BEKHTEREVA DISEASE (V. M. Bekhterev; Russian neurologist and psychiatrist, 1857 — 1927; synonym: Shtryumpellya — Bekhtereva — Mari a disease, an ankylosing spondylarthritis, a rhematoid spondylitis) — a general inflammatory disease of connecting fabric with preferential defeat of the joint and copular device of a backbone, and also peripheral joints and involvement in process of internals (heart, an aorta, kidneys). The disease has tendency to the chronic, progressing current with development of ankiloz.
For the first time under the name «oderevenelost of a backbone with a curvature» V. M. Bekhterev in 1892 gave the clinical description of a disease. In 1897 Mr. A. Striimpell described this disease, using the term «chronic ankylosing inflammation of a backbone and sacroiliac joint», and in 1898 P. Marie described one of forms of a disease — damage of a backbone with obligatory involvement in process of coxofemoral and shoulder joints, having called it a rizomelichesky spondylosis.
The disease affects preferential men (90%) at the age of 20 — 40 years, meets often (about 1 case for 1000 of the population).
Etiology and pathogeny
Aetiology and B.'s pathogeny. completely are not found out. Especially the importance in development of a disease is attached infectious allergic to a factor, heredity, a spine injury. The course of a disease is promoted by the overcooling raising a susceptibility to any focal infection which is available in an organism. Often the disease is preceded hron, by an infection of urinogenital bodies (e.g., hron, a nonspecific urethritis, prostatitis).
At 70 — 80% of sick B. the histocompatibility antigens of HLA-27 come to light that has diagnostic and predictive value.
Inflammatory process usually begins with sacroiliac joints, unevenly and slowly extending to overlying departments of a backbone. In response to inflammatory changes there is a reflex spasm of juxtaspinal muscles. This muscle tension in turn strengthens pains, causes disorder of blood supply. Further inflammatory process in intervertebral joints gradually leads to development of an anchylosis. At the same time there is ossification of the copular device and quite often degenerative and dystrophic changes of hyaline plates and bodies of vertebrae. Pathological process can
sometimes begin with damage of peripheral joints (coxofemoral, knee) with the subsequent damage of a backbone. At the same time process in peripheral joints proceeds as inflammatory at pseudorheumatism (see).
Classical descriptions of pathomorphologic changes at B. are based on studying of section materials of late stages of a disease. By means of a research of puncture biopsies it was succeeded to study a patomorfologiya of process at various stages of its development.
For B. early defeat intervertebral, costal pozvonkovykh joints and lumbosacral joints in which the phenomena of a synovitis, a chondritis and an extraarticular osteit are noted is characteristic. The earliest changes are found in a synovial membrane in the form of focal perivascular infiltration by lymphocytes and plasmocytes. Further in synovial membranes growth of the granulyatsionny fabric which is gradually filling joint space and destroying a cartilage (fig. 1) is observed. Later granulyatsionny fabric forms a basis for development of fibrous (fig. 2) and a bone anchylosis.
The bone tissue is also exposed to changes: joint surfaces become uneven, there are centers of destruction, the subchondral osteosclerosis develops. In an early stage of a disease pathological changes in intervertebral sheaves come to light (at first in a lobby longitudinal), emergence of signs of ossification of the copular device of a backbone is characteristic.
In late stages after ossification costal pozvonkovykh joints would come characteristic of B. ossification of intervertebral cartilages (fig. 3 and 4). In regional plates of bodies of vertebrae the osteosclerosis develops, intervertebral cartilages are considerably narrowed, losing elasticity and being replaced with a rough fibrous and bone tissue with development of bridges at the edges (syndesmophytes), and then and a full synostosis.
In the final of a disease the rachis takes a form of a curved inelastic bamboo stick, in the functional relation similar to a long tubular bone. In bodies of vertebrae the progressing atrophy of beams with the phenomena of osteoporosis is observed. The backbone becomes brittle and is easily injured. In attempt to unbend it on a corpse even at use of insignificant effort there are changes, especially in cervical department.
At B. also damages of internals are observed. Damages of heart can be in the form of myocarditis, an endocarditis, and in some cases in the form of an adhesive pericarditis. Deyvidson (P. Davidson, 1963) found on section symptoms of an endocarditis and myocarditis in 24% of cases. Also the mesaortitis and damage of large arteries of an upper half of a trunk, sometimes with development of an aortic arch syndrome are described (see. Takayasu syndrome ).
