Bone tuberculosis is a specific infection caused by Koch sticks, occurring with damage to the spine or limb bones. Pathology can be diagnosed at any age. It is manifested by gradually progressive pain, weakness, fatigue. In the final stages, the pain becomes unbearable, severe fever is noted, deformities of the bones of the skeleton develop. The diagnosis is made on the basis of radiography, tomography and other studies. At the initial stages, conservative therapy is indicated: medications, exercise therapy, massage. With significant bone destruction, operations are performed.
ICD 10
A18.0
Meaning
Bone tuberculosis is an infectious disease caused by tuberculous mycobacteria (Koch’s sticks). It affects areas of spongy matter with abundant blood supply, accompanied by the formation of foci of destruction, abscesses and fistulas. It often causes deformation of the affected segment, can cause contractures and shortening of the limb. With tuberculosis of the spine, pronounced curvature of the spine, the formation of a hump, and in severe cases, paralysis of the limbs is possible.
In more than half of cases, the spine suffers. Tuberculosis of the large joints of the lower extremities (knee and hip) occupies the second place in terms of prevalence. The combination with active pulmonary tuberculosis is observed quite rarely (in about 3% of cases), however, during lung radiography, patients show characteristic areas of calcification in the lymph nodes or upper lobes of the lungs (more often right). Treatment of this pathology is carried out by phthisiologists.
Bone tuberculosis causes
Bone tuberculosis, like other forms of tuberculosis, develops when Koch sticks enter the body. At the same time, infection with mycobacteria does not always lead to the development of the disease. The disease occurs in cases when the patient’s body is weakened by hypothermia, too heavy physical labor, other infectious diseases and unfavorable living conditions, and Mycobacterium tuberculosis are in a state of readiness for active division or a state of reproduction (as with active tuberculosis).
Pathogenesis
The primary focus occurs in the lungs, then mycobacteria spread through the lymphatic and blood vessels and enter the bone. The areas of bone with a good blood supply (vertebrae, epiphyseal parts of the femur, shin bones, shoulder bones and forearm bones) are at the greatest risk. As a result of the reproduction of Koch sticks, small bumps-granulomas appear in the bone. With an increase in granulomas, the bone substance is destroyed, abscesses are formed, which can subsequently open outwards, forming fistulas.
In most cases, mycobacteria “settle” in the immediate vicinity of the joint, so when the infection spreads, intraarticular structures are involved in the process. There are three phases of the development of bone tuberculosis. The first is primary ostitis (the formation of a focus in the bone), the second is secondary arthritis (the transition of infection to the joint), the third is postarthritic (residual phenomena, relapses, etc.). The severity of residual phenomena depends on the time of initiation of treatment, the adequacy of therapy and the state of the patient’s body.
Classification
Since the tuberculosis process in most cases captures not only the bone, but also the joint, scientists and practitioners usually use the term “osteoarticular tuberculosis”. The following variants of localization of tuberculosis foci are distinguished:
- Spine. Both one vertebra and several can suffer. In 60% of cases, there is a lesion of the thoracic region, in 30% – the lumbar region.
- The knee joint. Gonitis is the most common tuberculous lesion of the joints, it is more often detected in adolescence.
- Hip joint. Coxitis develops more often in children, can cause a significant shortening of the limb and the formation of a pathological dislocation of the hip joint.
- The ankle joint and the bones of the foot. Accompanied by the formation of long-existing fistulas and caverns. It often leads to ankylosis of the joint due to the fusion of articular surfaces.
- Shoulder joint. Omarthritis is rarely detected. The course is long, purulent effusion in the joint is usually absent.
- Wrist joint. Another rare form of the disease. There is a lesion of the joint and wrist bones, usually bilateral. It is often combined with tuberculosis of the elbow or knee joint.
- Elbow joint. Olenitis usually develops in adolescence. With a late start of treatment, leaky fistulas and abscesses are formed.
- Tubular bone without joint damage. It is very rare, usually detected in children, characterized by damage to the metacarpal bones and the main phalanges of the hand.
Bone tuberculosis symptoms
The disease begins gradually, gradually. There are no specific symptoms in the early stages. Patients are concerned about weakness, irritability, lethargy, decreased performance, aching or pulling muscle pain and a slight increase in temperature. In some patients, after physical exertion, non-intense pain appears in the affected part of the skeleton, quickly disappearing at rest. Children with bone tuberculosis become distracted, refuse outdoor games. The reason to be wary for parents should be raised shoulders, clubfoot, sudden stoop or limping without previous injury. Sometimes it is noticeable that the child takes care of the leg, tries to step on it less, does not jump on it or drags after a long walk.
