骨結(jié)核英文七年制培訓(xùn)課件

IntroductionIntroduction1Introduction

EpidemiologyandEtiology(流行病學(xué)及病因?qū)W)

Pathology(病理)DiagnosisandDifferentialDiagnosis(診斷與鑒別診斷)

ProphylaxisandTreatment(預(yù)防與治療)

Introduction2TuberculosisofbonesandjointsGenerallytobeachronicinflammatoryandinfectiousdiseasecausedbyMyobacterium

tuberculosis.Extrapulmonarysecondarydiseases Approximately95%casesoftuberculosisofbonesandjointsareduetopulmonarytuberculosis,butpulmonarytuberculosisisevidentinonlyhalfthepatientswithskeletalinvolvement.EpidemiologyTuberculosisofbonesandjoin3EpidemiologyIngeneral,mostpatientswiththisdiseaseareintheageof30orbelowatdiagnosisindevelopingcountries

Thesusceptiblepopulation

withthisdisease

isintheelderlyindevelopedcountries.Bothsexesareequallyaffected.EpidemiologyIngeneral,mostp4EpidemiologyTuberculosisofspineisthemostcommonsite,thenextinorderoffrequencybeingtheknee,hip,ankle,sacroiliac,shoulder,andwristjoints.LocationIncidenceEpidemiologyTuberculosisofsp5InSummaryTuberculosisofbonesandjointsisagranulomatousinflammationcausedbyMyobacteriumtuberculosis.About5%oftuberculosisismusculoskeletal.

最常見(jiàn)的肺外繼發(fā)性結(jié)核Tuberculosisofspineisthemostcommonsite,thenextinorderoffrequencybeingtheknee,hip,ankle,sacroiliac,shoulder,andwristjoints.

脊柱結(jié)核最常見(jiàn)

InSummaryTuberculosisofbone6EtiologyPathogen(致病菌)

Acid-fastbacilliMycobacteriumtuberculosisHumantuberclebacilli

（人型結(jié)核桿菌）commonBovinetuberclebacilli(牛型結(jié)核桿菌)rareThefluorescentstainingofacid-fastbacilli

EtiologyPathogen(致病菌)Thef7TheanteriorlesionCriterionofCure治愈標(biāo)準(zhǔn)Psoasabscess腰大肌膿腫起床活動(dòng)已達(dá)1年，仍保持上述4項(xiàng)指標(biāo)formingsequestruaandcavities.granulomasorcaseation(orcheesy)necrosisarea:43%LocalswellingJointfunction:insidethejointoroutsidethejointIntroductionTheanteriorlesionIftheoriginalfocusremainsactiveanduntreated,thelesionwillexacerbate,involvedbone,cartilageandsynovia,developingtotuberculouspanarthritis（全關(guān)節(jié)結(jié)核）.PositiveRateofPathologicalexam:70-80%(Langerhansgiantcells)TBoftheCancellousBoneEpidemiology最常見(jiàn)的肺外繼發(fā)性結(jié)核withoutformingsequestrumSystemicandregionallymphnods:singleratherthanmultipleappearanceEpidemiologyEffectiveTBControlGravitationabscessEtiologyOnMarch24,1882,RobertKochannouncedhisdiscoveryofthetuberclebacillus.HediscoveredastainingtechniquethatenabledhimtoseeMycobacteriumtuberculosis.

（結(jié)核桿菌）

Dr.RobertKochTheanteriorlesionEtiologyOn8EtiologyTransmissionRoutesHematogenousdissemination

（血液傳播）tolongbonesandvertebraeDirectspreadtobonefromadjacenttuberculouslymphadenitis

（結(jié)核性淋巴腺炎）Singleormulticentric（單發(fā)或多中心），particularlyinAIDSPredilectionforsynovium

（偏好滑膜）-higheroxygenpressureEtiologyTransmissionRoutes9Pathology(病理)Initialpathologicalchangesaretuberculous

osteomyelitis

(結(jié)核性骨髓炎,單純骨結(jié)核)andsynovialtuberculosis(滑膜結(jié)核)。Thearticularcartilagesremainintactatthisstage.Thelesionwillbehealedthroughpropertreatmentintime,andjointfunctionwillbereservedthoroughlyorpartially.Iftheoriginalfocusremainsactiveanduntreated,thelesionwillexacerbate,involvedbone,cartilageandsynovia,developingtotuberculouspanarthritis（全關(guān)節(jié)結(jié)核）.Pathology(病理)Initialpatholog10PathologyBasicPathologyChanges:

Exudation

滲出

Deterioration

變質(zhì)

Proliferation增殖PathologyBasicPathologyChang11SimpleSeletal

TBTBoftheCancellousBone

centrallesion

PeripherallesionTheanteriorlesion

Theparadiscallesion

TBoftheCorticalBoneTBoftheMetaphysisSimpleSeletalTBTBoftheCan12Pathology(SimpleSekeltal

TB)TBoftheCancellousBone

Centraltypepoorbloodsupplymainpathologicalchangesincludeskeletalerosionandnecrosisformingsequestruaandcavities.calcaneusPathology(SimpleSekeltalT13Pathology(SimpleSkeletal

TB)TBoftheCancellousBone

Peripheraltypeabundantbloodsupplylocalbonedefectwithoutformingsequestrum

Pathology(SimpleSkeletalTB)14Pathology(SimpleSkeletal

TB)TBoftheCorticalBone

Localizeddestroywithoutformingsequestrumonion-likeproliferation;thequantityofnewboneformationofperiosteumisdeterminedbytheage.Pathology(SimpleSkeletalTB)15Pathology(SimpleSkeletal

TB)TBofthemetaphysis(干骺端結(jié)核）

formingsequestrua(死骨片）

(cancellousbone)newboneformationofperiosteum

（骨膜）

(compactbone)Pathology(SimpleSkeletalTB)16Pathology

(TBoftheSynovialmembrane滑膜結(jié)核)Earlystage:Hyperaemia充血Synovialhypertrophy腫脹Exudateincreasing滲出增多Pannusformation（血管翳）&Ricebodies米粒體(small,freewhitebodiescomposedofcompactmassesoffibrin,necroticsynovialvilli,orcartilagefragments)Latestage:hyperplasiaofsynovium

滑膜肥厚增生Theriskofjointsinvolveknee,hip,elbowandankle.Pathology

(TBoftheSynovial17Pathology(Tuberculous

panarthritis)全關(guān)節(jié)結(jié)核DuetoSimpleTB

DuetosynovialTBPathology(Tuberculouspanart18ComplicationsofLateStageTBofBonesandJointsAbscess膿腫Pathologicalsubluxation,dislocationorfracture病理性半脫位、脫位或骨折Articulardeformityorstiffness關(guān)節(jié)畸形強(qiáng)直Shorteningofextremities肢體短縮

(epiphyseserosion)骨骺受損Paraplegia(spinalcordcompressed)截癱ComplicationsofLateStageTB19ComplicationsofLateStageTBofbonesandjointsAbscess(ColdAbscess)寒性膿腫Paraspinalabscess椎旁膿腫Gravitationabscess流注膿腫Psoasabscess腰大肌膿腫Lumbertrangleabscess腰三角膿腫OtherabscessComplicationsofLateStageTB20Paraspinalabscess椎旁膿腫Paraspinalabscess21最常見(jiàn)的肺外繼發(fā)性結(jié)核15~35歲男性，多發(fā)，（脊柱、髖、膝），對(duì)稱(chēng)性，無(wú)膿無(wú)死骨，HLAb27（+）Tuberculinskintest:TB-Controversy&tendencyHediscoveredastainingtechniquethatenabledhimtoseeMycobacteriumtuberculosis.X線片檢查（胸部和患肢）;MRI脊柱結(jié)核最常見(jiàn)Thesechangesareduetosynovitisandarenonspecific.anorexia厭食DifferentialDiagnosisColdabscess:withoutruborandcalorSynovialhypertrophy腫脹Polymerasechainreaction（多聚酶鏈反應(yīng)）–PCRExtrapulmonarysecondarydiseasesSpecialStandingstancePrincipleofTreatment（人型結(jié)核桿菌）common骨與關(guān)節(jié)結(jié)核的發(fā)展階段和分型及其X線特點(diǎn)全身情況良好，體溫正常，食欲（orexia）良好Tendernessatthert.lowfever低熱Calcificationoftheparaspinalabscessisessentiallypathognomonicfortuberculosis椎旁膿腫鈣化是結(jié)核的基本特征

Normalshadowofpsoasmajor正常腰大肌影Psoasabscess腰大肌膿腫最常見(jiàn)的肺外繼發(fā)性結(jié)核Calcificationofth22Deepgravitationabscessofgroin

腹股溝深部流注膿腫Deepgravitationabscessofg23Articularstiffnessanddeformity

關(guān)節(jié)強(qiáng)直畸形Articularstiffnessanddeform24LimbShortening肢體短縮LimbShortening25