Thus, pathomorphologic changes at B. generally remind those at rhematoid, arthritis (see), but process is localized preferential in slow-moving joints; at the same time tendency to bystry ossification of the copular device and cartilaginous tissue of a backbone is characteristic.
A clinical picture
Depending on localization of pathological process would distinguish several forms B.
1. The central form — defeat only a backbone: a) kyphosis of chest department of a backbone, hyperlordosis of cervical department (kifozny look); b) lack of a lordosis of lumbar department and a kyphosis of chest department of a backbone, spin of the patient gets a form of a board (a rigid look).
2. A peripheral form — except a backbone, peripheral joints are surprised: a) defeat humeral and hip joints (rizomelichesky look); b) damage of peripheral joints; c) damage of joints of brushes (Scandinavian look).
Stages of a disease are distinguished according to X-ray inspection: The I stage — existence of signs of a sacroileitis; The II stage — signs of an anchylosis of a sacroiliac joint; The III stage — existence of syndesmophytes in any department of a backbone.
In most cases B. begins imperceptibly, with defeat of lumbosacral and (or) cervical departments of a backbone. Quite often the beginning of a disease matches the postponed acute infection (flu, quinsy), overcooling.
Among early symptoms there are damages of a backbone — pain like an ischialgia or the lumbar ishialgias irradiating in hip joints and to the inguinal area; the lumbosacral department of a backbone of pain arises at an exercise stress, at long stay in one situation or in rest, pains can sometimes be only at an exercise stress, especially during the carrying in one hand of a big load; emergence of pains is frequent it is connected with a weather changing. At some patients pains in the field of calcaneuses, heelstrings, temporary various joint pains (humeral, coxofemoral, knee), subfebrile temperature are noted. There can be complaints to increased fatigue, weakness, loss of appetite, weight loss. Sometimes complaints are so insignificant that the disease is diagnosed only several years later after its beginning.
At survey if there are no changes of peripheral joints, deviations are not noted. The bearing of the patient is normal, the movements are kept, and only in the presence of the expressed pains gait becomes sparing, held down.
At a palpation morbidity in the field of sacroiliac, grudino-clavicular, grudino-costal joints, and also in places of an attachment of sinews is defined. In these cases it is necessary to check symptoms which allow to reveal damages of sacroiliac joints, napr, Kushelevsky's symptom (by simultaneous pressing by the doctor crests of both ileal bones of the patient notes pain in the field of sacroiliac joints).
When the chest department of a backbone is involved in pathological process, the intercostal neuralgia, girdle pains in a thorax amplifying at a deep breath, cough or descent on a ladder, and also pain at the level of a costal pozvonkovykh of joints from two parties are characteristic. Sometimes pains irradiate to the area of heart, stomach, kidneys. Weight loss is often observed, especially at the expressed pain syndrome.
In a late stage of a disease pathological process extends to all departments of a backbone. The pain syndrome which was less expressed however constant, especially at the movements, an exercise stress. Sharply working ability of patients decreases, they have short wind, especially after food as the respiratory excursion of a thorax decreases owing to the inflammatory phenomena, and then and an anchylosis costal pozvonkovykh joints.
At an objective research change of a bearing of the patient attracts attention. The kyphosis or kyphoscoliosis of chest department of a backbone is most often observed (see. Kyphosis ), hyperlordosis of cervical department, smoothness of lumbar lordosis (see). The expressed atrophy of direct muscles of a back takes place: the patient moves, widely placing legs, making the kachatelny movements by the head. For identification of a pain syndrome the following tests are used: Zatsepin's test — during the pressing at the place of an attachment X, XI, XII edges to vertebrae appear pains in connection with existence of an inflammation in a costal pozvonkovykh joints; Vershchakovsky's test — in attempt to deepen a brush in an interval between costal edge and a crest of an ileal bone is noted the sharp resistance of muscles of a stomach and back because of existence of inflammatory process in true joints of a backbone.
