Osteoarticular tuberculosis is attributed to an extensive group of extrapulmonary tuberculosis lesions characterized by the duration of the course, extensive destruction of the musculoskeletal system, leading to permanent disability. Tuberculosis most often affects the spine and large joints, mainly in young people and children.
Pathogenesis
The development of osteoarticular tuberculosis occurs with underlying general hematogenic dissemination developing from the primary focus. Mycobacterium tuberculosis enters the bloodstream and into the vascular-rich bone marrow of the vertebral bodies and metaepiphyseal parts of the limb bones.
At the beginning of the disease, foci of the so-called primary tuberculous osteitides are developed in the form of granuloma, which passes the stages of occurrence, development and maturation. At the end of the maturation stage, the focus is stabilized with the formation of an osteal cavern with an insulating wall and caseous or purulent contents. The cavern cavity often contains bony sequestrum. After the focus maturation, the most dangerous period begins - propagation of tuberculous inflammation to adjacent tissues with penetration into the joint or intervertebral discs. Thus, secondary arthritis or discitis is developed, and in case of soft tissue penetration - a hypostatic "cold" abscess.
Further progress of the disease is accompanied by the destruction of cartilage and bones forming the joint, propagation of tuberculous inflammation to adjacent vertebrae. Disfiguring deformities of the spine and joints develop with gross impairment of motor function. The likelihood of fistula formation with the discharge of the "cold" abscess contents, caseous masses and purulence is relatively small. In this case, after the discharge of necrotic masses and the formation of scar tissue, the process subsides. However, this does not indicate full recovery, as relapses of the disease may occur. Its long-term course with periodic exacerbation, detachment of soft tissues, formation of caseous masses and development of paravertebral or para-articular abscesses with extensive contents is most typical.
Tuberculous spondylitis
By the frequency of lesions, tuberculous spondylitis accounts for up to 45% of the total number of patients with osteoarticular tuberculosis and occupies a special place in phthisiological orthopedics due to the severity of clinical manifestations, difficulty of treatment and severe consequences.
Clinical manifestations
The clinical presentation of the disease is characterized by a certain pattern - a change of phases, depending on pathoanatomical changes:
- prespondylitic phase (development of primary osteitis in the vertebral body);
- spondylitic phase (destruction of the vertebral body, the process propagation to adjacent discs and vertebral bodies with manifestation of specific symptoms);
- postspondylitic phase (orthopedic and neurological consequences at the end of the tuberculous process evolution).
Prespondylitic phase
The initial period of tuberculous osteitis is manifested primarily not by local but by general symptoms. The patient's behavior changes. Children become restless for no reason, capricious, less mobile, lose appetite, weight. In adults, rapid fatigue, constrained movements due to discomfort in the spine or lumbago-type pain are observed. These signs are more prominent after physical exertion or sudden movements.
The results of patients' clinical examination are also scarce during this phase. Visually, a slight flattening of the physiological spinal curvatures, a reduced range of motion may be noted. A slight increase in the tone of the extensor muscles is noted on palpation. The load on the spinous processes and paravertebral points is moderately painful but without clear pain localization. The sign of axial load is negative or characterized by mild pain in the area of the affected vertebral segment. Pathology is not detected in the neurological status.
Thus, the clinical diagnosis of tuberculous spondylitis in the prespondylitic phase is extremely difficult due to the scarcity of manifestations and requires dynamic observation using modern instrumental examination methods.
Spondylitic phase - onset
The main clinical symptoms of the spondylitic phase are pain and impaired mobility of the spine with the development of characteristic deformities.
At the beginning, the pain is distinctly local, strictly in accordance with the affected vertebral segments, permanent and increases with movement and physical exertion. Nocturnal pain is typical. Acute pain during deep sleep, associated with muscle relaxation and higher mobility in the affected vertebral segments, is characteristic. The patient screams in pain, wakes up. At this point, muscle protection is activated, the pain subsides, and the patient falls asleep again. The described nature of pain is mainly observed in children. The pain syndrome is accompanied by the development of a protective myogenic contracture, an increase in muscle tone is observed visually and on palpation (Kornev sign).
The amplitude of spinal motion is sharply reduced. Patients bend with effort, cannot adopt a сat-сow pose. The twist is performed by the whole body, "wolf-like". When the thoracolumbar spine is affected, femoral-lumbar rigidity is often present - there is no movement in hip joints and lumbar spine during an attempt to lift straight legs. Patients prefer to sit with their backs against the chair with support on their hands.
Palpation of spinous processes and paravertebral points reveals distinct local soreness. The interstitial spaces are preserved, but their palpation is also painful at the lesion level. Symptoms of intoxication occur, along with hyperhidrosis, subfebrile body temperature. Fatigue, weakness, loss of appetite are aggravating. However, the defining symptoms are pain and hypodynamia.
Spondylitic phase - peak
The patient's general condition progressively declines, intoxication manifestations increase, hyperthermia reaches 40°. The pain becomes unbearable, so patients cannot walk, and sometimes even sit. In bed, they hardly find a painless pose. Visually, a pronounced Kornev sign, appearance of local spinal deformities such as spinous process protrusions (spondylitic hump) may be noted. Palpatory local soreness persists, especially with load on the spinous processes, expansion of interstitial spaces occurs. There may be symptoms of spinal cord and root compression in the neurological status up to deep paresis and paralysis; the degree of neurological disorders is directly related to the severity of the spondylitic hump and peridural abscesses. With a prolonged course of spondylitis, adjacent vertebrae may be involved in the destructive process. Kyphosis becomes more severe, and hypostatic abscesses - more extensive. Changes in peripheral blood are characteristic - accelerated ESR (up to 50-60 mm/h), moderate leukocytosis with neutrophil shift and eosinophilia.