Inflammatory diseases of the spine and back pain

The urgency of the problem of inflammatory, especially infectious, lesions of the spine is determined not only by the fact that in these diseases, two basic functions of the spine are violated: ensuring a stable vertical position of the trunk and protecting the spinal nerve structures.

At the present stage, attention to the problem of spondylitis is due to a number of objective reasons. Against the background of the general "aging" of the world's population, the number of patients with piogenic (purulent) diseases, characteristic of the older age group, including spondylitis, is increasing. Infectious lesions of the spine are often noted in patients who, a few decades ago, represented rare, isolated cases: drug addicts with intravenous drug use; at patients of groups of risk with a chronic endocrine pathology, first of all - with a diabetes mellitus; in patients with various diseases requiring long-term administration of hormonal and cytostatic therapy. It should be remembered that against the backdrop of the ever-increasing number of patients with acquired immunodeficiency syndrome, the number of patients with AIDS-associated infections is steadily increasing. According to SS Moon et al. (1997), in patients with tuberculous spondylitis in a number of countries, AIDS occurs in 30% of cases. There is no official domestic statistics on this issue, however, personal experience of one of the authors of the book in the clinic for patients with osteoarticular tuberculosis convinces us that recently such patients are meeting more and more often.

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

To describe 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 refer to spine lesions in infectious diseases, but to indicate its local bacterial or viral lesions

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

Affected parts of the spine	Affected structures	Disease names used
The anterior part of the spine	Vertebral bodies	Osteomyelitis of the spine Spondylodisitis Spondylitis Tuberculous spondylitis or Pott's disease
	Intervertebral discs	Discitis Paravertebral abscess
	Paravertebral spaces
		Psoas abscess Retropharyngeal abscess Mediastinitis, empyema
Posterior section of the spine	Subcutaneous pr-va	Superficial wound infection Infected seroma (in the presence of foreign bodies, including implants) Deep wound infection
	Subfascial pr-va	Paraspinal abscess Osteomyelitis, spondylitis
	Rear vertebral elements	Deep wound infection
Vertebral canal	Epidural production	Epidural abscess, epiduritis
	Shells of the spinal cord	Meningitis
	Subdural	Subural abscess
	Spinal cord	Myelitis, intramedullary abscess

The etiological factor is of paramount 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, it should be noted:
  • Primary osteomyelitis, which occurs in the absence of other visible foci of infection;
  • secondary hematogenous or septic (metastatic) osteomyelitis;
  • secondary posttraumatic osteomyelitis - wound (gunshot and non-fire);
  • contact osteomyelitis in the presence of a primary inflammation focus in the paravertebral soft tissues and
  • iatrogenic osteomyelitis developing after diagnostic procedures and surgical interventions;
• Infectious-allergic inflammatory diseases of the spine - rheumatoid arthritis, Bekhterev's disease, etc .;
• parasitic lesions of the spine with schistosomiasis, echinococcosis, etc.

Osteomyelitis of the spine according to the nature of the primary lesion of bone structures of the vertebra or intervertebral disc with contact departments of vertebral bodies is divided into spondylitis and spondylodiscites. Depending on the morphological features of the infectious process, two groups of osteomyelitis of the spine are distinguished:

• pyogenic or purulent osteomyelitis, which by the nature of the course of the disease can be acute and chronic. It should be noted that the concept of chronic inflammation implies, first of all, not the duration of the disease, but the morphological structure of the pathological focus. According to the type of bacterial microflora released, osteomyelitis can be nonspecific (staphylococcal, streptococcal, caused by Coli-flora) or specific (typhoid, gonorrhea, etc.);
• granulomatous osteomyelitis, among which three clinical variants are distinguished according to etiology: mycobacterial (tubercular), mycotic (fungal) and spirochete (syphilitic) spondylitis.

Tuberculosis spondylitis or Pop's disease (the clinic of the disease in the late 17th century described Persival Pott). A characteristic feature of the disease is its slow and steady progression in the natural course leading to severe cosmetic and neurological complications: coarse deformities of the spine, paresis, paralysis, disruption of pelvic functions. P.G. Kornev (1964, 1971) identified the following phases and stages in the clinical course of tuberculosis spondylitis:

1. a pre-episodic phase characterized by the emergence of a primary focus in the body of the vertebra, proceeding, as a rule, without local clinical symptoms and extremely rarely diagnosed in a timely manner;
2. spondylitis phase, which is characterized by the progressive development of the disease with bright clinical symptoms, which in turn passes through several clinical stages:
   • the stage of onset is characterized by the appearance of pain in the back and limitation of the mobility of the spine;
   • the height of the stage corresponds to the emergence of complications of the pathological process in the spine: abscesses, kyphotic deformities (hump) and spinal disorders;
   • the stage of remission corresponds to an improvement in the patient's condition and well-being, and radiologic changes in the form of possible blocking of vertebral bodies indicate stabilization of the process. Nevertheless, this stage is characterized by the preservation of residual caverns in vertebrae and residual, including calcified, incurable abscesses.
3. Post-dissolution 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 delimited foci and abscesses.

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

Localization and distribution of abscesses in tuberculous spondylitis is determined by the level of spinal cord injury and the anatomical features of the surrounding tissues. In connection with the location of the inflammation in the body of the vertebra, it is possible to spread the abscess beyond its limits in any direction: anteriorly (prevertebrally), laterally (paravertebrally) and posterior from the vertebral body towards the spinal canal (epidural.

Given the anatomical features of paravertebral tissues and interfascial spaces at different levels, abscesses can be detected not only near the spine, but also in remote regions.