Kyphosis（脊柱后凸）

Paraplegia（截癱）Kyphosis（脊柱后凸）26掌握要點(diǎn)骨與關(guān)節(jié)結(jié)核的發(fā)展階段和分型及其X線特點(diǎn)松質(zhì)骨結(jié)核：中心型壞死型邊緣型溶骨型密質(zhì)骨結(jié)核：層狀骨膜增生，梭型膨大干骺端結(jié)核：兼有松質(zhì)骨和密質(zhì)骨結(jié)核特性滑膜結(jié)核：無(wú)特殊。僅骨質(zhì)疏松全關(guān)節(jié)結(jié)核：早期；晚期骨與關(guān)節(jié)結(jié)核晚期并發(fā)癥：不同部位的寒性膿腫關(guān)節(jié)畸形、強(qiáng)直掌握要點(diǎn)骨與關(guān)節(jié)結(jié)核的發(fā)展階段和分型及其X線特點(diǎn)27Diagnosisand

DifferentialDiagnosisDiagnosisand

DifferentialD28ExtrapulmonarysecondarydiseasesCalcificationoftheparaspinalabscessisessentiallypathognomonicfortuberculosisTBofthemetaphysis:Polymerasechainreaction（多聚酶鏈反應(yīng)）–PCRLimbShorteningfartherstudyingenelevel:(HLAallele,ethnicdifferance;IL-6,IL8,IL-10,TNF-a)Earlydiagnosisandtheuseofantituberculousdrugshaveradicallyimprovedtheprognosisoftuberculousarthritis.Indicationsofoperation手術(shù)適應(yīng)證Synovialhypertrophy腫脹anemia貧血Thesechangesareduetosynovitisandarenonspecific.lowfever低熱Lumbertrangleabscess腰三角膿腫TBoftheCancellousBonePathology(SimpleSkeletalTB)Hematogenousdissemination（血液傳播）tolongbonesandvertebraeParaplegia（截癱）Skintractiontopreventionformingcontracturehip(bendingdeformity)thenfixwithhipspicafor3months.Jointfunction:insidethejointoroutsidethejointTreatment?Diagnosis

MedicalhistoryInsidiousonset隱匿起病Symptoms:

pain疼痛

lowfever低熱

nightsweats盜汗

anorexia厭食

anemia貧血

weightloss體重減輕

localswelling局限腫脹morbidnightcryingofbabies夜啼contacthistory接觸史Extrapulmonarysecondarydisea29DiagnosisClinicalexamination

Systemicandregionallymphnods:singleratherthanmultipleappearanceLocalswellingColdabscess:withoutruborandcalorLocalheatandrednessareusuallyabsent,andtendernessisminimal.

Sinustracts:multiple

appearance,periarticulartendernessandpercussingpainJointfunction:insidethejointoroutsidethejointSystemicsymptoms:mildexceptforchildDiagnosisClinicalexamination30DiagnosisRadiographicFindings(6-8weeksafter)SkeletalTBTBofthecancellousbone:Centrallesion:bonenecrosisPeripherallesion:bonelysisTBofthecorticalbone:layerperiosteumproliferation&shuttle-likeinflationTBofthemetaphysis:DiagnosisRadiographicFindings31DiagnosisRadiographicFindingsTBofthesynovialmembrane:Theearliestfindingsintheradiogramsareregionalboneatrophy,soft-tissueswelling,andcapsulardistention.Thesechangesareduetosynovitisandarenonspecific.Tuberculouspanarthritis:Theabovechangesarefollowedbyperipheralerosionoftheboneanddestructionofthesubchondralbone,withthejointspacenarrowing.

DiagnosisRadiographicFindings32Diagnosis

Labtestbloodrt.10%pt.whitecellThesedimentationrate:non-pathognomonicfortuberculosisbutaltersearlythanX-ray(male<15mm/h;femal<20mm/h)

Tuberculinskintest:immunocompetentpatients:alwayspostiveimmunocompromisedpatients:33%postiveDiagnosisLabtest33Diagnosis

LabfindingBacteriologicexamination

(thetuberclebacillusculture)

(3~6weeks)

orhistologicalexaminationofpusorbiopsyspecimen.PositiveRateofCultureforM.tuberculosis

onsmearpus:70%granulomasorcaseation(orcheesy)necrosisarea:43%jointasperationordeadbone:35%PositiveRateofPathologicalexam:70-80%(Langerhansgiantcells)

