Erfolgreiche operative Sanierung einer tuberkulösen Spondylodiszitis der Lendenwirbelsäule trotz verzögerter Indikation – 5-Jahres-Ergebnis

 

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Zusammenfassung

Mit 90 Mio. Neuinfektionen weltweit im letzten Jahrzehnt stellt die Tuberkulose eine bedeutende Krankheitsentität dar. 10 % dieser Infektionen manifestieren sich über hämatogene Aussaat in ossäre Strukturen. Die tuberkulöse Spondylodiszitis stellt deswegen weiterhin ein herausragendes Krankheitsbild in der Orthopädie dar. Differenzialdiagnostisch muss diese deshalb beim diffusen Rückenschmerz in Betracht gezogen werden. Der tuberkulösen Spondylodiszitis fehlen pathognomonische Merkmale und klinische, laborchemische und radiologische Parameter sind diagnostisch nicht zuverlässig wegweisend. Anhand einer Kasuistik mit 5-Jahres-Nachuntersuchungsintervall werden die Folgen einer verzögerten Indikation zur operativen Intervention dargelegt. Eine zeitlich frühe adäquate Schichtbildgebung und Keimidentifizierung sind essenziell zur weiteren Planung der Therapie. Ist aufgrund der klinischen Konstellation ein konservativer Therapieversuch möglich, muss dieser spätestens nach 6 bis 8 Wochen bezüglich einer operativen Intervention reevaluiert werden. Bei unverändertem Befund oder gar Progredienz der Infektion mit ossären Destruktionen oder neurologischen Defiziten ist die radikale operative Sanierung zu fordern.

Abstract

Tuberculosis constitutes an important clinical entity with 90 million new infections worldwide during the last decade. 10 % of these infections affect osseous structures based on haematogenous spread. Therefore, tuberculous spondylodiscitis remains a major illness in orthopaedics which needs to be considered in cases of unspecific back pain. Pathognomonic characteristics are absent and clinical, chemical and radiological parameters are not reliable. The consequences of a delayed surgical intervention are discussed based on a case report with 5 year follow-up. Both adequate early CT and MRI scans and identification of the pathogen are essential in order to plan the therapy. Final re-evaluation of a conservative treatment regime needs to be done no later than six to eight weeks depending on the clinical constellation. Persistent or progressive spondylodiscitis with osseous destructions or neurological deficits demands a radical surgical intervention.

