Spinal tuberculosis complicated with paraplegia

Introduction to spinal tuberculosis complicated with paraplegia Spinal tuberculosis complicated by paraplegia is caused by a combination of factors such as cavity fluid in the lesion, cheese material, dead bone or necrotic disc. In the late stage of the disease, the fibrous tissue of the granulation tissue in the spinal canal can be wrapped around the spinal cord, and the vertebral body is dislocated or subluxated. Sorrel and Sorrel-Dejerin (1925) who had a paraplegic period within 2 years of spinal tuberculosis were referred to as early paraplegia. Two years later, paraplegia was a late paraplegia. basic knowledge Sickness ratio: 0.0001-0.0005% Susceptible people: no specific population Mode of infection: respiratory transmission Complications: urinary retention, urinary incontinence, acne, constipation, bloating

Spinal tuberculosis complicated with paraplegia

First, the anatomical points

1, the composition of the spinal canal

The spinal canal is connected by the vertebral foramen of each vertebra, the upper end is from the occipital foramen, the lower end is finally the fistula, the anterior wall is the vertebral body, the intervertebral disc and the posterior longitudinal ligament, the posterior wall is the vertebral arch and the transverse ligament, and the spinal canal is in the cervical vertebra. The lower part and the lumbar vertebrae are the widest, while the middle part of the cervical spine and the thoracic part are narrower.

2, the contents of the spinal canal

There are spinal cord, spinal cord membrane, spinal nerve root, venous plexus and adipose tissue in the spinal canal.

(1) The capsule of the spinal cord has three layers from the outside to the inside, which are the dura mater, the arachnoid and the soft meninges, which are completely connected with the three layers of the brain.

(2) spinal cord luminal cavity

1 The subarachnoid space is between the arachnoid and perichondrium, and communicates with the intracranial ventricle and the subarachnoid space of the brain. The cavity is filled with cerebrospinal fluid. The subarachnoid space of L2S2 level is called the terminal pool. Here, the cerebrospinal fluid More, there are only ponytail and terminal filaments in the cavity, and lumbar puncture and anesthesia are carried out through this cavity.

2 The dural space is in the cavity between the dura mater and the spinal canal. The cavity is filled with adipose tissue and venous plexus, and the cavity is under negative pressure.

(3) The intra-vertebral venous plexus is located in the epidural space and is divided into the anterior and posterior plexus, which are located on the anterior and posterior walls of the spinal canal, and receive blood from the vertebrae and spinal cord, and merge into the intervertebral foramen. The vertebral vein, which is injected into the vertebral vein in the neck, flows into the azygous and semi-singular veins in the chest, and into the lumbar vein at the waist.

3. Blood supply to the spinal cord The main sources of blood supply to the spinal cord are as follows:

(1) The anterior spinal artery is an automatic vertebral artery, which is composed of a left and right sinus. It is located in the anterior medial fissure of the spinal cord and branches along the way into the spinal cord to reach the anterior horn, lateral angle, central gray matter, anterior bundle of the spinal cord and lateral cord. Supply 2/3 of the total length of the spinal cord.

(2) posterior spinal artery The artery is from the vertebral artery or the posterior cerebellar artery, and one left and right are descending along the posterolateral medial groove of the posterior root of the spinal cord, and are consistent with each segment and the posterior root artery, mainly supplying the posterior 1/3 of the spinal cord. .

(3) The arterial crown, also known as the coronary artery, is the vascular plexus of the anterior and posterior spinal cord and the branch of the soft-membrane artery at the surface of the spinal cord. The coronary artery is dense in the neck and lumbar enlargement, and is sparse in the thoracic segment. It is perpendicular to the surface of the spinal cord and branches out along the soft spinal cord into the spinal cord.

(4) The root arteries are emitted from the cervical artery, the intercostal artery and the lumbar artery respectively. The spinal canal is inserted into the spinal canal and the anterior and posterior arteries of the spinal cord, so that the anterior and posterior arteries of the spinal cord are continuously supplemented with blood during the descending process. Strengthen the blood of different sources of spinal cord, supply the anterior root artery to reach 6 to 10 spinal cords, 0 to 6 in the cervical spinal cord, 0 to 6 in the cervical spinal cord, 2 to 4 in the thoracic spinal cord, and lumbar spinal cord 1 2, one of the large anterior root arteries is called the lumbar enlargement artery (Adamkiewiez artery), and the posterior root artery is about 10 to 23, distributed on the dorsal side of the spinal cord, and is anastomosed with a pair of posterior spinal artery. The root artery is in the thoracolumbar region. Often the left side is more than the right side.