In this stage of a disease restriction of an excursion of a thorax, reduction of vital capacity of lungs, V. R. Ott, P. Schober's positive symptoms is noted. Ott's symptom is defined as follows: at the patient who is in vertical position note two points — at the level of VII of a cervical vertebra and on 30 hardly from top to bottom from it. Then the distance between the specified points is repeatedly measured at the maximum bending of a trunk forward and down; at healthy this distance equals 34 — 35 cm, and at sick B. it sharply decreases or remains equal 30 cm. For check of function of lumbar department of a backbone use P. Schober's symptom. At the patient in vertical position note two points — at the level of V of a lumbar vertebra and on 10 cm up from it. At the maximum bending forward at healthy faces this distance increases by 4 — 5 cm, and at sick B. changes a little.
When pathological process occupies cervical department of a backbone, pains at the movements of the head are characteristic, mobility in this department is limited, there can come the full immovability — the neck is fixed in the provision of an inclination forward, the head is hung down, the chin touches a breast. The phenomena of occipital or humeral neuralgia, disturbance of a pupillary test, cordial activity, attacks of suffocation are sometimes observed. In some cases the cervical department of a backbone is surprised in an initial stage of a disease, and within several years in it syndesmophytes can be formed. Such patients of pain have hl. obr. at the movement or at night as a result of stay long time in one situation. At a palpation morbidity in the field of occipital poles and muscles of a neck is defined.
It is known that approximately at 75% of patients, except a backbone, also peripheral joints are surprised.
The sequence of damage of a backbone and joints is various. In one case damage of joints of extremities can precede damage of a backbone; in another — develops after damage of a backbone; in the third simultaneous damage of both joints, and a backbone is observed; at last, patients meet the isolated damage of a backbone (25-30%).
To-rogo difficult to establish any monoarthritis or an oligoarthritis, an origin, can cause suspicion as primary clinical symptom of B. Most often coxofemoral, knee joints are surprised. Damage of other joints — talocrural, elbow, radiocarpal — in the form of an arthralgia and typical arthritis with changes of a bone tissue is less often observed. The number of the affected joints at the same patient can change from mono - to polyarthritises. In one joints restrictions of mobility, in others — ankiloza etc. are observed. Flexion contractures meet in coxofemoral, knee more often, is more rare — in other joints.
Process of an ankilozirovaniya happens preferential in hip joints, as a rule on both sides.
At B. along with damage of a backbone and joints other bodies and systems can be involved in pathological process.
Damage of the autonomic nervous system is often noted: pallor of integuments, the increased perspiration, a resistant dermographism, a hypertrichosis, fragility of nails. From mentality the acrimony, tearfulness, decrease in working capacity, a sleep disorder is stated, there can be a depression.
It is possible to find these or those changes in muscles in the prevailing most of patients (direct muscles of a back, trapezoid, muscles of a hip). The mialgiya, muscular contractures arising spontaneously or connected with a pain syndrome are usually observed. Further the atrophy of muscles develops.
Damages of internals are noted seldom. Aortites meet development of insufficiency of aortal valves, is more rare — perikardita, myocardites. In hard cases dystrophic changes of a muscle of heart which sometimes lead to development it hron, insufficiency can be caused by the general exhaustion.
Damage of lungs at B. — exclusively unusual occurrence, however disturbance of ventilating function of lungs comes early. Sometimes at B. there can be renal colic. As well as at a pseudorheumatism, quite often in an early stage of process signs of an amyloidosis of kidneys which in most cases develops at bystry progressing of a disease come to light.
Damages of eyes are often observed: the uveitis can lead to a phacoscotasmus, is more rare to an opacity of the vitreous body, development of a synechia can serve as the reason of glaucoma. It is established that B.'s harbingers. irites, iridocyclites and episclerites, resistant to usual methods of treatment, are. Approximately at 2 — 11% of patients eye symptoms appear for several years prior to development of pathological process in a backbone and joints.
the General clinical blood test reveals acceleration of ROE in 50 — 60% of cases. But at the central form of a disease of ROE for many years can remain normal.
For specification of activity of inflammatory process definition of a number of biochemical indicators in blood serum can matter: content of seromucoid, fibrinogen, difenilaminovy test, test on identification of the S-reactive protein. For B.'s diagnosis., especially at early stages of a disease, a certain value has detection of antigen of histocompatability of HLA-27.
The rhematoid factor characteristic of a pseudorheumatism would meet at B. only when peripheral joints are involved in pathological process.
In most cases characteristic radiological signs of B. come to light only 2 years later after the beginning of a disease, however precursory symptoms of a sacroileitis can be found in 3 — 4 months. As a rule, process extends kaudokranialno, but defeats also meet other distributional pattern (e.g., from upper lumbar part from top to bottom).