MRIandPCRuseforearlydiagnosisDiagnosisLabfinding34松質(zhì)骨結(jié)核：中心型壞死型leg,6monthswithhippainClearanceoffocallesion（病灶清除術(shù)）March2,2007Diagnosis?granulomasorcaseation(orcheesy)necrosisarea:43%Labtest:Wbcnormal,CRP,ESRGravitationabscesslocalswelling局限腫脹74yrs,female,formingsequestrua(死骨片）松質(zhì)骨結(jié)核：中心型壞死型anorexia厭食CastfixationimmunologicresearchneedtobegofartherTBofthemetaphysis:tendernessandpercussingpainThesedimentationrate:non-pathognomonicfortuberculosisbutaltersearlythanX-ray(male<15mm/h;femal<20mm/h)lowfever低熱MethodofJointAspirationforTB松質(zhì)骨結(jié)核：中心型壞死型Method35DifferentialDiagnosisRheumatoidArthritis:

20~55歲女性，多關(guān)節(jié)、小關(guān)節(jié)，對(duì)稱(chēng)性。RF因子（+）

AnkylosingSpondylitis:

15~35歲男性，多發(fā)，（脊柱、髖、膝），對(duì)稱(chēng)性，無(wú)膿無(wú)死骨，HLAb27（+）

Septicarthritis:關(guān)節(jié)穿刺

SepticOsteomyelitis:

全身中毒癥狀重。細(xì)菌學(xué)和病理檢查

BoneTumor:脊柱結(jié)核早期侵犯椎間盤(pán)，椎間隙狹窄消失DifferentialDiagnosisRheumat36急性骨髓炎(以破壞和增生為主）X線見(jiàn)骨質(zhì)廣泛破壞，大量死骨及大量骨膜新骨形成骨結(jié)核（破壞、疏松、萎縮為主）髓腔內(nèi)溶骨性破壞,無(wú)死骨；骨干周?chē)袕V泛新骨形成急性骨髓炎(以破壞和增生為主）X線見(jiàn)骨質(zhì)廣泛破壞，大量死骨及37慢性骨髓炎破壞與增生并存;骨質(zhì)硬化；大量死骨、包殼發(fā)生骨結(jié)核以破壞、疏松、萎縮為主;很少硬化；死骨少、小(沙粒狀）慢性骨髓炎骨結(jié)核38掌握要點(diǎn)骨與關(guān)節(jié)結(jié)核的診斷要點(diǎn)：分四步驟：病史與臨床表現(xiàn)結(jié)菌素皮膚實(shí)驗(yàn)X線片檢查（胸部和患肢）;MRI細(xì)菌學(xué)檢查（痰培養(yǎng)、膿腫穿刺液培養(yǎng)）主要鑒別的疾?。航Y(jié)締組織病骨關(guān)節(jié)感染性疾病骨腫瘤掌握要點(diǎn)骨與關(guān)節(jié)結(jié)核的診斷要點(diǎn)：39ProphylaxisandTreatmentProphylaxisandTreatment40EffectiveTBControlTheWHO-recommendedtreatmentstrategyfordetectionandcureofTBisDOTS.EffectiveTBControl41TreatmentEarlydiagnosisandtheuseofantituberculousdrugshaveradicallyimprovedtheprognosisoftuberculousarthritis.Othermeasuresadoptedareresttotheaffectedjointinfunctionalposition,tractionwhenneededanddietaryimprovement.Treatmentconsistsofgeneralmedicalmeasures,chemotherapy,localconservativeorthopediccare,andsurgery.TreatmentEarlydiagnosisandt42CriterionofCure治愈標(biāo)準(zhǔn)全身情況良好，體溫正常，食欲（orexia）良好局部癥狀消失，無(wú)疼痛，竇道閉合血沉3次結(jié)果正常X線顯示膿腫縮小乃至消失或鈣化，無(wú)死骨，病灶邊緣輪廓清晰起床活動(dòng)已達(dá)1年，仍保持上述4項(xiàng)指標(biāo)CriterionofCure治愈標(biāo)準(zhǔn)全身情況良好，體43Indicationsofoperation手術(shù)適應(yīng)證骨關(guān)節(jié)結(jié)核有明顯的死骨忽而大膿腫形成竇道流膿經(jīng)久不愈脊柱結(jié)核引起脊髓受壓Indicationsofoperation手術(shù)適應(yīng)證44骨干周?chē)袕V泛新骨形成Earlydiagnosisandtheuseofantituberculousdrugshaveradicallyimprovedtheprognosisoftuberculousarthritis.Polymerasechainreaction（多聚酶鏈反應(yīng)）–PCRGeneprobetechnic（基因探針技術(shù)）,March2,2007GenerallytobeachronicinflammatoryandinfectiousdiseasecausedbyMyobacteriumtuberculosis.TBofthemetaphysis:SearchingmoreidealdrugforTBwithlesssideeffectIftheoriginalfocusremainsactiveanduntreated,thelesionwillexacerbate,involvedbone,cartilageandsynovia,developingtotuberculouspanarthritis（全關(guān)節(jié)結(jié)核）.thequantityofnewboneformationofanorexia厭食weightloss體重減輕periosteumisdeterminedbytheage.(arthroscopy/locallesion,open/extensivelesion)Labtest:Wbcnormal,CRP,ESRThomastestHipTuberculosispain疼痛immunologicresearchneedtobegofartherSpinalTuberculosisClinicalManifestationCervical:NeckPain(mildtosever)NumbnessofarmduetoneuralcompressionObstructingbreathingandswallowingwithPostpharyngealabscess骨干周?chē)袕V泛新骨形成SpinalTuberculosis45TuberculosisofSpine

