From Big Medical Encyclopedia

SPONDYLITIS (spondylitis; Greek spondylos a vertebra + - itis) — the general name of inflammatory diseases of a backbone, preferential infectious origin, a characteristic sign to-rykh is primary destruction of bodies of vertebrae with the subsequent deformation of a backbone. The separate group C. is made by inflammatory diseases of joints of a backbone — spondylarthrites (see). On etiol. to the principle S. subdivide all on specific and nonspecific. The ground mass of specific S. is made by a spinal tuberculosis. Enter into the same group actinomycotic, brucellous, gonorrheal, syphilitic, typhus and nek-ry other types of S. K nonspecific S. refer damages of a backbone pyogenic flora (hematogenous purulent S.), and also rhematoid S. (see. Bekhtereva disease ).

Tubercular spondylitis

Tubercular spondylitis (spondylitis tuberculosa, ustar. the synonym a caries of a backbone) is the most common form of S., in this regard the term «spondylitis» in practice is usually connected with a spinal tuberculosis (see. Tuberculosis extra pulmonary, tuberculosis of bones and joints ).


Tubercular S. was known still in the ancient time, however the first scientific description of the basic a wedge, S.'s symptom — a hump — is made in 1779 by P. Pott, by name to-rogo a disease was called long time. A. E. Voskresensky in the monograph «Tubercular Disease of a Rachis» gave the first detailed description of a clinical symptom complex of S. in 1848. Morfol. S.'s communication with tuberculosis is revealed in the first half of 19 century by R. Laennek, J. Rust and R. Virkhov, and their etiological community is established after opening in 1882 by Koch of mycobacteria of tuberculosis.

Prior to the beginning of 20 century the dominating direction in tubercular S.'s treatment was conservative, issued in a certain system under the influence of O. Rollye, F. Keniga, E. Lekse-r, P. I. Tikhov, N. A works. Velyaminova, T. P. Krasnobayev, etc.

The separate attempts of operative measures made for the purpose of elimination of complications of S. (abscesses, fistulas, paralyzes, humps) led to purulent complications and generalization of tubercular process. It was a cause of failure from operational treatment of tubercular S. for long time. Only operation of back was carried out spondylodesis (see), offered for immobilization of the struck segment of a backbone and not including intervention on bodies of vertebrae. The greatest contribution to development of operational methods of treatment of S. at various stages was made by P. G. Kornev, V. D. Chaklin, Ya. B. Yudin, K. A. Palgov, etc.

Statistics. Among all localizations of a tuberculosis of bones and joints of S. makes apprx. 40%. Most often the chest department of a backbone is surprised. Men are ill tubercular S. slightly more often than women. Till rather recent time children and teenagers were the main contingent among patients with tubercular S. Now numerical dominance of adults among initially revealed patients is noted, and their considerable part is the share of advanced and senile age. It testifies to the general tendency of a tuberculosis of bones and joints to «postareniye».

The pathogeny

Tubercular S. arises owing to a hematogenous drift of mycobacteria of tuberculosis in the spongy substance of vertebrae differing in plentiful blood supply more often. Much less often it arises limfogenno or kontaktno — owing to tubercular lymphadenitis or pleurisy. Preferential bodies of vertebrae are surprised, is much more rare patol. process develops in arches and shoots of vertebrae. In tubercular S.'s development a role of a provocative factor it is in the presence hidden the current initial forms of a disease the injury, and also various superinfections reducing the general and local resistance of an organism plays.

Pathological anatomy

Pathomorphologic changes at tubercular S. begin with emergence and development of primary bone tuberculous focus (see Tuberculosis extra pulmonary, a tuberculosis of bones and joints). The center is surrounded by the reactive nonspecific changes conducting to its otgranicheniye. The necrotic mass (caseoses) which is formed as a result of an inflammation fill the center of destruction in a body of a vertebra. Progressing of tubercular process leads to destruction of compact substance of a body of a vertebra and distribution of tubercular process out of its limits. At the same time in soft tissues cold (congestive) abscesses can be formed (see. Natechnik ).

Fig. 1. The diagrammatic representation of some ways of distribution of tubercular process of a body of a vertebra at a tubercular spondylitis: and — through a front body wall of a vertebra (the arrow specified prevertebral abscess under a front longitudinal ligament of a backbone); — through a back body wall of a vertebra (1 — the abscess under a back longitudinal ligament of a backbone squeezing a spinal cord; 2 — a spinal cord); in — through an intervertebral disk; affected areas of vertebrae are designated in black color.
Fig. 2. Macrodrug of a part of chest and lumbar departments of a backbone with surrounding fabrics at a tubercular spondylitis: shooters specified spherical juxtaspinal abscesses, so-called swallow's nests.