The most valuable radiological sign is damage of joints of intervertebral arches, i.e. polyarthritis with initial localization in so-called small (back) joints. These changes in combination with changes of sacroiliac joints give the chance to timely make the diagnosis. Emergence of syndesmophytes («brackets») bordering intervertebral disks (fig. 5) is connected with calcification and ossification of fibrous rings of intervertebral disks and would be an important diagnostic character of B., however in most cases this sign develops later, than changes in sacroiliac joints. It is important to mean that typical coronoid osteophytes (signs of the deforming spondylosis) of any relation to B. have no. They are observed only in cases when B. develops against the background of already existing degenerative and dystrophic damage of a backbone. The signs of decrease in height of intervertebral disks characteristic of intervertebral osteochondrosis would be observed only in late stages of B. At early stages this sign either is not expressed at all, or expressed slightly.
Initial changes in sacroiliac joints are expressed by a subchondral osteosclerosis, roughness of joint contours, expansion of cracks of a joint. In the subsequent there is a narrowing of joint cracks. The final of process in sacroiliac joints is their partial or full anchylosis.
In true «small» joints of a backbone blurring of subchondral plates is noted, then there is a narrowing of cracks (fig. 6), and eventually joint cracks disappear and the bone ankilozirovaniye appears. At the same time, unlike arthrosis (see), the sclerosis and increase in the sizes of joints at the expense of regional osteophytes, increase in length of joint cracks, formation of neoarthroses of tops of joint shoots with the basis of arches of vertebrae is not observed. Syndesmophytes come to light without decrease in height of disks in the beginning, they can not unite to bodies of vertebrae, but then there is their spayaniye with corners of bodies of vertebrae. Further longitudinal ligaments of a backbone, both front, and back (fig. 6) ossify.
In B.'s outcome. formation of ossifying syndesmophytes gives to a backbone a type of a tubular bone. Disks fibrozirutsya and obyzvestvlyatsya. In hard cases also interspinal and nadostisty sheaves, sheaves costal pozvonkovykh joints with an ankilozirovaniye of the last ossify. Mobility of edges disappears. There can be similar defeats of grudino-clavicular joints, and at women of a pubic symphysis. At defeat of hip joints the subchondral sclerosis (seldom destructive changes), narrowing of a joint crack is observed. Feature of damage of the specified joints — rapid development of an anchylosis. At defeat of knee joints late there are bone changes and exclusively seldom the anchylosis develops.
Technique of X-ray inspection at B. it is connected with need of specification of a condition of sacroiliac joints, joints of arches of vertebrae, fibrous rings of disks if it is necessary — states pubic, grudino-clavicular joints and large joints.
Usually at suspicion on B. it is necessary to make a X-ray analysis of sacroiliac joints in a straight line and two slanting projections (at an angle 45 °), joints of arches of vertebrae of lumbar department in the same three projections, bodies of vertebrae in direct and side projections. Four projections are required also for cervical department (direct, side and two slanting at an angle 20 °).
For identification of a condition of joints of arches of lumbar vertebrae and sacroiliac joints the layer-by-layer research is useful. Optimum radiological information at the same time can be obtained on tomograms in projections at an angle 45 °.
At differential diagnosis it must be kept in mind other processes with a similar clinical picture (in particular, brucellous sacroileites and syndesmophytes, ossifying degenerative ligamentoz, local infectious osteochondrites). Seldom observed alkaptonuria also leads to an anchylosis of vertebrae as a result of adjournment of a pigment in intervertebral disks with the subsequent their sklerozirovaniye.
B.'s Diagnosis. in a late stage does not represent difficulty. However the early stage of this disease in most cases is not diagnosed since has a scanty clinical picture, proceeds quite often atypically, asymptomatically. The diagnosis in an early stage can be made on the basis of existence of pains in lumbosacral department within more than 3 months, pains and rigidity in chest department of a backbone, damage of grudino-costal, grudino-clavicular joints, morbidity in the field of calcaneuses, in places of an attachment of sinews, existence of an iritis, iridocyclitis, acceleration of ROE, signs of a sacroileitis on the roentgenogram. It is also necessary to consider Kushelevsky, Zatsepin, Ott, Shober's symptoms, restriction of an excursion of a thorax, etc.