ClinicalManifestationThoracic:BackpainGibbousdeformityLumbar:SpecialStandingstancePick-uptest(+)GravitationabscessTuberculosisofSpine

46OsseousdestroyanddecreaseinoneormorediscspacesColdAbscess:Cervical:

Lumbar

ThoracicTuberculosisofSpine

RoentgenographicFindings

Osseousdestroyanddecrease47PrincipleofTreatmentCastfixationSurgicaltreatmentEvacuationorexcisionofsofttissueabscesses（切開(kāi)排膿）

Clearanceoffocallesion（病灶清除術(shù)）

Osteotomy,Arthrodesisandarthroplasty.

（矯形手術(shù)）PrincipleofTreatmentCastf48HipTuberculosisClinicalManifestationHippainLimpAbscessofgroinPE:Figure4testHiphyperextensiontestThomastestHipTuberculosisClinicalManif49HipTuberculosis

RoentgenographicFindingsX-rayCTMRIHipTuberculosisRoentgenograp50HipTuberculosisPrincipleofTreatmentChemotherapySkintractiontopreventionformingcontracturehip(bendingdeformity)thenfixwithhipspicafor3months.SimplesynovialTB:Intra-articularinjectionwithanti-tuberclemedicineSynovectomyorcurettageforthecaseswithintra-articulardropsytoreservefemoralhead.(arthroscopy/locallesion,open/extensivelesion)Tuberculouspanarthritis:(anti-tbdrug>1yr.ESR,CRPNormal.)Osteotomy,ArthrodesisandarthroplastyHipTuberculosisPrincipleofT51Casereport74yrs,female,lowbackpain,radiatetothert.leg,6monthswithhippainlimitedinbed2monthsprogressiveweightloss,anorexia,nofever,Tendernessatthert.groinofthehipLimitedrangofmotionofrt.hip,Thomassign(-)Labtest:Wbcnormal,CRP,ESRCasereport74yrs,female,52Oct.26,2006Oct.26,200653Feb.23,2007Feb.23,200754March2,2007March2,200755March2,2007March2,200756HipjointaspirationPus-likeliquid5mlCulture(-)HipjointaspirationPus-likel57Q&ADiagnosis?Treatment?Q&ADiagnosis?58TB-Controversy&tendencyPathogenesisimmunologicresearchneedtobegofartherfartherstudyingenelevel:(HLAallele,ethnicdifferance;IL-6,IL8,IL-10,TNF-a)TB-Controversy&tendencyPath59TB-Controversy&tendencyEarlydiagnosis:themolecularbiologytechnicisstilladevelopmentaltendencyofstudy.Geneprobetechnic（基因探針技術(shù)）,Polymerasechainreaction（多聚酶鏈反應(yīng)）–PCRNucleicacidamplification(核酸擴(kuò)增）invitro…TB-Controversy&tendencyEarl60TB-Controversy&tendencySearchingmoreidealdrugforTBwithlesssideeffectTB-Controversy&tendencySear61ThanksThanks62Earlydiagnosisandtheuseofantituberculousdrugshaveradicallyimprovedtheprognosisoftuberculousarthritis.Pick-uptest(+)SkeletalTB最常見(jiàn)的肺外繼發(fā)性結(jié)核Gravitationabscess流注膿腫Coldabscess:withoutruborandcalorTheabovechangesarefollowedbyperipheralerosionoftheboneanddestructionofthesubchondralbone,withthejointspacenarrowing.Hyperaemia充血Centrallesion:bonenecrosisHematogenousdissemination（血液傳播）tolongbonesandvertebrae(arthroscopy/locallesion,open/extensivelesion)Localheatandrednessareusuallyabsent,andtendernessisminimal.About5%oftuberculosisismusculoskeletal.Pathology