Various ways of distribution of tubercular process of primary center through front, back and side body surfaces of a vertebra (an extra disk way), and also through an intervertebral disk (an intra disk way) are possible. The process extending in the extra-disk way leads to extensive destructions of vertebrae. Breaking through a front surface of a body of a vertebra, pus otslaivat a front longitudinal sheaf, spreads under it, forming prevertebral abscess (fig. 1, a), also causes contact damage of other vertebras, a so-called superficial caries. Prevertebral abscesses depending on the direction of distribution of pus cause ascending or descending periostitis (see). At break of the center under a back longitudinal sheaf usually arise nevrol. the disturbances caused by hypostasis spinal cord (see), a prelum its pus (fig. 1, b), the sequesters acting kzad as the remains of the destroyed vertebrae, a so-called wedge of Urban, a thickening of a meninx owing to pachymeningitis (see). Character nevrol. disturbances is defined by localization of process and the mechanism of a prelum of a spinal cord. At break of pus through side surfaces of a body of a vertebra juxtaspinal abscesses are formed, to-rye extend preferential in the parties from a backbone and therefore to a lesser extent kontaktno affect bodies of the next vertebrae. In chest department of a backbone such abscesses can take the form of a spindle, hemispheres, lentils, spheres, or so-called swallow's nests (fig. 2). In underlying departments — lower chest, lumbar and lumbosacral — abscesses extend on the muscles which are attached to the affected vertebras. So, from lumbar department pus can spread to the ileal area of N further — through muscle compartment to a hip. From lumbosacral department the most typical way of distribution on the course of pear-shaped muscles to a rump. At an intra disk way process extends vertically in the direction of an intervertebral disk, then the jellylike kernel, and through it kontaktno — the next vertebra is involved (fig. 1, c). Intra disk distribution of pus is in most cases combined with small destruction of vertebrae and bent to an otgranicheniye of process.

In some cases abscesses break with education outside or internal fistulas (see). Through fistulas there is emptying of abscesses and the centers of destruction that temporarily reduces the phenomena of intoxication. However formation of fistulas is fraught with accession of consecutive infection that considerably complicates treatment and the forecast. It is long the existing fistulas especially having long gyrose the fistular course with zatekam (see), rather quickly lead to development amyloidosis (see) internals.

Fig. 3. The diagrammatic representation of formation of scoliotic deformation of a backbone at a tubercular spondylitis: the arrow specified the center of destruction of side departments of bodies of vertebrae.

Destruction of bodies of vertebrae is followed by their wedge-shaped deformation — it conducts to an ugloobrazny kyphotic rachiocampsis (see. Kyphosis ) in the form of a hump (gibbus) that is the most characteristic sign of S. U of children a kyphosis appears earlier and progresses quicker, than at adults. Kyphotic deformation reaches the greatest degree at localization of process in chest department of a backbone. With the advent of a kyphosis all thorax is gradually deformed, the vessels and bodies which are in it are displaced and squeezed, the pulmonary heart and other disturbances develops. At side destruction of bodies of vertebrae scoliotic deformation develops (see. Scoliosis ), more characteristic of lumbar department of a backbone (fig. 3). More often the combined deformations take place. Intervertebral disks owing to disturbance of a trophicity gradually decrease in sizes and become thinner. Bodies of vertebrae, collapsing, approach, adjoin and at it is long the existing process form quite often uniform conglomerate, the block of bodies of vertebrae including the centers of destruction, the remains of razvoloknenny disks. Back departments of a backbone also merge together in the form of the armor closing a spinal cord.

A clinical picture

According to P. G. Kornev's data, in tubercular S.'s development it is possible to allocate prespondilitichesky, spondylitic and post-spondylitic phases of development.

The Prespondilitichesky phase connected with emergence and development patol. process within one vertebra, the wedge, is characterized by manifestations uncertain. In this phase the symptoms characteristic of initial stages prevail tuberculosis (see) any localizations (weakness, subfebrile temperature, vegetative disturbances, etc.). The local symptomatology consists in feeling a nek-swarm of awkwardness, constraint in the struck segment of a backbone. Patients during this period of a disease ask for the help seldom.

The spondylitic phase in connection with distribution of process out of limits of one vertebra is characterized by progressing of manifestations, clearness and definiteness of symptomatology. In this phase allocate stages of the beginning, a heat and a zatikhaniye. Pain concentrates in one site of a backbone though can irradiate on the course of peripheral nerves that quite often simulates radiculitis, neuritis, and also various pathology of internals. In a stage of a heat pain reaches big intensity, amplifying at load of a backbone. Its noticeable reduction or disappearance during the unloading of a backbone (appointment to the patient of a bed rest is characteristic, especially at its laying in a plaster bed).