The transitional zone of blood supply from different sources in the spinal cord is most prone to ischemic disorders. For example, the upper thoracic spinal cord is mainly supplied by intercostal artery branches. When adjacent several intercostal arteries are damaged or ligated, the anterior spinal artery branches The spinal cord blood supply is insufficient in this segment, especially the fourth thoracic spinal cord is most vulnerable. Similarly, the first lumbar segment is also the distribution of the upper and lower root arteries and the transition zone, which is easily damaged.

Second, the causes and classification of spinal tuberculosis complicated with paraplegia

The purpose of paraplegia classification is to provide an objective basis for selecting treatment options, comparing treatment effects and prognosis.

Pathologically active paraplegia

The cavity fluid, cheese substance and granulation tissue (soft pressure-induced substance) in the lesion are subjected to pressure of 2 to 2.66 Pa (15 to 20 mmHg); dead bone or necrotic disc (hard pressure) local vascular embolization of spinal cord edema; A small number of cases from tuberculous granulation tissue through the dura mater, causing tuberculous scurvy myelitis (Hodgson et al. 1967) and other comprehensive causes of paraplegia, this type accounts for about 89% of paraplegia cases, except for cases of vascular embolism and tuberculous myelitis The treatment effect is generally better.

2. Pathologically cured paraplegia

In the late stage of the disease, the fibrotic scar of the spinal canal can be wrapped around the spinal cord, and the vertebral body is dislocated or subluxated. The special lesion is in the upper thoracic and thoracolumbar segments of the cervical and thoracic segments, and the spine is deformed. Elongation, the spinal cord is overextended and stretched across the epiphysis in front of the spinal canal, atrophy or degeneration, abrasion and other causes of paralysis. This type accounts for 11% of paraplegia cases, and the prognosis is poor.

Spinal tuberculosis complicated with paraplegia prevention

Active treatment of tuberculosis, enhance physical fitness, and prevent the spread of tuberculosis are the key to the prevention and treatment of this disease.

Spinal tuberculosis complicated with paraplegia complications Complications, urinary retention, incontinence, hemorrhoids, constipation, bloating

First, neurogenic bladder dysfunction

The urinary function of the bladder requires close coordination between the hamstring and the urethral sphincter. After spinal cord injury, the brain and the medullary nucleus lose control of the detrusor and urethral sphincters, that is, the central nervous system cannot control urinary function, collectively referred to as neurogenic bladder dysfunction. Patients often have urinary tract infections due to urinary dysfunction or even loss.

1, classification

In the past, urinary dysfunction was divided into two types: autonomous bladder and reflex bladder. Recently, the classification of bladder bladder was more detailed into the classification of neurogenic bladder:

(1) Detrusor hyperreflexia, according to the function of the sphincter, is further divided into:

1 sphincter coordination is normal, which is characterized by urinary urgency.

2 external sphincter synergistic disorder, manifested as urinary retention.

3 internal sphincter synergistic disorder, manifested as urinary retention.

(2) Detrusor no reflection

1 sphincter coordination is normal, showing urinary retention.

2 external sphincter tendons, manifested as urinary retention.

3 internal sphincter spasm, manifested as urinary retention.

4 external sphincter denervation (relaxation), manifested as urinary incontinence.

2, clinical manifestations

The powerful bladder with detrusor hyperreflexia, its sphincter coordination is normal, the clinical manifestations are urinary urgency, most of the patients in the early stage showed urinary retention, except for patients with sphincter denervation (relaxation), which showed urinary incontinence. The urinary muscle is powerful or weak, because the internal and external sphincter can not be coordinated, the urine can not be discharged, when the bladder has more urine, the internal pressure exceeds the tension of the sphincter force, the urine overflows, the late sphincter relaxes, especially the long-term retention catheter , it shows urinary incontinence.

Second, hemorrhoids

1, the index of hemorrhoids

Local skin redness and swelling, hard I°; epidermis purple, blisters did not reach subcutaneous II °; hemorrhoids deep into the subcutaneous tissue, sometimes showing muscle or tendon III °; local tissue necrosis up to bone IV °.

2, common parts of acne

Below the paraplegic plane, the skin feels disappeared, and the skin at the prominent part of the bone is prone to occur. The part that is easy to develop when lying down is the ankle, the big trochanical heel and the toad area on both sides; the prolapsed anterior superior iliac spine and the front of the humerus Hemorrhoids occur.

