryLesionBoneTuberculosisJointTuberculosisTubercularSinusJointTuberculosisSynovialTuberculosisClinicalfeatures

Painandswellingintheregionofthehipandlimpingaretheusualpresentingsymptoms.

"4"TextStageI(Synovitis):Thediseaseisasynovitiswitheffusionintothecavity.StageII(Arthritis)Thedestructiveprocessspreadstothearticularsurfaces.Coldabscessesappea