Fig. 4. The diagrammatic representation of formation of a «dot» hump at a tubercular spondylitis: the acantha forming a «dot» hump (it is specified by an arrow), is lifted up as a result of a compression fracture of bodies of vertebrae and destruction of a disk; the center of destruction in bodies of the next vertebrae is designated in black color.

The rachiocampsis at S. in the form of ugloobrazny kyphotic deformation is caused by destruction of bodies of vertebrae, their compression change and wedge-shaped deformation. At a compression of one — two bodies of vertebrae the acantha rises up and is stuck out, forming a «dot» hump (fig. 4). At distribution of process kyphotic deformation increases. In cervical and lumbar departments the hump is usually small or is absent completely, and deformation of a backbone is more often shown by a smoothness of a lordosis (see). At patol. process in chest, and especially in lumbar department of a backbone the trunk of the patient is shortened owing to what there is a disproportion between a trunk and extremities. In process of a zatikhaniye of process progressing of deformation is slowed down, and then stops. At the same time the general condition of patients improves. In a stage of a zatikhaniye of pain usually are absent though there can be a morbidity of a backbone caused by its deformation, disturbance of an oporosposobnost, patol. mobility, compression of roots of spinal nerves.

The post-spondylitic phase is characterized by rather safe condition of patients. However there can be radicular pains, the phenomena of instability of a backbone, its curvature. At children the affected vertebras lag behind in growth that aggravates a disproportion between a trunk and extremities. In this phase there can periodically be aggravations patol. process, caused by activation of the delimited, not liquidated centers and abscesses; at the same time the wedge, signs characteristic of active tubercular process develop anatomo-functional disturbances progress.

Nevrol. disturbances at S., especially radicular, are observed rather often (approximately at 10 — 17% of sick S.). Most often they are observed at defeat of chest department of a backbone in a stage of a heat of S. So-called early disturbances are caused by a prelum of a spinal cord and the vessels feeding it abscesses, sequesters. They arise unexpectedly and rather quickly progress. Sometimes early paresis or paralysis is the first sign of Page. These disturbances are characteristic of a spondylitic phase of a disease. Late nevrol. disturbances arise usually in a post-spondylitic phase and are caused pachymeningitis (see), leading to long narrowing of the vertebral channel owing to a thickening of a meninx, formation of commissures and hems in the vertebral channel. Late disturbances develop slowly, testify usually to a degeneration of a spinal cord and therefore predictively it is much more dangerous. In a post-spondylitic phase at an aggravation of process nevrol. disturbances can quickly progress if they arise owing to an acute prelum of a spinal cord.

Nevrol. disturbances at S. are clinically shown by the spastic paresis (as a rule, bilateral) which is gradually passing into paralysis. Motive and sensitive functions are broken, develop decubituses (see), conducting to heavy septic complications. Spastic paralyzes pass in sluggish over time that testifies to a degeneration spinal cord (see). Pelvic frustration at paresis and paralyzes consist in a delay of an urination and defecation in the beginning, edges is replaced by their involuntary departure. Stagnation of urine and repeated forced catheterization can lead to the ascending infection of uric ways and an urosepsis (see. Sepsis ).

The most frequent complication Pages are congestive abscesses. Clinical displays of abscesses are various and are defined generally by their localization, distribution of pus and a prelum of these or those internals. So, in cervical department of a backbone retropharyngeal abscesses are formed (see), to-rye can cause a dysphagy or suffocation. From chest department pus can migrate on a postmediastinum on a neck, and on mezhreberye — on a chest wall. In chest and lumbar departments the prelum of vessels, peripheral nerves, muscles, ureters with corresponding a wedge, manifestations, napr is possible, abscess in the thickness of big lumbar muscles causes a flexion contracture of a hip joint (see the Psoitis). Except a prelum of internals, abscesses are a source intoxications (see), aggravations patol. process, formation of fistulas, amyloidosis.

At 4 — 7% of sick S. at break of abscesses the fistulas opening outside or in any hollow body (bronchial tubes, intestines) are formed. Fistulas meet at tuberculosis of the bottom of chest and lumbar departments of a backbone, usually in the period of a heat or an aggravation of process more often.

Diagnosis of tubercular Page. it is based on the complex research of patients including clinical, radiological and laboratory methods. The greatest difficulties are presented by diagnosis of initial forms C., at to-rykh there is no typical deformation of a backbone and characteristic complications (abscesses, fistulas, paresis and paralyzes). In initial stages of a disease see a doctor seldom. Difficulties of diagnosis increased in connection with tubercular S.'s «postareniye», increase in frequency of atypical forms, need of differentiation with a large number of other diseases of a backbone.