(TBoftheSynovialmembrane滑膜結(jié)核)骨與關(guān)節(jié)結(jié)核的發(fā)展階段和分型及其X線特點(diǎn)起床活動(dòng)已達(dá)1年，仍保持上述4項(xiàng)指標(biāo)ArticularstiffnessanddeformityChemotherapyAcid-fastbacilliTheanteriorlesionDeterioration變質(zhì)EtiologyOnMarch24,1882,RobertKochannouncedhisdiscoveryofthetuberclebacillus.HediscoveredastainingtechniquethatenabledhimtoseeMycobacteriumtuberculosis.

（結(jié)核桿菌）

Dr.RobertKochEarlydiagnosisandtheuseof63Pathology(SimpleSkeletal

TB)TBoftheCancellousBone

Peripheraltypeabundantbloodsupplylocalbonedefectwithoutformingsequestrum

Pathology(SimpleSkeletalTB)64Diagnosis

MedicalhistoryInsidiousonset隱匿起病Symptoms:

pain疼痛

lowfever低熱

nightsweats盜汗

anorexia厭食

anemia貧血

weightloss體重減輕

localswelling局限腫脹morbidnightcryingofbabies夜啼contacthistory接觸史DiagnosisMedicalhistory65DiagnosisClinicalexamination

Systemicandregionallymphnods:singleratherthanmultipleappearanceLocalswellingColdabscess:withoutruborandcalorLocalheatandrednessareusuallyabsent,andtendernessisminimal.

Sinustracts:multiple

appearance,periarticulartendernessandpercussingpainJointfunction:insidethejointoroutsidethejointSystemicsymptoms:mildexceptforchildDiagnosisClinicalexamination66掌握要點(diǎn)骨與關(guān)節(jié)結(jié)核的診斷要點(diǎn)：分四步驟：病史與臨床表現(xiàn)結(jié)菌素皮膚實(shí)驗(yàn)X線片檢查（胸部和患肢）;MRI細(xì)菌學(xué)檢查（痰培養(yǎng)、膿腫穿刺液培養(yǎng)）主要鑒別的疾?。航Y(jié)締組織病骨關(guān)節(jié)感染性疾病骨腫瘤掌握要點(diǎn)骨與關(guān)節(jié)結(jié)核的診斷要點(diǎn)：67ProphylaxisandTreatmentProphylaxisandTreatment68Feb.23,2007Feb.23,200769TB-Controversy&tendencyEarlydiagnosis:themolecularbiologytechnicisstilladevelopmentaltendencyofstudy.Geneprobetechnic（基因探針技術(shù)）,Polymerasechainreaction（多聚酶鏈反應(yīng)）–PCRNucleicacidamplification(核酸擴(kuò)增）invitro…TB-Controversy&tendencyEarl70IntroductionIntroduction71Introduction

EpidemiologyandEtiology(流行病學(xué)及病因?qū)W)

Pathology(病理)DiagnosisandDifferentialDiagnosis(診斷與鑒別診斷)

ProphylaxisandTreatment(預(yù)防與治療)

Introduction72TuberculosisofbonesandjointsGenerallytobeachronicinflammatoryandinfectiousdiseasecausedbyMyobacterium

tuberculosis.Extrapulmonarysecondarydiseases Approximately95%casesoftuberculosisofbonesandjointsareduetopulmonarytuberculosis,butpulmonarytuberculosisisevidentinonlyhalfthepatientswithskeletalinvolvement.EpidemiologyTuberculosisofbonesandjoin73EpidemiologyIngeneral,mostpatientswiththisdiseaseareintheageof30orbelowatdiagnosisindevelopingcountries

Thesusceptiblepopulation

withthisdisease

isintheelderlyindevelopedcountries.Bothsexesareequallyaffected.EpidemiologyIngeneral,mostp74EpidemiologyTuberculosisofspineisthemostcommonsite,thenextinorderoffrequencybeingtheknee,hip,ankle,sacroiliac,shoulder,andwristjoints.LocationIncidenceEpidemiologyTuberculosisofsp75InSummaryTuberculosisofbonesandjointsisagranulomatousinflammationcausedbyMyobacteriumtuberculosis.About5%oftuberculosisismusculoskeletal.

