脊柱結核

SpineTuberculosis(TB)瞿東濱By:ProfDrQuDongbin南方醫科大學南方醫院脊柱骨科SouthernMedicalUniversityNanfangHospital第1頁SkeletalremainsfromaNeolithicSettlementintheEasternMediterraneanshowprehistorichumans(7000BC)hadTB,andtuberculardecayhasbeenfoundinthespinesofmummiesfrom3000–2400BC第2頁25-4950-99100-3000-910-24300ormoreNoestimateRateper100,000Source:WHO2023.Morbidityrateoftuberculosisin2023

第3頁EstimatedTBincidence,prevalenceandmortality,2023

Incidence1Prevalence2Mortality(excl.HIV)WHOregionNhousands%of

globaltotalRate

per100

000pop3NhousandsRate

per100

000pop3NhousandsRate

per100

000pop3Africa2

80030%

3403

900

450

430

50TheAmericas

2702.9%

29

350

37

202.1EasternMediterranean

6607.1%

1101

000

180

99

18Europe

4204.5%

47

560

63

62

7South-EastAsia3

30035%

1804

900

280

480

27WesternPacific1

90021%

1102

900

160

240

13Globaltotal9

400100%

14014

000

1641

300

191Incidenceisthenumberofnewcasesarisingduringadefinedperiod.

2Prevalenceisthenumberofcases(newandpreviouslyoccurring)thatexistsatagivenpointintime.

3Popindicatespopulation.FromWHO2023data第4頁Tuberculosis(TB,forTubercleBacilli)iscontagious

andairborne.Itisadiseaseofpovertyaffectingmostlyyoungadultsintheirmostproductiveyears.ThevastmajorityofTBdeathsareinthedevelopingworld

1.7millionpeoplediedfromTB(including380000women)in2023,including380000peoplewithHIV,equalto4700deathsaday

TheTBdeathratehasfallenby35%since1990,andthenumberofdeathsisalsodeclining

TBisamongthethreegreatestcausesofdeathamongwomenaged15-44

Therewere9.4millionnewTBcases(including3.3millionwomen)in2023,including1.1millioncasesamongpeoplewithHIV

FromWHO2023data第5頁MycobacteriumTuberculosisacid-fastbacillus第6頁RobertKochfoundTBbacilliin1882Theday,March24,hedeclaredhisfindingsinBerlin,iscelebratedasWorldTuberculosisDayfrom1995202023年攝于柏林Charite醫院第7頁

BacillumCalmette-Guérin,orBCG,forshort（1921）LéonCharlesAlbertCalmette（1863-1933）Jean-MarieCamilleGuérin(1872–1961)第8頁Antibioticchemotherapy:thecornerstonestreptomycin（1946）isoniazid（1951）pyrazinamide（1956）rifampicin（1965）ethumbutol（1961）----first-linedrugsSelmanWaksman第9頁第10頁SongoftheBurialofFlowers------Iholdaburialwhenyoudietoday,Butthere’snotellingwhenIpassaway.爾今死去儂收葬，未卜儂身何日喪？Otherslaughatmethathaveburiedthee,Whowillbetheonethatshallburyme?

儂今葬花人笑癡，他年葬儂知是誰？Theendofspringmakesflowersfallonebyone,It’salsothetimewhenbeautymeetsitsdoom.試看春殘花漸落，便是紅顏老死時。Oncebeautyiscarriedtoitsverytomb,Bothbeautyandflowersperishknowntonone.一朝春盡紅顏老，花落人亡兩不知！FromCaoXueqin

:Thestoryofthestone第11頁SpinalTuberculosisDescribedfirstbyPervicalPottin1782Countsfor3~5%ofTBCountsfor15%ofextrapulmonaryTBCountsfor50%ofskeletalTBCervicalspine5%Thoracicspine25%Lumbarandsacralspine20%第12頁

ClinicalmanifestationssymptomssignspainswellingPathologicalfracturefistulafeverfatigueNightsweatsAppetitelossdisturbancesinusparalysisdeformity第13頁AngularkyphosisParalysis9-year-oldchildtreatedsuccessfullyin1998第14頁Paravertebralabscess第15頁Sinusformationcausedbylumbartuberculosis第16頁DiagnosisofSpineTBsymptoms+signsX-ray/MRI/CTfindingsESR/CRP↑PathologicalfindingsTB-SPOT(+)ClinicalDiagnosisAntituberculouschemotherapytrialsLangerhans’cell第17頁T12L1X-raySandwich-likedestructionNote:pediclemorphology第18頁X-rayParavertebralabscess:Spindle-shapedsofttissuemassNote:spanovertwoormorevertebralbodies第19頁CT-scanParavertebralabscess:spindle-shapedandring-likesofttissuemassNote:deadboneorsequestration第20頁MRI-scanT1W1/T2:low-densitysignalsEnhanced:high-densitysignalsDestructionofadjoiningvertebralbodiesParavertebralabscessSpinalcordcompression第21頁MRI-scan第22頁MRI-scan第23頁Psoasabscess第24頁椎間盤型椎體型椎弓型全椎骨型跳躍型多骨結核型椎管內型腫瘤轉移癌骨髓瘤淋巴瘤炎癥強直性脊柱炎

終板炎

骨質疏松椎體壓縮骨折感染布魯氏菌病

化膿性脊柱炎

真菌第25頁DifferentialDiagnosis:spinemetastatictumoritemsSpineTBmetastatictumorHistorylongShort/quickdevelopmentsymptoms:painbenignpainviciouspainExercise-inducedpainrestpainNonightpainNightpain/nocturnalpainNomedicinestrongpainkillerGeneralstatusGoodappetitesleep……Bad:dyscrasialossofappetitesleepless……LaboratoryexaminationsNoobviousanemia/hypoproteinemiaanemia/hypoproteinemiaX-ray/CT/MRIimportantcontent第26頁intervertebraldisc(discgap)pedicle/posteriorstructures第27頁vertebralbodyvsposteriorstructuresSpinalstructuresaffected第28頁adjoiningvsskippingVertebraeaffected第29頁anteriorp.vsposteriorp.Vertebralbodyaffected第30頁Endplateaffectedinsect-bitevsfracture第31頁ParavertebralmassLongspindle-likeorlocalpeakhill第32頁ringvslocalParavertebralmass第33頁liquidcompositionwithinthemassParavertebralmass第34頁“deadbone”andhardenring第35頁Ifstillconfused?CT-guidedbiopsymetastaticbreastcancer第36頁BedrestFreshairNutrientsSunshineSupportivemanagement

第37頁SpineTBisthegeneralTB-inducedinfectiousdiseaseaffectingthespineConservativemanagement

Regularanti-tuberculouschemotherapyimmobilization第38頁AimsDebridementReleasecompressionofspinalcordandnerves