Inflammatory spinal conditions and back pain

The relevance of the problem of inflammatory, primarily infectious, lesions of the spine is determined not only by the fact that these diseases disrupt two main functions of the spine - ensuring a stable vertical position of the body and protecting the spinal nerve structures.

At the present stage, attention to the problem of spondylitis is explained by a number of objective reasons. Against the background of the general "aging" of the planet's population, the number of patients with pyogenic (purulent) diseases typical of the older age group, including spondylitis, is increasing. Infectious lesions of the spine are often observed in patients who, just a few decades ago, were rare, isolated cases: in drug addicts with intravenous drug administration; in patients from risk groups with chronic endocrine pathology, primarily with diabetes mellitus; in patients with various diseases requiring long-term hormonal and cytostatic therapy. It should be remembered that against the background of a constantly increasing number of patients with acquired immunodeficiency syndrome, the number of patients with AIDS-associated infections is also steadily growing. According to SS Moon et al. (1997), in patients with tuberculous spondylitis in a number of countries, AIDS occurs in 30% of cases. There are no official domestic statistics on this issue, but the personal experience of one of the authors of the book in a clinic for patients with bone and joint tuberculosis convinces us that such patients have been encountered more and more frequently recently.

Any anatomical area of the spine and adjacent tissues can potentially be involved in the inflammatory process.

To designate and describe inflammatory diseases of the spine, different authors use different terms, the nature of which is largely determined by the localization (zone) of the lesion.

The term "infectious" in this article is not used to denote spinal lesions caused by infectious diseases, but to denote local bacterial or viral lesions.

Clinical terminology used in inflammatory diseases of the spine (Calderone RR, Larsen M., CapenDA., 1996)

Affected areas of the spine	Affected structures	Names of diseases used
Anterior spine	Vertebral bodies	Osteomyelitis of the spine Spondylodiscitis Spondylitis Tuberculous spondylitis or Pott's disease
	Intervertebral discs	Discitis Paravertebral abscess
	Paravertebral spaces
		Psoas abscess Retropharyngeal abscess Mediastinitis, empyema
Posterior spine	Subcutaneous products	Superficial wound infection Infected seroma (in the presence of foreign bodies, including implants) Deep wound infection
	Subfascial production	Paraspinal abscess Osteomyelitis, spondyloarthritis
	Posterior elements of the vertebrae	Deep wound infection
Spinal canal	Epidural production	Epidural abscess, epiduritis
	Spinal cord membranes	Meningitis
	Subdural pr-vo	Subdural abscess
	Spinal cord	Myelitis, intramedullary abscess

The etiological factor is of primary importance in determining the pathogenesis of inflammatory diseases of the spine and the tactics of their treatment. Depending on the etiology, the following types of inflammatory diseases of the spine are distinguished:

• Infectious diseases of the spine or osteomyelitis proper. Among them, the following should be highlighted:
  • primary osteomyelitis, which occurs in the absence of other visible foci of infection;
  • secondary hematogenous or septic (metastatic) osteomyelitis;
  • secondary post-traumatic osteomyelitis - wound (gunshot and non-gunshot);
  • contact osteomyelitis in the presence of a primary focus of inflammation in the paravertebral soft tissues and
  • iatrogenic osteomyelitis developing after diagnostic procedures and surgical interventions;
• infectious and allergic inflammatory diseases of the spine - rheumatoid arthritis, Bechterew's disease, etc.;
• parasitic lesions of the spine in schistosomiasis, echinococcosis, etc.

Osteomyelitis of the spine, by the nature of the predominant lesion of the bone structures of the vertebra or intervertebral disc with the contact sections of the vertebral bodies, is divided into spondylitis and spondylodiscitis. Depending on the morphological features of the infectious process, two groups of osteomyelitis of the spine are distinguished:

• pyogenic or purulent osteomyelitis, which, depending on the nature of the disease, can be acute or chronic. It should be noted that the concept of chronic inflammation primarily implies not the duration of the disease, but the morphological structure of the pathological focus. Depending on the type of bacterial microflora isolated, osteomyelitis can be nonspecific (staphylococcal, streptococcal, caused by Coli flora) or specific (typhoid, gonorrheal, etc.);
• granulomatous osteomyelitis, among which, according to etiology, three clinical variants are distinguished: mycobacterial (tuberculous), mycotic (fungal) and spirochetal (syphilitic) spondylitis.