Third, defecation dysfunction

Paralyzed patients with defecation dysfunction, mostly manifested as constipation, after study to observe the patient's ascending colon, the transverse movement and sigmoid colon peristalsis sequence is no different from normal people, the cause of constipation, the anal sphincter movement is not coordinated, the anal sphincter is nervous when defecation, For this case, use an anal plug instead of a laxative or use your fingers to dig out the stool block.

The patient often causes abdominal distension due to constipation, especially if the paralysis plane is higher, the patient is more uncomfortable, and after the constipation is relieved, the abdominal distension can be improved.

Spinal tuberculosis complicated with paraplegia symptoms common symptoms motor dysfunction spinal cord compression sphincter dysfunction palsy paraplegia weakness paralysis dull pain spinal cord lesion dysfunction

1, the main function of the spinal cord is the three functions of the cerebral cortex on movement, sensation and sphincter control, the transmission of sensory and urinary control, paraplegia is based on active motor dysfunction, some scholars will divide the degree of motor dysfunction in paraplegic patients It is a four-stage, easy to observe the development of paraplegia in treatment and the effect after treatment.

Grade I: The patient walks normally, consciously has a strong lower limb, and has or is not kicked, and the pathological reflex is positive.

Level II: When the patient walks, the muscles are tense, weak, uncoordinated, need or need to be able to walk, and check the limbs for convulsions.

Grade III: The lower extremity muscles are unable to walk, the patient is forced to stay in bed, the examination shows a straight paraplegia, and about 50% of the cases are perceptually impaired.

Grade IV: Patients with flexion-type paraplegia, more than 50% of patients with sensory disturbances, often with acne, or more sphincter dysfunction, including soft palate.

2, paraplegia index

According to the degree of loss of three functions of the spinal cord, it is represented by three indexes: 0, 1, and 2. 0 represents normal or near normal function, 1 represents loss of function, and 2 represents complete loss or near complete loss. The degree of loss of function is not completely parallel. When the spontaneous movement of both lower extremities is completely lost, the sensation and sphincter function can still exist. For comparison before and after treatment, it should be recorded in detail.

For example, if a patient's lower limb motor function is nearly completely lost, the index is 2, and the patient is dull but not completely lost. The patient has a total paraplegia index of 4. After the treatment, the patient's sphincter function and sensory disturbances completely recover, and the motor function does not recover. The total paraplegia index is 2, indicating that the treatment plan is correct and effective and can continue.

The paraplegia index has its advantages. Because the classification is small, the degree of loss of the three functions is only a rough indication, but it is still a useful indicator.

3, spinal cord compression positioning diagnosis

It is usually difficult to determine the upper and lower boundaries of the lesion. X-ray radiographs are severely damaged and the paravertebral enlargement shadow can be located. However, when the X-ray film has a paravertebral resistance of 4 to 6 vertebral bodies and the vertebrae are destroyed. When it is not obvious, the neurological examination should be performed in detail, and the results of other image examinations can be used to determine the level of longitudinal compression.

(1) Determining the upper boundary nerve root pain of spinal cord disease is of great significance. Root pain is the direct stimulation of the posterior root of the sensory, with dull pain, string pain, and dispersal along the nerve root. The release area is roughly consistent with the lesion root distribution area. More often accompanied by cerebrospinal fluid impact pain (ie coughing, sneezing, increased pain when exerting force).

After the spinal cord shock is relieved, the level of the lesion can be determined by reflection, that is, the highest segment where the reflection disappears, possibly the segment in which the lesion exists.

(2) Determining the lower boundary of spinal cord lesions According to the change of reflex, the lower segment of the lesion can often be inferred from the highest segment of the hyperreflexia. For example, the patient's diaphragmatic paralysis (C4) but the triceps reflex is hyperthyroidism, it means that the lesion involves C4 and has not been involved in C5. ~6.

1Babinski enlisted a blunt-tip irritant to stimulate the outer edge of the patient's foot. The normal person induced five toe flexion; when the pyramidal beam was damaged, the thumb was stretched with or without the remaining four-toed fan-shaped shape, which was positive. In most cases, the cone system has stenotic lesions, and the connection between the low-level exercise device and the cerebral cortex is interrupted.

2Chaddock excavated the blunt tip to stimulate the lateral edge of the foot, near the junction of the foot and the palm, and the reflection was similar to the Babinski sign.

The 3Oppenheim enrolled examiner pressed the thumb and forefinger back against the front of the calf and moved from top to bottom. The resulting reaction was the same as the Babinski sign, which was also the extension of the toe.

The 4Gordon levy inspector pinched the gastrocnemius muscle and caused the thumb to extend.