The main features of the anamnesis at tubercular S. are: the gradual beginning, a slow course of a disease, uncertainty and a nelo-kalizovannost for a long time pains, the termination or easing them with purpose of a bed rest, dependence on load of a backbone. At the same time symptoms of tubercular intoxication are characteristic: subfebrile temperature, increased fatigue, perspiration, weight loss, tachycardia. Clinical diagnosis is based on an orthopedic research of patients (see. Backbone, methods of a research ). At survey constraint of a backbone, so-called proud gait comes to light.

At damage of the lower chest and lumbar vertebras of the movement or effleurage by a hammer in the area between the affected vertebra and shovels cause emergence of the muscular rollers formed reflex by the reduced muscles (a symptom of «reins» of Kornev). At the same time above and below the affected vertebra deepenings (a symptom of «excavation» of Kornev) are palpated. The rachiocampsis before everything appears in chest department. Kyphotic deformation increases eventually, keeping most often angular character. Quite often a side rachiocampsis in combination with a kyphosis meets. In the corresponding stages of a disease at survey reveal eminating abscesses, the functioning fistulas, decubituses, contractures, etc.

Local morbidity of a backbone is defined by a palpation and percussion of acanthas of vertebrae, axial load of a backbone by the careful pressure upon the head and shoulder girdles of the patient. By means of a palpation retropharyngeal and ileal abscesses, and also the abscesses migrating on a hip can be revealed. At persons of subnutrition perhaps palpatorny research of lumbar vertebrae through a front abdominal wall.

Mobility of a backbone at S. is limited that is the most noticeable in attempt of the patient to lift any objects from a floor: he does not bend, and squats, leaning hands on hips.

At suspicion on a prelum of a spinal cord carry surely out careful nevrol. inspection for identification of level of defeat and clinical features of paresis or paralysis. Basic value for the solution of a question of tactics of treatment has definition of passability of likvorny ways in this connection are obligatory liquorodynamic tests (see). Specification of level of a prelum of a spinal cord is reached by means of contrast methods of a research of the vertebral channel (see. Miyelografiya , Epidurografiya ).

Laboratory diagnosis of tubercular S. includes all-clinical, biochemical, bacteriological and serological trials, the general for all localizations of tuberculosis (see). Pus from abscesses, a discharge of fistulas usually is exposed to a bacteriological research. At the same time a research objective is not only diagnostic allocation of microflora, but also definition of its sensitivity to antibacterial agents.

X-ray inspection (see) is method of primary recognition patol. process in a backbone, and also allows to track dynamics of a disease. Big role rentgenol. the method plays in differential diagnosis of Page. Use of such techniques as a tomography, a zonografiya, contrast methods of researches and others, considerably improves diagnostic opportunities rentgenol. method.

It is accepted to distinguish two main options of an arrangement patol. the centers in a body of a vertebra: central and peripheral (regional). Both at central, and at peripheral option the most often primary centers are localized in front departments of bodies of vertebrae. However in process of progressing patol. process extends p to back departments of a body of a vertebra. The small centers of destruction which are in the central departments of bodies of vertebrae on standard roentgenograms can not come to light. In process of increase in the centers of defeat, their approach to cortical substance and emergence of a rim of consolidation they become radiological visible. Sometimes in the depth of the center small sequesters are defined. Especially clearly it happens it is visible on tomograms and zonogramma.

At tubercular S. chest vertebrae most often are surprised, and defeat several a number of the located vertebrae is characteristic (5 — 6 and more vertebras can be at the same time affected). Sometimes patol. process extends to related departments of edges. As a result of a compression and a spayaniye of bodies of the destroyed chest vertebrae position of edges changes, to-rye in back departments approach, and in the direction of a knaruzha fanlikely disperse. The account of the destroyed vertebrae should be carried out on arches and acanthas, to-rye clearly are defined on the roentgenograms which are carried out in a side projection. At tubercular damage of bodies of cervical and lumbar vertebrae process happens more limited. Most often related departments two a number of the located vertebrae with destruction of an intervertebral disk are surprised what narrowing of intervertebral space indirectly testifies to.

At the central arrangement of primary center I. L. Tager and V. A. Dyachenko allocate four phases of development of tubercular S. V to the first phase the isolated bone cavity is formed, cover detection perhaps only at emergence of a zone of sclerous consolidation around the center of destruction. In the second phase the break of contents of a cavity is noted. Usually there is an intra disk break to destruction of an intervertebral disk, Is much more rare — extra disk, towards the vertebral channel. Along with destruction of a bone tissue in this phase narrowing of an intervertebral crack is defined. In the third phase there is a contact destruction of the next vertebra, destruction of an intervertebral disk and formation of congestive abscess. In the fourth phase far come destruction in the form of destruction several a number of the located vertebrae, rapprochements of the remained their departments with formation of the block of bodies of vertebrae and consolidation of a shadow of abscess comes to light.

