不典型脊柱结核的临床特点分析

[目的]探讨脊柱结核的一些临床特征,分析其原因,提高对脊柱结核的早期诊断水平.[方法]对本院2006年10月～2010年9月收治的39例脊柱结核患者的临床资料作回顾性研究.[结果]39例脊柱结核患者具有不典型的临床特点:结核菌素全身中毒症状表现不明显;体征以腰腿痛为主,少有后凸畸形;影像学表现在早期常不典型;实验室检查无敏感性、特异性.[结论]脊柱结核患者的临床特点常不典型,应完善实验室和影像学检查,注意随访,提高早期诊断的成功率.     

多椎体结核的影像学诊断价值及手术治疗进展

脊柱结核在全身骨关节结核中发病率最高，占全身骨关节结核50％左右。单椎体结核比较少见，病灶常涉及多个椎体，但多椎体结核在早期诊断中往往被漏诊。近年来，由于影像学的发展，特别是CT、MRI的检查，使多椎体结核的早期诊断及病灶涉及椎体范围有了更明确的证据。在诊断脊柱结核过程中，合理应用X线片、CT、MRI就显得比较重要，可以提高结核病灶的早期诊断水平。     

T-SPOT.TB检测在脊柱结核诊断中的应用

目的探讨结核感染T细胞斑点(T-SPOT.TB)检测在脊柱结核诊断中的应用价值。方法对2012年1月至2014年10月郑州市骨科医院收治的110例疑似脊柱结核病例同时进行结核菌素皮试试验(TST)及T-SPOT.TB检查,其中TST分别采用红肿硬结直径≥5 mm和≥15 mm两种标准,标记为TST 5和TST 15。以临床诊断结果作为标准,对比分析上述检测方法的敏感度、特异度、阳性预测值和阴性预测值。结果 110例疑似脊柱结核患者最终诊断为脊柱结核68例、非脊柱结核42例。TST 5、TST 15和T-SPOT.TB检测的敏感度、特异度、阳性预测值、阴性预测值分别为93%、33%、69%、74%,47%、83%、82%、49%和91%、90%、94%、86%。T-SPOT.TB检测敏感度优于TST 15,特异度优于TST 5,阳性预测值和阴性预测值均优于TST 5和TST 15(P0.05)。结论与TST比较,T-SPOT.TB检测诊断脊柱结核敏感度、特异度均较高,可用于脊柱结核的早期诊断。     

脊柱结核74例诊断分析

[目的]分析脊柱结核的临床特点及影像学表现,提高对本病的诊断水平。[方法]回顾性分析2004年4月～2009年2月收治、经病理检查证实为脊柱结核的74例患者临床资料,总结临床特点及影像学表现在本病诊断中的价值。[结果]根据患者的临床症状及体征在首诊时即考虑脊柱结核并经影像学、病理学检查证实者28例,占37.8%。行X线片检查后诊断为脊柱结核者51例,占68.9%,行CT及MRI检查后诊断为脊柱结核者73例,占98.6%。临床、影像资料齐全,术前仍误诊为脊柱转移瘤1例,占1.4%。[结论]早期的脊柱结核或不典型脊柱结核很难根据临床表现在首诊时即诊断为脊柱结核,影像学检查是该病的主要诊断方法,CT及MRI对于脊柱结核的确诊具有重要价值。极少数诊断困难的病例,可以作介入穿刺检查或者行术中冰冻切片病理检查。     

脊柱结核诊断中的几个问题

目前结核病在全球范围内呈上升趋势，脊柱结核是肺外结核常见部位，占全身骨关节结核的首位，发病年龄以20～30岁的青年为高峰。其中绝大多数为椎体结核，如诊治不及时，极易累及椎管，产生脊髓、神经压迫。因而脊柱结核早期诊断在整个骨关节结核的防治中占有重要位置。现就目前脊柱结核诊断中的几个问题作一讨论。     

脊柱结核诊断数学模型的建立及评价

[目的]建立脊柱结核诊断的数学模型应用于临床诊断,以提高该病的诊断正确率.[方法]收集脊柱结核与非脊柱结核两类病例标本的主要临床观察指标数据,并对数据进行非条件logistic回归分析以及对各指标建立数学方程等统计方法研究.[结果]椎旁或腰大肌脓肿,骨质破坏,血沉,椎间隙变窄,C反应蛋白等是重要的鉴别诊断指标.[结论]本研究所建立的脊柱结核诊断的数学模型判别准确率达88％以上,个体测的Y值临界值拟定为1,Y值≥1倾向于脊柱结核诊断,可以帮助骨科医师在脊柱结核诊断上提供理论公式.     