最常見(jiàn)的肺外繼發(fā)性結(jié)核Tuberculosisofspineisthemostcommonsite,thenextinorderoffrequencybeingtheknee,hip,ankle,sacroiliac,shoulder,andwristjoints.

脊柱結(jié)核最常見(jiàn)

InSummaryTuberculosisofbone76EtiologyPathogen(致病菌)

Acid-fastbacilliMycobacteriumtuberculosisHumantuberclebacilli

（人型結(jié)核桿菌）commonBovinetuberclebacilli(牛型結(jié)核桿菌)rareThefluorescentstainingofacid-fastbacilli

EtiologyPathogen(致病菌)Thef77TheanteriorlesionCriterionofCure治愈標(biāo)準(zhǔn)Psoasabscess腰大肌膿腫起床活動(dòng)已達(dá)1年，仍保持上述4項(xiàng)指標(biāo)formingsequestruaandcavities.granulomasorcaseation(orcheesy)necrosisarea:43%LocalswellingJointfunction:insidethejointoroutsidethejointIntroductionTheanteriorlesionIftheoriginalfocusremainsactiveanduntreated,thelesionwillexacerbate,involvedbone,cartilageandsynovia,developingtotuberculouspanarthritis（全關(guān)節(jié)結(jié)核）.PositiveRateofPathologicalexam:70-80%(Langerhansgiantcells)TBoftheCancellousBoneEpidemiology最常見(jiàn)的肺外繼發(fā)性結(jié)核withoutformingsequestrumSystemicandregionallymphnods:singleratherthanmultipleappearanceEpidemiologyEffectiveTBControlGravitationabscessEtiologyOnMarch24,1882,RobertKochannouncedhisdiscoveryofthetuberclebacillus.HediscoveredastainingtechniquethatenabledhimtoseeMycobacteriumtuberculosis.

（結(jié)核桿菌）

Dr.RobertKochTheanteriorlesionEtiologyOn78EtiologyTransmissionRoutesHematogenousdissemination

（血液傳播）tolongbonesandvertebraeDirectspreadtobonefromadjacenttuberculouslymphadenitis

（結(jié)核性淋巴腺炎）Singleormulticentric（單發(fā)或多中心），particularlyinAIDSPredilectionforsynovium

（偏好滑膜）-higheroxygenpressureEtiologyTransmissionRoutes79Pathology(病理)Initialpathologicalchangesaretuberculous

osteomyelitis

(結(jié)核性骨髓炎,單純骨結(jié)核)andsynovialtuberculosis(滑膜結(jié)核)。Thearticularcartilagesremainintactatthisstage.Thelesionwillbehealedthroughpropertreatmentintime,andjointfunctionwillbereservedthoroughlyorpartially.Iftheoriginalfocusremainsactiveanduntreated,thelesionwillexacerbate,involvedbone,cartilageandsynovia,developingtotuberculouspanarthritis（全關(guān)節(jié)結(jié)核）.Pathology(病理)Initialpatholog80PathologyBasicPathologyChanges:

Exudation

滲出

Deterioration

變質(zhì)

Proliferation增殖PathologyBasicPathologyChang81SimpleSeletal

TBTBoftheCancellousBone

centrallesion

PeripherallesionTheanteriorlesion

Theparadiscallesion

TBoftheCorticalBoneTBoftheMetaphysisSimpleSeletalTBTBoftheCan82Pathology(SimpleSekeltal

TB)TBoftheCancellousBone

Centraltypepoorbloodsupplymainpathologicalchangesincludeskeletalerosionandnecrosisformingsequestruaandcavities.calcaneusPathology(SimpleSekeltalT83Pathology(SimpleSkeletal

TB)TBoftheCancellousBone

Peripheraltypeabundantbloodsupplylocalbonedefectwithoutformingsequestrum

Pathology(SimpleSkeletalTB)84Pathology(SimpleSkeletal

TB)TBoftheCorticalBone

Localizeddestroywithoutformingsequestrumonion-likeproliferation;thequantityofnewboneformationofperiosteumisdeterminedbytheage.Pathology(SimpleSkeletalTB)85Pathology(SimpleSkeletal