Fig. 5. Roentgenograms of a part of chest and lumbar departments of a backbone of the patient with a tubercular spondylitis: and — a side projection; — a direct projection; 1 — a bone cavity in bodies X and XI chest vertebrae; 2 — a shadow of congestive abscess.

In many cases at tubercular S. congestive abscesses can be diagnosed radiological. In cervical department of a backbone abscess is distinguished on the arc-shaped protrusion of a back wall of a trachea and throat. In chest department the shadow of abscess against the background of pulmonary fields quite clearly is differentiated and has the form of a spindle, a bulb etc. Outlines of abscess smooth and accurate (fig. 5). Apply an abstsessografiya to specification of volume and prevalence of abscess (rentgenol. a research after filling of the emptied abscess cavity with a contrast agent), and in the presence of fistula — fistulografiya (see). In lumbar department abscesses are diagnosed on indirect signs — to protrusion of the outer edge of a big lumbar muscle.

Fig. 6. Roentgenograms of a part of chest and lumbar departments of a backbone of the patient with a tubercular spondylitis: and — a side projection (an angular kyphosis in the field of a spayaniye of the vertebrae destroyed the XII chest and the I lumbar); — a direct projection (the arrow specified calciphied congestive abscess).

In process of a zatikhaniye and the subsequent stabilization of tubercular process congestive abscess can resolve or obyzvestvitsya. Calciphied sites have an appearance of small or large conglomerates (fig. 6). Rentgenol. signs of a zatikhaniye of tubercular S. are: reduction of the sizes of abscess, increase in its density or calcification; stability rentgenol. signs without emergence of new destructive changes, an accurate otgranichennost of cavities; ossification of fibrous rings and longitudinal ligaments of a backbone in the form of brackets and regional growths; bone spaya-ny (ankilozirovaniye) of arches and joint shoots of vertebrae.

Differential diagnosis of tubercular S. is carried out first of all with inflammatory processes in a backbone of not tubercular character (see below). In some cases there is a need of differentiation with the inborn and acquired deformations of a backbone, dystrophic processes (see. to Kalva disease , Klippelya — Feylya a disease , Kummel disease , Osteochondrosis , Scoliosis , Sheyermanna — Mau a disease ), tumors of a backbone, its parasitic defeats (see the Backbone, pathology). Timely and correct differential diagnosis is especially important at suspicion of a tumor of a backbone and is carried out by means of modern methods rentgenol. researches.

Treatment tubercular S. includes the conservative and operational methods which are closely interconnected and supplementing each other. Conservative treatment as an independent method is shown in early stages of S., in the absence of rough destructive changes of a backbone and complications of basic process (abscesses, fistulas, paralyzes), and also in the presence of contraindications to operations: in other cases the operational treatment supplemented before operation and after it conservative is shown.

Conservative treatment includes the orthopedic treatment which is carried out for the purpose of unloading and an immobilization of the struck department of a backbone, antibacterial therapy, and also the fortifying treatment directed to increase in stability and body resistance.

For the purpose of unloading and an immobilization of the struck department of a backbone appoint a high bed rest in the plaster bed which is precisely simulated on a back surface of a body of the patient (see. Plaster equipment ). At an early unstable kyphosis, especially at children and teenagers, under top of a hump in a bed enclose wadded and gauze laying (small pillows, crosses), to-rye gradually thicken (Fink's method). It provides the constant uniform pressure upon top of a hump and gradual correction of deformation. After cancellation of a bed rest of the patient carries the constant plaster corset later replaced on removable, made of the skin, a canvas or jersey impregnated gelatinous and formalin or of a polivik (see Orthoses).

Antibacterial therapy at S. is based on complex and continuous use antituberculous remedies (see). Usually at active process appoint two — three drugs with various mechanism of antibacterial action. Antitubercular therapy is carried out continuously to a zatikhaniye of process, and then annually, before removal of the patient from the account, appoint so-called antirecurrent courses.

It is the most reasonable to include a dignity in a complex of fortifying actions. - hens. the treatment providing the sparing mode, good nutrition with the sufficient content of vitamins, a systematic aerogeliotherapy. The fortifying and medical fizgeultura, massage directed to prevention of a muscular atony and atrophy are obligatory.