儿童生长期脊柱结核外科治疗现状及进展

回顾性研究近年来大量儿童生长期脊柱结核外科治疗文献,探讨儿童脊柱结核的特点,分析儿童生长期脊柱结核外科治疗的进展,总结了儿童脊柱结核手术治疗的指征,分析各种脊柱结核手术方法的临床疗效,目前认为前路病灶清除联合前后路植骨融合往往能获得良好的生长率和畸形校正。椎弓根内固定对儿童脊柱结核是安全可行的。早期积极手术,能防治儿童脊柱后凸畸形。微创外科技术是儿童生长期脊柱结核治疗的发展方向。     

脊柱结核的早期诊断和治疗

目的探讨脊柱结核早期的临床表现和影像学特点。方法对19例脊柱结核患者行X线、CT和MRI检查，同时行PPD试验、血沉、胸片、胸部CT和ECT等检查。明确诊断后再进行正规抗结核治疗。结果脊柱结核早期患者全身结核毒性症状并不典型，患者均表现为不同程度的局部疼痛，其中8例患者曾被误诊。CT检查能清晰地显示椎体内较小的溶骨性、虫蚀状改变等骨质破坏灶及其内毛玻璃状高密度的死骨（19例），周围可伴有骨增生硬化带（10例），可伴有椎前软组织肿胀。MRI发现椎体骨炎（19例）及终板破坏，以及骨内小脓肿。早期椎间盘信号正常或高信号为主、椎间隙正常。结论脊柱结核早期患者常表现为局部疼痛，可不伴有典型的结核中毒症状。CT能显示早期微小的脊柱结核病变如骨质破坏、死骨等现象；MRI能清楚显示椎体骨炎、终板和（或）椎间盘的破坏和椎体内小灶骨脓肿。结合CT和MRI两者优点，可较早诊断脊柱结核；从而指导临床尽早进行抗结核治疗，避免漏诊、延迟诊断或误诊带来的不良后果，具有较大临床意义。     

脊柱结核637例的回顾性分析

目的 探讨脊柱结核的诊断和治疗.方法 回顾分析1991年7月～2008年2月收治的637例脊柱结核(腰椎为主)患者的手术治疗资料.结果 术后复发率占7%,无死亡病例,发生脊柱后凸畸形者11例,平均治疗时间6～18个月.根据改良PROLO功能评分,术后疗效优良率93%.VAS评分显示,术前平均7.8分,术后平均2.9分,术后比术前有显著降低.结论 早期诊断、手术与规律性全程抗结核是脊柱结核的治疗原则,延误诊断可能导致严重后果并影响愈后.     

不典型脊柱结核的诊断

目的探讨不典型脊柱结核的误诊原因及诊断方法．方法分析23例不典型脊柱结核患者的临床特征和辅助检查资料。结果不典型脊柱结核具有某些结核的共有特征．X线片、CT、MRI对其诊断有重要意义,手术探查、病理检查可以明确诊断。结论导致误诊的原因主要在于对结核的认识不足及缺乏整体的观点,对有伴随症状的椎体破坏．应将脊柱结核作为主要的鉴别诊断。     

Spinal tuberculosis: a review

Spinal tuberculosis is a destructive form of tuberculosis. It accounts for approximately half of all cases of musculoskeletal tuberculosis. Spinal tuberculosis is more common in children and young adults. The incidence of spinal tuberculosis is increasing in developed nations. Genetic susceptibility to spinal tuberculosis has recently been demonstrated. Characteristically, there is destruction of the intervertebral disk space and the adjacent vertebral bodies, collapse of the spinal elements, and anterior wedging leading to kyphosis and gibbus formation. The thoracic region of vertebral column is most frequently affected. Formation of a 'cold' abscess around the lesion is another characteristic feature. The incidence of multi-level noncontiguous vertebral tuberculosis occurs more frequently than previously recognized. Common clinical manifestations include constitutional symptoms, back pain, spinal tenderness, paraplegia, and spinal deformities. For the diagnosis of spinal tuberculosis magnetic resonance imaging is more sensitive imaging technique than x-ray and more specific than computed tomography. Magnetic resonance imaging frequently demonstrates involvement of the vertebral bodies on either side of the disk, disk destruction, cold abscess, vertebral collapse, and presence of vertebral column deformities. Neuroimaging-guided needle biopsy from the affected site in the center of the vertebral body is the gold standard technique for early histopathological diagnosis. Antituberculous treatment remains the cornerstone of treatment. Surgery may be required in selected cases, e.g. large abscess formation, severe kyphosis, an evolving neurological deficit, or lack of response to medical treatment. With early diagnosis and early treatment, prognosis is generally good.     