Tuberculous spondylitis or Pop's disease (the clinical picture of the disease was described by Persival Pott at the end of the 17th century). A characteristic feature of the disease is its slow and steady progression during its natural course, leading to severe cosmetic and neurological complications: gross deformations of the spine, paresis, paralysis, and pelvic dysfunction. P.G. Kornev (1964, 1971) identified the following phases and stages in the clinical course of tuberculous spondylitis:

1. prespondylitic phase, characterized by the occurrence of a primary lesion in the vertebral body, which usually occurs without local clinical symptoms and is extremely rarely diagnosed in a timely manner;
2. spondylitic phase, which is characterized by the progressive development of the disease with clear clinical symptoms, which in turn goes through several clinical stages:
   • the onset stage is characterized by the appearance of back pain and limited mobility of the spine;
   • the peak stage corresponds to the appearance of complications of the pathological process in the spine: abscesses, kyphotic deformity (hump) and spinal disorders;
   • the stage of attenuation corresponds to an improvement in the patient's condition and well-being, and radiographic changes in the form of possible blocking of the vertebral bodies indicate stabilization of the process. However, this stage is characterized by the preservation of residual cavities in the vertebrae and residual, including calcified, abscesses.
3. The post-spondyligic phase is characterized by two features:
   • the presence of secondary anatomical and functional disorders associated with orthopedic and neurological complications of spondylitis, and
   • the possibility of exacerbations and relapses of the disease with the activation of unresolved isolated foci and abscesses.

Typical complications of tuberculous spondylitis are abscesses, fistulas, kyphotic deformity and neurological disorders (myelo/radiculopathy).

The localization and spread of abscesses in tuberculous spondylitis is determined by the level of damage to the spine and the anatomical features of the surrounding tissues. Due to the location of the inflammation in the vertebral body, the abscess may spread beyond it in any direction: forward (prevertebral), to the sides (paravertebral), and backward from the vertebral body toward the spinal canal (epidural).

Taking into account the anatomical features of paravertebral tissues and interfascial spaces at different levels, abscesses can be detected not only near the spine, but also in areas distant from it.

Localization of abscesses in tuberculous spondylitis

Level of spinal lesion	Localization of abscesses
1. Cervical vertebrae	a) retropharyngeal, b) paraoccipital, c) abscess of the posterior mediastinum (typical for lesions of the lower cervical vertebrae).
2. Thoracic vertebrae	a) intrathoracic paravertebral; b) subdiaphragmatic (characteristic for lesions of the T1-T12 vertebrae).
3. Lumbar vertebrae	a) psoas abscesses, with possible spread under the inguinal ligament along the lacuna musculorum to the anteroinner surface of the thigh and into the popliteal region; b) local paravertebral abscesses (rare); c) posterior abscesses, spreading through the lumbar triangle into the lumbar region.
4. Lumbosacral region and sacral vertebrae	A) presacral, b) retrorectal, c) gluteal, extending along the piriformis muscles to the outer surface of the hip joint.

One of the typical complications of tuberculous spondylitis is kyphotic deformation of the spine. Depending on the appearance of the deformation, several types of kyphosis are distinguished:

• button kyphosis is typical for local damage to one or two vertebrae. Such deformations often develop in patients who become ill in adulthood;
• gentle trapezoid kyphosis is typical for widespread lesions, usually not accompanied by total destruction of the vertebral bodies;
• angular kyphosis is typical for widespread lesions accompanied by total destruction of the bodies of one or more vertebrae. Such destruction, as a rule, develops in individuals who became ill in early childhood. The deformation inevitably progresses as the child grows in the absence of adequate surgical treatment. It is for the designation of angular kyphosis that the terminology committee of the Scoliosis Research Society (1973) recommends using the term gibbus, or hump.

Neurological complications of tuberculous spondylitis may be associated with both direct compression of the spinal cord and its secondary ischemic disorders. It is customary to differentiate dysfunctions of the spinal cord (myelopathies), spinal roots (radiculopathies) and mixed disorders (myeloradiculopathies).

The issues of qualitative assessment of myelo/radiculopathy in tuberculous spondylitis are widely discussed in the literature. The most widely used classifications of paraplegia (paraparesis) in Pott's disease are those that are very similar to the detailed Frankel scale. It should be noted, however, that the author of one of the classifications, K. Kumar (1991), considers it necessary to make changes to the Frankel scale as applied to tuberculous spondylitis on the basis that "..this disease is characterized by gradual development of compression and wide distribution in extent."

Tub. (1985) classification of neurological disorders in tuberculous spondylitis

Degree of paraparesis	Clinical characteristics
I	Normal gait without any motor weakness. Clonic and plantar flexed feet may be present. Tendon reflexes are normal or brisk.
II	Complaints of discoordination, spasticity or difficulty walking. The ability to walk independently with or without external support is preserved. Clinically - spastic paresis.
III	Severe muscle weakness, the patient is bedridden. Spastic paraplegia with a predominance of extensor tone is revealed.
IV	Spastic paraplegia or paraplegia with involuntary spastic contractions of the flexors; paraplegia with predominant extensor tone, spontaneous spastic contractions of the flexors, sensory loss of more than 50%, and severe sphincter disorders; flaccid paraplegia.