Literatur

• 1 Reichman L B. Tuberculosis elimination – what's to stop us?.  Int J Tuberc Lung Dis. 1997;  1 3-11
  PubMedGoogle Scholar
• 2 Tuli S M. Tuberculosis of the Spine: an Historical Review.  Clin Orthop Relat Res. 2007;  460 29-38
  Google Scholar
• 3 World Health Organization .Groups at risk: WHO Report on the Tuberculosis Epidemic. Geneva, Switzerland; World Health Organization 1996
  Google Scholar
• 4 Tay B K, Deckey J, Hu S S. Spinal infections.  J Am Acad Orthop Surg. 2002;  10 188-197
  PubMedGoogle Scholar
• 5 Chen W J, Chen C H, Shih C H. Surgical treatment of tuberculous spondylitis. 50 patients followed for 2–8 years.  Acta Orthop Scand. 1995;  66 137-142
  PubMedGoogle Scholar
• 6 Medical Research Council Working Party on Tuberculosis of the Spine . Five year assessments of controlled trials of ambulatory treatment, debridement and anterior spinal fusion in the management of tuberculosis of the spine: studies in Bulawayo (Rhodesia) and in Hong Kong.  J Bone Joint Surg [Br]. 1978;  60 163-177
  PubMedGoogle Scholar
• 7 Pertuiset E, Beaudreuil J, Liote F, Horusitzky A, Kemiche F, Richette P. et al . Spinal tuberculosis in adults. A study of 103 cases in a developed country, 1980–1994.  Medicine (Baltimore). 1999;  78 309-320
  CrossrefPubMedGoogle Scholar
• 8 Mehta J S, Bhojraj S Y. Tuberculosis of the thoracic spine. A classification based on the selection of surgical strategies.  J Bone Joint Surg [Br]. 2001;  83 859-863
  CrossrefPubMedGoogle Scholar
• 9 Sanal H T, Kocaoglu M, Sehirlioglu A, Bulakbasi N. A rare cause of flank mass: psoas abscess due to extensive primary thoracolumbar tuberculous spondylodiscitis.  AJNR Am J Neuroradiol. 2006;  27 1735-1737
  PubMedGoogle Scholar
• 10 Nussbaum E S, Rockswold G L, Bergman T A, Erickson D L, Seljeskog E L. Spinal tuberculosis: a diagnostic and management challenge.  J Neurosurg. 1995;  83 243-247
  CrossrefPubMedGoogle Scholar
• 11 Alothman A, Memish Z A, Awada A, Al-Mahmood S, Al-Sadoon S, Rahman M M. et al . Tuberculous spondylitis: analysis of 69 cases from Saudi Arabia.  Spine. 2001;  26 E565-E570
  CrossrefPubMedGoogle Scholar
• 12 Rath S A, Neff U, Schneider O, Richter H P. Neurosurgical management of thoracic and lumbar vertebral osteomyelitis and discitis in adults: a review of 43 consecutive surgically treated patients.  Neurosurgery. 1996;  38 926-933
  CrossrefPubMedGoogle Scholar
• 13 Turunc T, Demiroglu Y Z, Uncu H, Colakoglu S, Arslan H. A comparative analysis of tuberculous, brucellar and pyogenic spontaneous spondylodiscitis patients.  J Infect. 2007;  55 158-163
  CrossrefPubMedGoogle Scholar
• 14 Weber M, Heller K-D, Wirtz D, Zimmermann-Picht S, Keulers P, Zilkens K W. Percutane CT-gesteuerte Punktion und Drainage der Spondylodiszitis – ein minimal invasives Verfahren.  Z Orthop. 1998;  136 375-379
  PubMedGoogle Scholar
• 15 Arazi M, Erikoglu M, Odev K, Memik R, Ozdemir M. Primary echinococcus infestation of the bone and muscles.  Clin Orthop Relat Res. 2005;  432 234-241
  PubMedGoogle Scholar
• 16 Bass Jr J B, Farer L S, Hopewell P C, O'Brien R, Jacobs R F, Ruben F. et al . Treatment of tuberculosis and tuberculosis infection in adults and children. American Thoracic Society and The Centers for Disease Control and Prevention.  Am J Respir Crit Care Med. 1994;  149 1359-1374
  PubMedGoogle Scholar
• 17 Chen W J, Chen C H, Shih C H. Surgical treatment of tuberculous spondylitis. 50 patients followed for 2–8 years.  Acta Orthop Scand. 1995;  66 137-142
  PubMedGoogle Scholar
• 18 Bernard L, Perronne C. [Osteoarticular tuberculosis today].  Presse Med. 1997;  26 308-310
  PubMedGoogle Scholar
• 19 Yao D C, Sartoris D J. Musculoskeletal tuberculosis.  Radiol Clin North Am. 1995;  33 679-689
  PubMedGoogle Scholar
• 20 Modic M T, Feiglin D H, Piraino D W, Boumphrey F, Weinstein M A, Duchesneau P M. et al . Vertebral osteomyelitis: assessment using MR.  Radiology. 1985;  157 157-166
  PubMedGoogle Scholar
• 21 Krödel A, Stürz H. Differenzierte operative und konservative Therapie der Spondylitis und Spondylodiszitis.  Z Orthop. 1989;  127 587-596
  Article in Thieme ConnectPubMedGoogle Scholar
• 22 Krödel A, Stürz H, Siebert C. Indications for and results of operative treatment of spondylitis and spondylodiscitis.  Arch Orthop Trauma Surg. 1991;  110 78-82
  PubMedGoogle Scholar
• 23 Griffiths D L, Seddon H, Ball J, Darbyshire J, Fox W, Kemp H BS. et al . A 10-year assessment of a controlled trial comparing debridement and anterior spinal fusion in the management of tuberculosis of the spine in patients on standard chemotherapy in Hong Kong. Eighth Report of the Medical Research Council Working Party on Tuberculosis of the Spine.  J Bone Joint Surg [Br]. 1982;  64 393-398
  PubMedGoogle Scholar
• 24 Griffiths D L, Seddon H, Ball J, Darbyshire J, Fox W, Kemp H BS. et al . A 10-year assessment of controlled trials of inpatient and outpatient treatment and of plaster-of-Paris jackets for tuberculosis of the spine in children on standard chemotherapy. Studies in Masan and Pusan, Korea. Ninth report of the Medical Research Council Working Party on Tuberculosis of the Spine.  J Bone Joint Surg [Br]. 1985;  67 103-110
  PubMedGoogle Scholar
• 25 Oga M, Arizono T, Takasita M, Sugioka Y. Evaluation of the risk of instrumentation as a foreign body in spinal tuberculosis. Clinical and biologic study.  Spine. 1993;  18 1890-1894
  Google Scholar
• 26 Rajasekaran S, Soundarapandian S. Progression of kyphosis in tuberculosis of the spine treated by anterior arthrodesis.  J Bone Joint Surg [Am]. 1989;  71 1314-1323
  PubMedGoogle Scholar

Dr. Christian Karl Georg Spies

Universitätsklinikum Aachen
Klinik für Orthopädie und Unfallchirurgie

Pauwelsstraße 30

52074 Aachen

Phone: 02 41/8 08 94 10

Fax: 02 41/8 08 94 11

Email: christianspies1@gmx.net