The 5Hoffmann levy examiner uses the left hand to hold the patient's wrist, the right index finger and the middle finger grip the patient's middle finger, and the thumb is flicked to bring out the anti-Beijing opera. The patient's thumb and the rest of the fingers have a flexion response.

Spinal tuberculosis complicated with paraplegia

I. Imaging examination

1.X paper film

The positive side of the spine shows that the enlarged paravertebral shadow and the obvious destruction of the vertebral body are usually the plane of the spinal cord compression. If the paraspinal abscess is as long as 4 to 6 vertebral bodies, and the plane of bone compression, combined with signs, etc. Determine, if necessary, myelography, CTM or MRI.

2. Myelography

It shows signs of epidural compression: the main feature is that the orthophotograph can be brush-like or irregular in the obstruction section, but there is no patchy filling defect, and the lateral position sees the contrast agent displacement and bone in the compression area. Increased spinal canal distance or filling defect, lesion in the dura mater, contrast agent without pressure shift, but the contrast agent in the subarachnoid space becomes thin or intermittent, with patchy or small cup filling defect, or small Patchy scattered distribution showed no complete correlation between complete obstruction or partial obstruction and the degree of paraplegia (complete or partial).

3. CT is more valuable for the positioning of small dead bones.

4.MRI

In patients with severe paraplegia such as flexion type, slow type paraplegia and lesion cure type, MRI is the first choice except X-ray conventional radiography. It shows relatively high signal in T1 weighted image low signal and T2 weighted image, showing vertebrae. Abscess and its invasive spinal canal, the sagittal plane combined with the axial surface can accurately show the position of the spinal cord under the pressure of pus or granulation tissue. When the image shows that the epidural space above the horsetail is 60% stressed, the general clinical examination does not have the same degree. Spinal nerve dysfunction.

MRI can be found in cystic changes in the spinal cord of the lesion on the T1-weighted image plane. In the lesion-caught paraplegia T1-weighted image and T2-weighted sagittal plane, the spinal cord is atrophied at the most severe location, even in the T1-weighted phase. There is still an abnormal strip signal in the spinal cord itself.

2. Somatosensory evoked potential (SEP) monitoring spinal cord function

For more than a decade, SEP technology has been used for the monitoring of spinal cord function in traumatic or pathological paraplegia surgery and scoliosis correction. In spinal surgery, the spinal cord may be subjected to different degrees of compression, traction, vibration or spinal cord. Changes in blood perfusion, etc., may cause sensory and dyskinesia in postoperative patients. For this reason, it is very important to awaken the patient's test or/and SEP to monitor the patient's spinal cord function in time. It is worthwhile to ask for treatment. In the SEP monitoring, there is a false negative, so the patient should be awakened at the same time.

1. SEP intraoperative monitoring method

(1) Instruments and equipment There are many kinds of instruments in the market at present. Pay attention to the following points when purchasing: 1 miniaturization; 2 strong anti-interference ability; 3 clear, stable and repeatable signals; 4 flexible software system for graphical analysis and measurement .

(2) The monitoring parameter amplifier gain is 20 to 400,000 times, the filtering passband ball is 1 to 1000 Hz; the square pulse width of the stimulator is 0.1 to 0.5 ms, the frequency is 2.5 times/second; the stimulation intensity is adjusted to the obvious ankle joint before anesthesia. Back extension exercise, after anesthesia administration, due to the influence of muscle relaxant, the same amount of electrical stimulation does not appear ankle joint movement, the stimulation intensity should be appropriately increased, the current output can be 10 to 30 mA, and the voltage output can be adjusted to 20 ~60V, the stimulation intensity should not be too large to avoid nerve damage, the number of superposition is 200-500 times, and the analysis time is 200ms. In patients with spinal cord injury, the SEP peak latency is extended, sometimes exceeding 200ms, and it is mistaken that SEP disappears and the monitoring is flexible. use.

(3) The negative point of stimulation and recording site stimulation is 3cm in front of it, the recording part adopts the International Electrotechnical Society Standard 10/20 system, 2cm backward at Cz point, the reference electrode is on one side of the auricle, and the stimulation and recording electrodes are both Stainless steel needles are used.

2. SEP spinal monitoring indicators

The peak latency and amplitude of SEP can be used as indicators of monitoring. It is generally believed that the P1 peaks are more stable and stable in the waves, and the peak latency of each wave of SEP changes from normal to abnormal delay during operation. The order of occurrence is N2. , P2, N1, P1, and the order of recovery is reversed, P1, N1, P2, N2, but there are also cases where only P1 occurs and abnormal changes occur.