TB)TBofthemetaphysis(干骺端結(jié)核）

formingsequestrua(死骨片）

(cancellousbone)newboneformationofperiosteum

（骨膜）

(compactbone)Pathology(SimpleSkeletalTB)86Pathology

(TBoftheSynovialmembrane滑膜結(jié)核)Earlystage:Hyperaemia充血Synovialhypertrophy腫脹Exudateincreasing滲出增多Pannusformation（血管翳）&Ricebodies米粒體(small,freewhitebodiescomposedofcompactmassesoffibrin,necroticsynovialvilli,orcartilagefragments)Latestage:hyperplasiaofsynovium

滑膜肥厚增生Theriskofjointsinvolveknee,hip,elbowandankle.Pathology

(TBoftheSynovial87Pathology(Tuberculous

panarthritis)全關(guān)節(jié)結(jié)核DuetoSimpleTB

DuetosynovialTBPathology(Tuberculouspanart88ComplicationsofLateStageTBofBonesandJointsAbscess膿腫Pathologicalsubluxation,dislocationorfracture病理性半脫位、脫位或骨折Articulardeformityorstiffness關(guān)節(jié)畸形強(qiáng)直Shorteningofextremities肢體短縮

(epiphyseserosion)骨骺受損Paraplegia(spinalcordcompressed)截癱ComplicationsofLateStageTB89ComplicationsofLateStageTBofbonesandjointsAbscess(ColdAbscess)寒性膿腫Paraspinalabscess椎旁膿腫Gravitationabscess流注膿腫Psoasabscess腰大肌膿腫Lumbertrangleabscess腰三角膿腫OtherabscessComplicationsofLateStageTB90Paraspinalabscess椎旁膿腫Paraspinalabscess91最常見(jiàn)的肺外繼發(fā)性結(jié)核15~35歲男性，多發(fā)，（脊柱、髖、膝），對(duì)稱(chēng)性，無(wú)膿無(wú)死骨，HLAb27（+）Tuberculinskintest:TB-Controversy&tendencyHediscoveredastainingtechniquethatenabledhimtoseeMycobacteriumtuberculosis.X線片檢查（胸部和患肢）;MRI脊柱結(jié)核最常見(jiàn)Thesechangesareduetosynovitisandarenonspecific.anorexia厭食DifferentialDiagnosisColdabscess:withoutruborandcalorSynovialhypertrophy腫脹Polymerasechainreaction（多聚酶鏈反應(yīng)）–PCRExtrapulmonarysecondarydiseasesSpecialStandingstancePrincipleofTreatment（人型結(jié)核桿菌）common骨與關(guān)節(jié)結(jié)核的發(fā)展階段和分型及其X線特點(diǎn)全身情況良好，體溫正常，食欲（orexia）良好Tendernessatthert.lowfever低熱Calcificationoftheparaspinalabscessisessentiallypathognomonicfortuberculosis椎旁膿腫鈣化是結(jié)核的基本特征

Normalshadowofpsoasmajor正常腰大肌影Psoasabscess腰大肌膿腫最常見(jiàn)的肺外繼發(fā)性結(jié)核Calcificationofth92Deepgravitationabscessofgroin

腹股溝深部流注膿腫Deepgravitationabscessofg93Articularstiffnessanddeformity

關(guān)節(jié)強(qiáng)直畸形Articularstiffnessanddeform94LimbShortening肢體短縮LimbShortening95

Kyphosis（脊柱后凸）

Paraplegia（截癱）Kyphosis（脊柱后凸）96掌握要點(diǎn)骨與關(guān)節(jié)結(jié)核的發(fā)展階段和分型及其X線特點(diǎn)松質(zhì)骨結(jié)核：中心型壞死型邊緣型溶骨型密質(zhì)骨結(jié)核：層狀骨膜增生，梭型膨大干骺端結(jié)核：兼有松質(zhì)骨和密質(zhì)骨結(jié)核特性滑膜結(jié)核：無(wú)特殊。僅骨質(zhì)疏松全關(guān)節(jié)結(jié)核：早期；晚期骨與關(guān)節(jié)結(jié)核晚期并發(fā)癥：不同部位的寒性膿腫關(guān)節(jié)畸形、強(qiáng)直掌握要點(diǎn)骨與關(guān)節(jié)結(jié)核的發(fā)展階段和分型及其X線特點(diǎn)97Diagnosisand

DifferentialDiagnosisDiagnosisand

DifferentialD98ExtrapulmonarysecondarydiseasesCalcificationoftheparaspinalabscessisessentiallypathognomonicfortuberculosisTBofthemetaphysis:Polymerasechainreaction（多聚酶鏈反應(yīng)）–PCRLimbShorteningfartherstudyingenelevel:(HLAallele,ethnicdifferance;IL-6,IL8,IL-10,