In the second phase of bone tuberculosis, the process spreads beyond the bone or vertebra, the symptoms become more pronounced. The body temperature rises even more, weakness, lethargy and weakness increase. Intense pain appears in the affected area. When the focus is localized in the vertebra, a violation of posture is formed, the parotid muscles become inflamed, bulge out and become painful on palpation. When a limb is affected, the joint turns red and swells, progressive deformation occurs, gait disorders and lameness are noted.
With further progression of bone tuberculosis, the patient’s condition is further aggravated. There is a pronounced general weakness, an increase in body temperature to 39-40 degrees and weight loss. The intensity of pain increases, the pain syndrome becomes unbearable. Deformations are amplified, movements are even more limited. The outcome, depending on the severity and prevalence of the process, may be limited mobility, atrophy of the back muscles, spinal deformity, deformity and shortening of the limb, contracture or ankylosis of the joint.
Diagnostics
To confirm the diagnosis, chest x-ray, radiography of the affected segment and MRI of the affected segment are prescribed. Chest images of patients suffering from bone tuberculosis reveal calcified primary tuberculous foci in the upper lung and intra-thoracic lymph nodes. Radiographs of the spine or affected limb bones show foci of destruction and sequestration. In some cases, it is possible to notice the shadows of leaky abscesses.
Tuberculin tests are performed, sometimes microbiological examination of the contents of the fistula or abscess is carried out to identify Koch sticks. Immunodiagnostics of tuberculosis can detect both active and latent infection. Currently, 2 types of IGRA tests are used for this purpose: T-SPOT.TB and QuantiFERON.
With fistulas or abscesses, abscessography or fistulography is performed. During the study, the cavity is filled with a contrast agent, after which a series of images are taken to assess the size and configuration of abscesses and fistula passages. This technique is of great practical importance when preparing a surgical intervention plan.
Bone tuberculosis treatment
The treatment is complex, includes a diet, general restorative measures and drug therapy. Patients are sent to specialized centers, dispensaries and sanatoriums. In the active phase, bed rest is prescribed, in the future it is recommended to spend more time in the fresh air and take sun baths, massage and physical therapy are used.
In the active phase, an increased breakdown of proteins occurs in the patient’s body, therefore, the amount of food is increased by 1/3 compared to the norm and an easily digestible diet with a high protein content is prescribed, including eggs, boiled fish, minced meat dishes, soups on fish and meat broth. During the recovery period, the amount of dairy products is increased, during the period of antibiotic therapy, it is recommended to consume a large amount of fresh vegetables and fruits.
Patients with bone tuberculosis are prescribed antibacterial therapy: ethambutol, pyrazinamide, isoniazid, rifampicin and other drugs. If necessary, surgical interventions are performed. The scope of the operation depends on the absence or presence of fistulas and abscesses, as well as on the degree of bone destruction. Sequesters are excised, fistula passages and abscess cavities are washed with solutions of antibiotics and antiseptics. With a favorable course, the cavities eventually close, with an unfavorable course, they are excised by the surgeon.
In case of gross defects and serious anatomical disorders in the late period, corrective and reconstructive operations are performed. At the final stage, rehabilitation measures are carried out aimed at restoring the function of the affected segment and returning the patient to normal life. In the process of rehabilitation of patients with bone tuberculosis, physiotherapy procedures, massage and physical therapy are used, social and professional rehabilitation is carried out.
Prognosis and prevention
The prognosis for life with bone tuberculosis is favorable. The use of combined methods of treatment and modern antibacterial drugs has allowed to reduce mortality to almost zero. However, in the long-term period, many patients have deformations of the affected segment of varying severity. Half of patients with spinal tuberculosis are disabled. Patients with foci in the bones of the extremities often retain lameness, shortening and deformity of the limb, as well as contractures of varying severity.
Prevention of the disease consists in minimizing contacts with patients with active tuberculosis, preventing intoxication, injury and hypothermia. An essential role is played by improving the overall standard of living and ensuring social well-being. Parents are advised not to abandon routine tuberculin tests for children. Non-specific symptoms (weakness, bruising, slight fever) should be taken seriously if they persist for several weeks. It is necessary to consult a doctor if there is constant pain in the bones and muscles, even if these pains are poorly expressed.