3. The effect of surgical operation on SEP

Spinal tuberculosis complicated with paraplegia surgery decompression surgery operation on the spinal cord, according to our observation of the cause of SEP changes or disappearance can be summarized as: 1 surgical operation shock or decompression of the spinal cord; 2 nights with paraplegia in the surgical removal of bone exposure Spinal canal, extensive resection of the periorbital bone, may be related to the destruction of residual blood supply; 3 SEP changes or even disappears when the spinal cord is washed with saline below 20 °C; 4 after the surgery to remove the epidural fiber scar tissue, SEP is obviously changed. Of course, some of the above reasons can simultaneously have the function of comprehensively affecting the spinal cord. Looking at the above factors, the surgical operation should be accurate, and the light weight and moderate decompression may obtain better surgical results.

4. There are SEP examination results and prognosis

According to the examination data, the preoperative examination of spinal tuberculosis complicated with paraplegia, 93% of SEP in 86 cases of incomplete paraplegia, and 64% of SEP in 53 cases of complete paraplegia did not disappear, indicating that paraplegia caused by chronic compression injury, spinal cord injury is incomplete There is a gradual process between the normal and disappearance of SEP, which is mainly caused by the prolongation of peak potential and the decrease of amplitude or increase, and the severe peak potential of injury is prolonged, but we find that there is no strict correspondence between peak latency and clinical signs.

Spinal tuberculosis complicated with paraplegia early compression injury is mainly due to peak latency. Preoperative examination of SEP with disappearance of spinal tuberculosis complicated with paraplegia usually has a poor prognosis. Conversely, the prognosis is good, and SEP can appear or improve after spinal canal decompression. It was related to the length of disappearance of preoperative SEP. SEP was performed within 1 to 3 weeks after SEP disappeared. SEP was improved in spinal decompression, and 87.5% of postoperative patients had different degrees of functional recovery.

Third, the waist and cerebrospinal fluid dynamic test

It is not appropriate to have a infected area or a lumbar vertebra 1 tuberculosis near the puncture site.

1.Qeckenstedt test

This is a method for checking the presence or absence of obstruction in the subarachnoid space of the spinal canal. After conventional lumbar puncture, one person wraps the blood pressure meter bag around the patient's neck, one person records, and the operator connects the pressure measuring tube and measures the initial pressure. After the height of the water column, the assistant will pump the blood pressure meter to 2.67 kPa (20 mmHg). After that, the pressure will be reported every 5 seconds until the pressure is no longer raised. The assistant will quickly release the airbag and report the pressure every 5 seconds. Until the original level or no longer dropped, the test was followed by pressurization of 5.33 kPa (44 mmHg) and 8.00 kPa (60 mmHg), which were also recorded. Finally, the results were plotted.

(1) The lower part of the spider web is not blocked, and the pressure rises to the highest point after 15 seconds of pressurization. After 15 seconds, the pressure drops to the initial pressure level. When the pressure is 8kPa (60mmHg), it can be raised to 66.67kPa (500mmHg). about.

(2) Subarachnoid cavity partially blocked neck pressure logistics work Cerebrospinal fluid pressure rise and fall are slow, or the ascending speed is normal and the decline is slow, and the final pressure drops less than the original level.

(3) The subarachnoid space is not blocked until 8 kPa (600 mmHg).

Cerebrospinal fluid is normal colorless and transparent, the number of cells is less than 10, the protein is 20%~40mg%, the cerebrospinal fluid is yellowish transparent when obstructed, the protein content can be increased to hundreds of milligrams, the sugar and chloride are mostly normal, and the number of cells does not change. Large, such as the number of cells also increased significantly, may be tuberculous myelitis (Hodgson 1967).

2. Clinical significance

There is no need for decompression before operation. There is obstruction before operation. There is obstruction before operation. After operation, the paraplegia is not restored and there is no need to re-operation. If the operation is still unsmooth and the paraplegia is not restored, it means that the decompression is not complete. For decompression.

This test is simple and easy, but according to the study data, it is considered that it is not completely consistent with myelography. If necessary, it should be confirmed by myelography.

Before the decompression of the spinal canal, the operation is performed during the operation and the operation, and before and after the comparison, the satisfaction of the decompression can be monitored to improve the curative effect.

Diagnosis and differentiation of spinal tuberculosis complicated with paraplegia

diagnosis

Diagnosis can be based on medical history, clinical symptoms, and laboratory tests.

Differential diagnosis

The disease mainly needs to be differentiated from other types of paraplegia, but the disease generally has a clear history of tuberculosis, X-ray examination can find the performance of spinal tuberculosis, and tuberculosis examination is also conducive to the identification of this disease.

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