The early rational conservative treatment which is carried out, as a rule, for a long time allows to recover a normal form and function of a backbone at patients with initial phases C., especially at children, to achieve a resistant zatikhaniye or treatment of process.

At the expressed destructive processes by means of conservative treatment it is possible to expect only an otgranicheniye of the centers and abscesses, to-rye further can become sources of an aggravation patol. process since antibacterial agents do not get through connective tissue membranes and calciphied capsules of abscesses. At destructive processes elimination patol is considered optimum. centers in the operational way.

Operative measures at S. are numerous and various. They differ raised herbs-matichnostyo, are followed by danger of development of shock, a hypoxia and other complications, especially at the expressed kyphosis and deformations of a thorax. In this regard operations at S. demand preliminary preoperative preparation (normalization of activity cardiovascular, respiratory and other systems of an organism). Operations are performed under an intubation narkozokhm with the managed breath.

At S. back accesses are used (see. Laminectomy , Spondylodesis ), posterolateral (see. Costotransversectomy , Backbone ), the front and side and front, creating best conditions for manipulations in the depth of an operational wound at interventions on bodies of vertebrae. In cervical department is more often than others accesses on Cheyna (knaruzh from a vascular bundle) and to Burgkhardt are applied (knutr from a vascular bundle). In chest department the thoracotomy with mobilization of a lung allows to open in front juxtaspinal abscesses, during the opening to-rykh the front surface of the affected bodies of vertebrae is bared that creates optimal conditions for sanitation of abscess, patol. the center in a body of a vertebra and if necessary — front stabilization of a backbone (see the Spondylodesis). More often transthoracic access is applied on the right. In the bottom chest and lumbar departments of a backbone favorable conditions for operations on bodies of vertebrae are created torakodiafragmalny access across Kovalenko — to Dribinsky and posterolateral on Smitvika — to Yudin. In the first case after opening of a thorax and a parietal pleura carry out a juxtaspinal diaphragmotomy then there are available affected bodies lower chest and - lumbar vertebrae. In the second case the section of skin is made by pases-ravertebralno at the level of X edge and then continue to the middle of an inguinal fold. Soft tissues cut to a peritoneum, to-ruyu will hardly mobilize and bare ileal abscess. In an upper part of a wound carry out a typical costotransversectomy of the lower chest vertebrae. This access is shown at the expressed destruction of bodies of vertebrae and large abscesses. Accesses to lumbar vertebrae represent various options lumbotomies (see), and approach lumbosacral department by a nizhnesredinny laparotomy of Müller.

Fig. 7. The diagrammatic representation of the main stages of radical recovery operation at a tubercular spondylitis: and — after a thoracotomy make a trial puncture of naked prevertebral abscess on the right (the line of a skin section is shown at the upper right) (1 — the retractor; 2 — the capsule of abscess; 3 — the syringe); — the dissect capsule of abscess is taken on handles, in bodies of vertebrae after removal of the caseous masses (necretomy) residual cavities are visible (are specified by shooters); in — in the cleared intraspinal cavity the bone transplant is implemented (it is specified by an arrow); — the capsule of abscess together with a parietal pleura is taken in by noose sutures, the drainage tube is entered into a wound (it is specified by an arrow).

Operations at S. conditionally divide into several basic groups (radical, stabilizing, radical recovery, decompressive, palliative, etc.). Radical operations are a necretomy of bodies of vertebrae (see. Necretomy ) or their resection. If at a necretomy make an ekskokhleation (scraping) of the center of destruction, then at a resection of bodies of vertebrae delete also next to the center sclerosed fabrics, the remains of the destroyed intervertebral disks. Thus, as a result of a necretomy or a resection in bodies of vertebrae the cavity is created. Radical operations are shown at destructive processes with one or several centers in bodies of vertebrae. The Oporosiosobnost of a backbone broken as a result patol. process in its front department, after radical operations it is even more broken, especially after a resection of bodies of vertebrae. Recovery of an oporosposobnost of a backbone is reached by means of lobbies or (more rare) than the back stabilizing operations (see the Spondylodesis). With radical it is accepted to call a combination of the stabilizing operations radical recovery interventions (fig. 7). At S.'s effects (disturbance of an oporosposobnost, patol. mobility, compressions of roots of spinal nerves) the stabilizing operations have independent value.

Radical and radical recovery transactions of the corresponding indications often are followed by audit of a spinal cord and its release from a prelum.