The role of polymerase chain reaction in the management of osteoarticular tuberculosis

A dependable method for the rapid diagnosis of osteoarticular tuberculosis has become increasingly important, as routine methods are neither very sensitive nor very specific. The objective of this study is to verify the reliability of polymerase chain reaction (PCR) in the diagnosis and management of osteoarticular tuberculosis. This investigation was a prospective study conducted at the Kasturba Medical College, Manipal, India. Tissue samples of 74 patients suspected of osteoarticular tuberculosis were sent for PCR and histopathologic examination. Taking histopathology as the gold standard, PCR has a sensitivity of 73.07% and a specificity of 93.75% (with 95% confidence interval [CI] 62.97; 83.17).The positive agreement between histology and PCR was 0.693, indicating good agreement. PCR showed a sensitivity of 90% with spinal samples. It has a low false positivity of 13.63%. We conclude that conventional methods are neither sensitive nor specific enough and are also time consuming. PCR is an effective method for diagnosing tuberculosis and antitubercular treatment can be started if PCR is positive, since false-positive rates are very low.     

Spinal tuberculosis: A review

Abstract

Spinal tuberculosis is a destructive form of tuberculosis. It accounts for approximately half of all cases of musculoskeletal tuberculosis. Spinal tuberculosis is more common in children and young adults. The incidence of spinal tuberculosis is increasing in developed nations. Genetic susceptibility to spinal tuberculosis has recently been demonstrated. Characteristically, there is destruction of the intervertebral disk space and the adjacent vertebral bodies, collapse of the spinal elements, and anterior wedging leading to kyphosis and gibbus formation. The thoracic region of vertebral column is most frequently affected. Formation of a ‘cold’ abscess around the lesion is another characteristic feature. The incidence of multi-level noncontiguous vertebral tuberculosis occurs more frequently than previously recognized. Common clinical manifestations include constitutional symptoms, back pain, spinal tenderness, paraplegia, and spinal deformities. For the diagnosis of spinal tuberculosis magnetic resonance imaging is more sensitive imaging technique than x-ray and more specific than computed tomography. Magnetic resonance imaging frequently demonstrates involvement of the vertebral bodies on either side of the disk, disk destruction, cold abscess, vertebral collapse, and presence of vertebral column deformities. Neuroimaging-guided needle biopsy from the affected site in the center of the vertebral body is the gold standard technique for early histopathological diagnosis. Antituberculous treatment remains the cornerstone of treatment. Surgery may be required in selected cases, e.g. large abscess formation, severe kyphosis, an evolving neurological deficit, or lack of response to medical treatment. With early diagnosis and early treatment, prognosis is generally good.     

结核分枝杆菌相关γ-干扰素定量检测在脊柱结核诊断中的应用

目的探讨结核分枝杆菌相关γ-干扰素定量检测(TB-IGRA)在脊柱结核诊断中的应用价值。方法分析44例疑似脊柱结核病例资料,结合最终临床诊断,分为脊柱结核组和非脊柱结核组,计算TB-IGRA、抗结核抗体(TB-Ab)检测、利福平耐药实时荧光定量核酸扩增检测(Xpert MTB/RIF)及病理学检测4种方法诊断脊柱结核的灵敏度、特异度、阳性预测值和阴性预测值,采用kappa一致性检验评估TB-IGRA与TB-Ab检测、Xpert MTB/RIF及病理学检测结果的一致性。结果纳入的44例患者中,确诊或高度怀疑脊柱结核病28例,确诊非脊柱结核16例。TB-IGRA的灵敏度、特异度、阳性预测值和阴性预测值分别为85.7%、68.8%、82.8%和73.3%;TB-Ab检测的灵敏度、特异度、阳性预测值和阴性预测值分别为53.6%、87.5%、88.2%和51.9%;Xpert MTB/RIF的灵敏度、特异度、阳性预测值和阴性预测值分别为68.8%、71.4%、84.6%和50.0%;病理学检测的灵敏度、特异度、阳性预测值和阴性预测值分别为92.9%、100%、100%和88.9%。TB-IGRA与TB-Ab诊断结果一致性较差(κ=0.25),与Xpert MTB/RIF及病理学诊断结果一致性较高(κ=0.68、0.71)。结论TB-IGRA作为脊柱结核的辅助诊断手段,简便、快速,灵敏度和特异度较高,尤其适用于不方便获取病灶组织的患者。     