At defeat of all departments of a backbone would develop characteristic of B. changes: a kyphosis of chest department, a smoothness of a lumbar lordosis, an atrophy of direct muscles of a back, sharp restriction of mobility of a backbone, change of a bearing — «a pose of the applicant», a doskoobrazny shape of a back.
When the disease begins with damage of peripheral joints, it is necessary to consider that for B. defeat first of all of coxofemoral and knee joints, arthritis at the same time recuring with the high-quality course and a long absence of bone changes on the roentgenogram is characteristic.
The differential diagnosis
Difficulties in differential diagnosis arise at an early stage of a disease, when there is no a bright clinical picture and there are no characteristic changes on the roentgenogram. In this stage first of all it would be necessary to otdifferentsirovat B. from dystrophic damage of a backbone (see. Spondylosis ), a cut develops preferential after 30 — 40 years. Pains arise or amplify after an exercise stress at the end of the working day, restriction of the movement is caused by the expressed pain syndrome and development of secondary radiculitis.
X-ray inspection at dystrophic process can reveal characteristic changes of hl. obr. in chest department of a backbone, while at B. early changes can be found in the field of sacroiliac joints.
Often damages of peripheral joints precede damage of a backbone therefore it would be necessary to distinguish an initial form B. from pseudorheumatism (see). Of a pseudorheumatism which develops at women (75%) more often it is characteristic: existence of constraint in joints in the mornings, their symmetric defeats (preferential joints of hands), permanent changes of joints with the subsequent bystry development of a muscular atrophy, contractures, existence of rhematoid small knots, a rhematoid factor in blood, early radiological changes.
It is especially difficult to otdifferentsirovat B. from a disease of Reuters (see. Reuters disease ) if the last develops after an urological infection and is not expressed by a classical triad (arthritis, an urethritis and conjunctivitis), and shown by one or two of the specified symptoms together with early changes in sacroiliac joints. Usually the disease of Reuters begins with sharp fervescence, deterioration in the general state, the expressed inflammatory changes in joints. In these cases differential diagnosis does not represent any difficulties. However the classical form of a disease of Reuters, according to some authors, occurs only at 25% of patients. At other patients the listed symptoms arise gradually and in various time therefore at a single research of the patient it is possible to note only one or two symptoms. Symptoms of conjunctivitis or an urethritis remain of several days till several o'clock. It is necessary to emphasize that at the patients having a disease of Reuters damages of a mucous membrane of an oral cavity, genitalias, integuments, nails are often observed.
Defeat of one coxofemoral or knee joint, especially at an early stage of B., sometimes it is necessary to differentiate with tubercular arthritis (see. Arthritises ). At tubercular arthritis the morphological changes found at a biopsy of synovial membranes and also results of a bioassey (infection of a Guinea pig with joint liquid) can be specific characters. Besides, the pulmonary tuberculosis is found in patients with tubercular damages of joints in 50% of cases. Pleurisy, an adenopathy, especially cervical limf, nodes, sometimes with formation of fistulas, can also play an important role at diagnosis. In an initial stage of tubercular damage of joints of change on the roentgenogram do not come to light. Further there are regional destructions, roughness of surfaces and later cold abscess. The spinal tuberculosis, as a rule, has character of local damage of two or several vertebras.
Forecast depends on a form, a stage of a disease and timeliness of the begun treatment. Usually concerning working capacity the forecast adverse. Concerning life of programs noz worsens in cases of defeat of visceral bodies, especially kidneys.
Philosophy of treatment of sick B. are as follows: 1) timely treatment by antirheumatic means; 2) preservation and recovery of function of a backbone and joints.
The good medical effect renders antiinflammatory drug — Indocidum and other drugs of this group (see. Indometatsin ). Comparing results of treatment by Indocidum to results of treatment by other antirheumatic means, most of authors came to a conclusion that this drug renders the best effect, however its intolerance is possible.
At damage of internals the symptomatic treatment is added. The satisfactory result is yielded by drugs of pyrazolon group (Butadionum, Rheopyrinum, Pyrabutolum, etc.). Some authors consider that the specified means have specific effect. Therefore they appoint drugs of pyrazolon group for the purpose of differential diagnosis (improvement would testify to B.). For treatment of visceral defeats at B. apply also corticosteroids (Prednisolonum, Triamcinolonum, dexamethasone, etc.). It is better to carry out hormonal treatment by small doses in combination with antirheumatic means.