By means of radical recovery operations in some cases rough deformations of a backbone, napr can partially be eliminated, after a resection of bodies of vertebrae partial correction of a hump then the backbone is fixed bone transplants in new situation is made manual or by means of special devices (rekli-nator). In such a way it is possible to reduce kyphotic deformation on 10 — 20 °. Correction of a hump by means of a corrective vertebrotomiya across Tsivyan is more effective. This operation represents an osteotomy of a backbone (see. Osteotomy ) with the subsequent single-step or stage correction of a hump. A result of operation is not only the cosmetic effect, but also increase in capacity of a thorax, reduction of a prelum of its bodies. The vertebrektomiya offered by M. S. Makarov, i.e. full removal of one or several vertebrae at top of a hump with the subsequent its correction, is effective in sense of correction of a backbone, but is fraught with dangerous complications (paralyzes, ruptures of vessels, etc.) owing to what it did not gain distribution.

At the paresis and paralyzes caused by narrowing of the vertebral channel decompressive operations of various type are shown. Treat them laminectomy (see), a gemilaminektomiya, an anterogemilaminektomiya, a rakhitomiya on Seddona (see. Backbone ) and their various modifications. The purpose of these operations is elimination of a prelum of a spinal cord by means of opening of the vertebral channel behind and sideways. In some cases the number of decompressive actions includes separation of the commissures squeezing a spinal cord, removal from the vertebral channel of sequesters, suppurating etc. Because the laminectomy considerably weakens a back half ring of a backbone and by that leads to its instability, resort to it seldom especially as this operation does not liquidate basic process at an active spinal tuberculosis.

Palliative (medical and auxiliary) operations, such as a puncture of abscess, an abstsessotomiya, fistulas an otomiya, back spondplodez and others as independent interventions are now applied seldom, in cases when more traumatic interventions are contraindicated. In combination with rational conservative treatment palliative operations can sometimes lead to a zatikhaniye of process. Abstsessektomiya and the fistulectomy, i.e. full excision of abscesses and fistulas, are not recommended since it leads only to an additional and unjustified injury. The scraping of an inner piogenic layer of abscesses and fistulas for their subsequent closing and an obliteration on condition of radical sanitation of the center is quite sufficient.

The problem of treatment of sick S., complicated by fistulas, considerably was facilitated thanks to the operation developed Root — the shortening fistulotomy, at a cut scrape out and hardly tampon the long gyrose fistular courses for the purpose of their isolation from the center. At the same time artificially create the shortest outflow tract of pus from the affected vertebras. Artificial short fistula is kept before closing of the long fistular courses, and then if the center is debrided rather considerably, short fistula is closed independently. Difficulties with fistulas considerably increase in treatment of patients at secondary infection of fistulas with banal flora.

After operation for S. it is necessary to watch a hemodynamics, function of kidneys, to fight against an atony of intestines, pelvic disturbances, etc. Careful postoperative care of such patients is necessary without what efficiency of many operative measures sharply decreases.

Forecast depends on timely diagnosis, the choice of medical tactics and its implementation, the general condition of the patient, associated diseases. For the last decades mortality from S. was sharply reduced, even in the presence of fistulas of ii nevrol. complications, to-rye earlier in most cases led to death of the patient. The amyloidosis of internals, septic complications are the most frequent causes of death, especially at paralyzes. Early treatment of patients from S. allows at most of them not only to liquidate tubercular process, but also to correct or prevent deformations of a backbone. At untimely treatment, the old fixed hump, contractures functional and cosmetic outcomes it is much worse.

Prevention comes down to the general prevention tuberculosis (see). Any means and ways of the prevention of tubercular S. do not exist, however systematic routine maintenances, first of all TB patients, especially children and teenagers, and the timely address to the orthopedic surgeon promote early identification and effective treatment of S.

the Actinomycotic spondylitis

the Actinomycotic spondylitis is secondary localization of an actinomycosis since there is almost always primary defeat of other bodies (see. Actinomycosis ). Vertebrae of all departments are surprised, but is more often — chest owing to transition of process from a mediastinum. The actinomycosis of lumbar department of a backbone can be a complication of an intestinal form of a disease. Usually two-three vertebras are involved in process. Process has superficial character, first of all the periosteum is surprised, and then process can extend in depth of a bone tissue. Almost always there are abscesses, from to-rykh dot fistulas with scanty white kroshkovaty separated later open. At a research of pus in it find druses of actinomycetes. Treatment is directed first of all to the main center patol. process. Operations of radical type — a necretomy of bodies of vertebrae are sometimes shown.

The brucellous spondylitis

the Brucellous spondylitis arises more often at the age of 25 — 40 years, men are ill more often. Favourite localization patol. process is L3 and L4 vertebrae. Pain amplifies at a palpation and percussion of acanthas of the affected vertebras and does not stop from the beginning of an immobilization. Crucial importance in brucellous S.'s diagnosis has a X-ray and laboratory inspection (see. Brucellosis ).