Treatment of tuberculosis of the spine with neurologic complications

Neurologic complications are the most dreaded complication of spinal tuberculosis. The patients who have paraplegia develop in the active stage of tuberculosis of the spine require active treatment for spinal tuberculosis and have a better prognosis than the patients who have paraplegia develop many years after the initial disease has healed. Neurologic dysfunctions in association with active tuberculosis of the spine can be prevented by early diagnosis and prompt treatment. Prompt treatment can reverse paralysis and minimize the potential disability resulting from Pott's paraplegia. When needed, a combination of conservative therapy and surgical decompression yields successful results in most patients with tuberculosis of the spine who have neurologic complications. The vertebral body primarily is affected in tuberculosis; therefore, decompression has to be anterior. Laminectomy is advocated in patients with posterior complex disease and spinal tumor syndrome. Late onset paraplegia is best avoided by prevention of the development of severe kyphosis. Patients with tuberculosis of the spine who are likely to have severe kyphosis develop (< 60 degrees) on completion of treatment should have surgery in the active stage of disease to improve kyphus.     

Imaging presentation highly manifested as tuberculosis in a case of spinal metastatic carcinoma

Usually the clinical manifestations between spinal tuberculosis (Pott's disease) and metastasis are not characteristic. Nevertheless, their respective imaging presentations are typical and specific, which makes it relatively easier to attain a correct diagnosis. Imaging features of Pott's disease, in general, include narrowing of intervertebral disk space, collapse of vertebral bodies with eventual progression to kyphotic deformity, destruction of the anterior parts of adjacent vertebrae, formation of a large paravertebral abscess, and calcifications or sequestra within the paravertebral abscess. Spinal tuberculosis is usually endemic, especially in Eastern countries. However, the trend of cancer incidence is also increasing in modern society, which makes it difficult to diagnose spinal osseous lesions. This article presents a case of a 45-year-old man with a 9-month history of low back pain. Both computed tomography and magnetic resonance imaging of the lumbar spine supported the initial diagnosis of spinal tuberculosis. However, pathological examination on the excised specimen resulted in the diagnosis of spinal metastatic adenocarcinoma. We suggest that a definitive diagnosis of spinal metastasis or tuberculosis should not be based on imaging alone. Instead, more attention should be paid to atypical imaging presentations. In addition, biopsy is usually necessary for final diagnosis.     

关节镜技术在青少年膝关节结核诊治中的初步应用

目的 总结关节镜技术在青少年膝关节结核诊断和治疗中的经验.方法 2002年6月至2006年12月,对36例诊断为结核,5例不具备结核诊断标准,按滑膜炎待查的患儿采用膝关节镜下清理及抗结核药物治疗,男13例,女28例;年龄7~16岁,平均12.5岁;均有不同程度的膝关节肿胀、轻度疼痛及功能障碍;病史3~14个月,平均4.8个月.随访时利用Lysholm进行问卷调查,同时对其临床资料进行回顾性分析.结果 41例患儿,术后病理共确诊37例,另4例报告为滑膜组织慢性炎症或坏死组织.随访6~58个月,平均43.5个月,所有患膝经关节镜和术后药物治疗均无复发.Lysholm评分75~98分,平均91.4分.6例患儿残留不同程度膝关节活动受限,活动范围70°~110°,其中2例全关节结核伸直滞缺分别为10°和25°.结论 青少年膝关节结核的诊治较为特殊,在病程早期采用膝关节镜下清理、药物治疗结合术后早期康复锻炼的方案具有创伤小、病灶清除彻底等优点,并可最大限度保留膝关节功能,避免外科介入过晚而导致的膝关节融合,是一种较为理想的治疗方法.