Pattisson's (1986) classification of neurological disorders in tuberculous spondylitis

Degree of paraparesis	Clinical characteristics
0	Absence of neurological disorders.
I	The presence of pyramidal signs without sensory impairment and motor disorders with preserved ability to walk.
II (A)	Incomplete loss of movement, no sensory disturbances, ability to walk independently or with external assistance (support) preserved.
II (B)	Incomplete loss of movement, no sensory disturbances, walking is lost.
III	Complete loss of movement. No sensory disturbances, walking is impossible.
IV	Complete loss of movement, sensitivity is impaired or lost, walking is impossible.
V	Complete loss of movement, severe or total sensory impairment, loss of sphincter control and/or spasmodic involuntary muscle contractions.

Having presented the above classifications, we note that in our own work we still prefer to use the Frankel scale modified for children, which we present in Chapter 7, dedicated to spinal cord injury.

Among the inflammatory diseases of the spine, the most peculiar and least studied is ankylosing spondylitis or Marie-Strumpell-Bechterew disease. In Russian literature, the disease was first described by V.M. Bekhterev (1892) under the name "Stiffness of the spine with curvature". The possibility of combining ankylosing spondylitis with damage to large (the so-called "root") joints of the extremities - hip and shoulder, was first noted by foreign authors, who called the pathology "rhizomelic spondylosis". The pathogenesis of ankylosing spondylitis is not precisely known; infectious-allergic and autoimmune mechanisms of pathology development are currently considered generally accepted.

Clinical forms of Bechterew's disease

Clinical form	Clinical features
Central (with isolated damage to the spine and sacroiliac joints)	Kyphosis type - kyphosis of the thoracic spine with hyperlordosis of the cervical spine (described by V.M. Bekhterev as the "supplicant" pose) Rigid appearance - absence of lumbar lordosis and thoracic kyphosis (board-like back)
Rhizomelic	Damage to the spine, sacroiliac joints and “root” joints (shoulder and hip).
Scandinavian	Rheumatoid-like, occurring with damage to small joints. The diagnosis is established by typical changes in the sacroiliac joints and spine.
Peripheral	Damage to the sacroiliac joints, spine and peripheral joints: elbow, knee, ankle.
Visceral	Regardless of the stage of spinal damage, it occurs with damage to internal organs (heart, aorta, kidneys, eyes)
Youthful	The onset of the disease is mono- or oligoarthritis, often persistent coxitis with late developing radiographic changes: subchondral osteoporosis, bone cysts, marginal erosion

To date, six clinical forms of Marie-Strumpell-Bechterew disease have been described.

The peculiarity of the vertebral syndrome in tuberculous spondylitis is explained by the immobilization of the spine, and the radiographic picture is a combination of osteoporosis of the vertebrae with compaction of the cortical plates and ankylosis of the facet joints, which leads to the formation of typical radiographic symptoms of "bamboo stick" and "tram rails".

The peculiarity of clinical forms, the vagueness of early clinical manifestations and the inevitable progression of Bechterew's disease have led many authors to repeated attempts to determine those signs, the presence of which would allow establishing a diagnosis at the initial manifestations of the disease. In the literature, these signs are described as "diagnostic criteria" with the names of the places where the conferences were held at which they were adopted.

Diagnostic criteria for Bechterew's disease

Criteria	Clinical signs
"Rome" diagnostic criteria (1961)	Pain and stiffness in the sacroiliac region lasting more than 3 months and not relieved by rest; pain and stiffness in the thoracic spine; limited range of motion in the lumbar spine; limited range of motion of the thoracic cage; history of iritis, iridocyclitis and their sequelae; radiographic evidence of bilateral sacroiliitis.
New York Diagnostic Criteria (1966)	Limited mobility of the lumbar spine in three directions (flexion, extension, lateral bending); pain in the thoracolumbar and lumbar spine in the anamnesis or during examination; limited chest excursions during breathing, less than 2.5 cm (measured in the area of the 4th intercostal space).
"Prague" diagnostic criteria (1969)	Pain and stiffness in the sacroiliac region; pain and stiffness in the thoracic spine; limited range of motion in the lumbar spine; limited thoracic excursion; history of or current iritis.
Additional signs of initial manifestations (Chepoy V.M., Astapenko M.G.)	Pain on palpation of the symphysis region; damage to the sternoclavicular joints; history of urethritis.

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