According to S. A. Reynberg, at brucellous S. melkoochagovy destruction along platforms of bodies of vertebrae radiological is noted. The centers merge among themselves and form deeper uzura. The centers of destruction are surrounded with a zone of a sclerosis, on side surfaces of bodies of vertebrae periosteal stratifications can appear. The intervertebral disk collapses partially and therefore the full bone spayaniye of bodies of vertebrae does not happen. At the level of damage of bodies of vertebrae and intervertebral disks ossification of fibrous rings and longitudinal ligaments of a backbone is noted. In the expressed cases the destruction of a vertebra sometimes taking a half of his body therefore wedge-shaped deformation develops is observed. «Cold» abscesses at brucellous S. meet seldom, the thickening of soft tissues around a rachis is sometimes observed cylindrical or slightly spindle-shaped form. The differential diagnosis is carried out with tubercular S., and also with banal osteomyelitis of a backbone. Treatment of a basic disease is carried out; at destruction of vertebrae and deformation of a backbone treatment operational.

The gonorrheal spondylitis

the Gonorrheal spondylitis is extremely rare, arises as a complication of gonorrhea. Is followed by severe pain. The bystry ankilozirovaniye of bodies of the affected vertebras is characteristic. Diagnosis is based on data of the anamnesis and rentgenol. pictures. Treatment conservative (see. Gonorrhoea ).

The syphilitic spondylitis

the Syphilitic spondylitis represents a big rarity, especially at young age. Moderate backbone pain at night, lack of kyphotic deformation of a backbone, a bystry ankilozirovaniye of the affected vertebras are characteristic. As a rule, displays of syphilis of other bodies are found. Results serological and rentgenol have important diagnostic value. researches. Treatment conservative (see Syphilis).

The typhus (post-typhus) spondylitis

the Typhus (post-typhus) spondylitis proceeds as a complication of a basic disease, usually — returnable or a sapropyra. Arises in two-three months after an onset of the illness. It is characterized by the high temperature, the severe, accurately localized pain in the affected vertebras arising sharply. Quickly there comes the anchylosis of two-three affected vertebras due to bone growths on their edges. In diagnosis plays an important role rentgenol. research. Initially process develops in an intervertebral disk that is shown on the roentgenogram in the form of narrowing of an intervertebral crack and the subsequent uzuration of adjacent surfaces of bodies of vertebrae. The destroyed surfaces of bodies of vertebrae approach and form the bone block due to ossification of longitudinal ligaments of backbone. At S.'s localization in chest department and deeper uzuration of surfaces of bodies of vertebrae there can occur peeling of longitudinal ligaments of backbone that sometimes mistakenly take for congestive abscess. Post-typhus S.'s treatment is defined by an etiology of a disease (see. Typhinia , Sapropyra epidemic ).

A hematogenous purulent spondylitis

the Hematogenous purulent spondylitis (a synonym osteomyelitis of a backbone) — the nonspecific form of damage of a backbone arising in the hematogenous way. Activators — golden staphylococcus, are more rare — a streptococcus. More often back departments of vertebrae — arches and shoots are surprised. The most typical localization is the lumbar department of a backbone, 2 — 3 vertebras usually are surprised. The disease is characterized by the acute rough beginning with the expressed pain in the affected vertebras. The general serious condition, as well as at other localizations osteomyelitis (see). Rather quickly there are abscesses, fistulas, at break of pus in the vertebral canal develop nevrol. disturbances, to-rye can arise also in connection with purulent meningitis — a complication of purulent Page. At localization of process in a back half ring of vertebrae pus usually breaks outside that leads to formation of fistulas over acanthas, process gains chronic character. Deformation of a backbone at purulent S. is, as a rule, small, a kyphosis the arc-shaped.

Hron. hematogenous purulent S. develops from acute or arises as an independent form. The symptomatology reminds tubercular S. V process all departments of a backbone are involved by time, and aggravations arise in different segments of a backbone independently one from another. Of osteomyelitis of a backbone it is characteristic typical rentgenol. the picture, a diagnostic role a cut is especially important at a chronic form of a disease.

Treatment of osteomyelitis of a backbone consists in an immobilization, purpose of antibacterial agents taking into account sensitivity of microflora, according to indications in radical operative measures. As indications to operations serve usually destructive and complicated forms patol. process.

Actinomycotic, brucellous, gonorrheal, syphilitic, typhus, and also nonspecific hematogenous purulent S.'s forecast at timely begun and rational treatment favorable. Their prevention consists in early treatment of the centers of a specific or nonspecific infection and the prevention of generalization of process.

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AA. P. Mathis; M. K. Klimova (rents.).