Ortopedo-hirurgichesky treatment at B. apply generally at ankiloza of hip joints. More favorable results at such patients are observed after operation of an alloplasty — full replacement of a hip joint with a metal endoprosthesis. For this purpose the Soviet orthopedists with success use an all-metal endoprosthesis of a hip joint from titanium alloy of an original design of K. M. Sivash. Operation of an osteotomy of a backbone in various modifications is applied to correction of permanent deformation of a backbone at a kyphosis. Operative measure of character of corrective osteotomies (see) and artificial ankylosis (see) has the subordinated value. At its performance for the purpose of shortening of terms of an immobilization of the operated lower extremity the method metal or compression is used osteosynthesis (see).
For the prevention of development of various deformations systematic occupations by physiotherapy exercises, massage are recommended.
The exercises strengthening muscles of a back and breathing exercises are especially important. In hard cases the gymnastics is made in a lying and sitting position. In the presence of the shift of separate vertebrae extension with the subsequent temporary immobilization is reasonable. Patients are recommended to sleep on a firm, equal bed without pillow. For the purpose of creation of a comfortable position it is necessary to use soft rollers under a nape. Also swimming in special pools with water temperature not less than 24 ° is recommended. As well as at rheumatic diseases, at B.'s treatment. the fiziobalneoterapiya is of great importance. Ultrasound and fonoforez a hydrocortisone, the diadynamic and harmonic modulated currents paravertebralno and are recommended for the affected joints, the general hydrosulphuric, chloride, sodium and radonic bathtubs, a sanatorium therapy (Pyatigorsk, Sochi, Nalchik, Mendzhi, etc.). To Fiziobalneolecheniye it is shown in the absence of visceral defeats.
Important not only use of a stationary, out-patient and resort therapy, but also use of the principles of medical rehabilitation of the patient (see. Rehabilitation ).
Bibliography: Astapenko M. G. and Pikhlak E. G. Diseases of joints, page 176, M., 1966, bibliogr.; Bekhterev V. M. Oderevenelost of a backbone with its curvature as a special form of a disease, the Doctor, t. 13, page 899, 1892; N. K. Ankiloziruyushchy spondilartroz (spondilartrit) Residents of Perm, Mnogotomn. the management on a stalemate. annate., under the editorship of A. I. Strukov, t. 6, page 329, M., 1962; Chepy V. M. K to diagnosis of various options of a disease of Bekhterev, Vopr, revm., No. 2, page 55, 1972; Davidson P. and. lake of Cardiac and aortic lesions in rheumatoid spondylitis, Proc. Mayo Clin., v. 38, p. 427, 1963; E m m - rich R. Chronische Krankheiten des Bindegewebes, Lpz., 1961, Bibliogr.; F i 1 - 1 about 1 M. Les coxites de la spondylarthrite ankylosante, Vie m6d., t. 51, p. 3677, 1970; Fores tier J., Jaqueline F. e t Rotes-Quirol J. La spondylarthrite ankylosante, P., 1951; Marie P. Sur la spondylose rhizom61ique, Rev. M£d. (Paris), t. 18, p. 285, 1898; About t t V. R. Zur klinischen Stellung der Spondylitis ankylo-poetica (Morbus Strumpell — Marie — Bechte-rew), Z. Rheumaforsch., Bd 18, S. 14, 1959, Bibliogr.; O t t V. R. u. W u r m H. Spondylitis ankylopoetica, Darmstadt, 1957; Strumpell A. Lehrbuch der speziellen Pathologie und Therapie der inneren Krankheiten, Bd 2, Lpz., 1884; it, Bemerkungen uber die chronische ankylosierende Entziindung der Wirbelsaule und der Hiiftgelenk, Dtsch. Z. Nervenheilk., Bd 11, S. 338, 1897.
Radiodiagnosis — Reyn6erg S.A. Radiodiagnosis of diseases of bones and joints, t. 2, page 540, M., 1964, bibliogr.; T and of e ρ I. L. and Dyachenko V. A. Radiodiagnosis of diseases of a backbone, page 188, M., 1971, bibliogr.; In about with h e r J. E. W. Die Wirbelsaulentuberkulose und ihre Differentialdiagnose, S. 122, Stuttgart, 1952.
L. T. Pyay, V. M. Chepoy; M. I. Panova (injuries.), N. K. Permyakov (stalemate. An.), I. L. Tager (rents.).