Localization of abscesses in tuberculous spondylitis

Level of spinal cord injury	Localization of abscesses
1. Cervical vertebrae	a) retropharyngeal, b) caescula, c) abscess of the posterior mediastinum (typical for lesion of the lower lower vertebrae).
2. Thoracic vertebrae	a) intrathoracic paravertebral; b) subdiaphragmatic (typical for the lesion of T1-T12 vertebrae).
3. Lumbar vertebrae	a) psoas abscesses, with possible dissemination under the ligamentous ligament along the lacuna musculorum to the anterior inner thigh and the popliteal region; b) localized near-vertebral abscesses (rarely); c) posterior abscesses extending through the lumbar triangle into the lumbar region.
4. Lumbosacral and sacral vertebrae	A) presacral, b) retrectectal, c) gluteal, extending along the pear-shaped muscles to the external surface of the hip joint.

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

• buttoned kyphosis is characteristic for local destruction of one or two vertebrae. Similar deformations are more common in patients who become ill during adulthood;
• gently trapezoidal kyphosis is typical of common lesions, usually not accompanied by total destruction of vertebral bodies;
• angular kyphosis is typical for common lesions, accompanied by total destruction of the bodies of one or more vertebrae. Such destruction, as a rule, develops in people who are sick in early childhood. Deformity inevitably progresses with the growth of the child in the absence of adequate surgical treatment. It is for the designation of angular kyphosis that the terminology committee of the Scoliosis Reseach Society (1973) recommends the use of the term gibbus, or the hump itself.

Neurological complications of tuberculosis spondylitis can be associated with either direct compression of the spinal cord or with secondary ischemic impairment. It is customary to differentiate the dysfunction of the spinal cord (myelopathy), spinal roots (radiculopathy), and mixed disorders (mieloradiculo-patia).

The issues of qualitative assessment of myelo / radiculopathy in tuberculosis spondylitis are widely discussed in the literature. The most practical applications were those classifications of paraplegia (paraparesis) in Pott's disease, which are very similar to the detailed scale of Frankel. It should be noted, however, that the author of one of the classifications of K. Kumar (1991) considers it necessary to make changes in the Frankel scale for tuberculosis spondylitis on the grounds that "..for this disease is characterized by a gradual development of compression and a large spread in length."

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

Degree of paraparesis	Clinical Characteristics
I	Normal gait without any motor weakness. It is possible to identify the clone of the feet and their plantar flexion. Tendon reflexes are normal or animated.
II	Complaints about discoordination, spasticity, or difficulty walking. The ability to walk independently with or without external support is retained. Clinically, spastic paresis.
III	Severe muscle weakness, the patient is bedridden. Spastic paraplegia with predominance of extensor flexion is revealed.
IV	Spastic paraplegia or paraplegia with involuntary spastic contractions of flexors; paraplegia with predominance of the extensor tone, spontaneous spastic contractions of flexors, loss of sensitivity by more than 50%, and severe sphincter disorders; sluggish paraplegia.

Classification of Pattisson (1986) neurological disorders in tuberculous spondylitis

Degree of paraparesis	Clinical Characteristics
0	Absence of neurological disorders.
I	Presence of pyramidal signs without disturbance of sensitivity and motor disorders with the preserved possibility of walking.
II (A)	Incomplete loss of movement, lack of sensitivity, there is a possibility of self-walking or walking with external help (support).
II (B)	Incomplete loss of movement, no sensitivity disorders, walking lost.
III	Complete loss of movement. There are no sensory abnormalities, walking is impossible.
IV	Full loss of movement, sensitivity is broken or lost, walking is impossible.
V	Complete loss of motion, severe or total sensory impairment, loss of control over sphincters and / or spastic involuntary muscle contractions.

Given these classifications, we note that in our own work, we prefer to still use the modified Frankel scale for childhood, which is given in Chapter 7, devoted to vertebral-spinal trauma.

Among inflammatory diseases of the spine the most peculiar and least studied is ankylosing spondylitis or Marie-Stryumpel-Bekhterev disease. In the domestic literature, the disease was first described by V.M. Bekhterev (1892), entitled "Stiffness of the spine with curvature". The possibility of combining ankylosing spondylitis with the defeat of large (so-called "root") joints of the limbs - hip and shoulder, was first noted by foreign authors who called pathology "rhizome spondylosis". The pathogenesis of ankylosing spondylitis is not exactly known, the currently recognized are infectious-allergic and autoimmune mechanisms of pathology development.

Clinical forms of Bechterew disease

Clinical form	Clinical Features
Central (with an isolated lesion of the spine and sacroiliac joints)	The kyphoid appearance is the kyphosis of the thoracic spine with hyperlordosis of the cervical region (described by VM Bekhterov as the "petitioner" posture) A rigid form is the absence of lumbar lordosis and thoracic kyphosis ("dorsal" back)
Risolimic	Defeat of the spine, sacroiliac joints and "root" joints (humeral and hip).
Scandinavian	Rheumatoid-like, flowing with lesion of small joints. The diagnosis is established by the typical changes in the sacroiliac joint and spine.
Peripheral	The defeat of sacroiliac joints, spine and peripheral joints: elbows, knees, ankles.
Visceral	Regardless of the stage of the lesion of the spine, it proceeds with the defeat of internal organs (heart, aorta, kidneys, eyes)
Youth	The onset of the disease by type of mono- or oligoarthritis, often - persistent coxites with late developing radiographic changes: subchondral osteoporosis, bone cysts, marginal usurization

To date, six clinical forms of Marie-Strumentel-Bekhterev's disease have been described.

The peculiarity of the vertebral syndrome in tuberculous spondylitis is explained by the immobilization of the spine, and the radiologic picture - by the combination of osteoporosis of the vertebrae with compaction of the cortical plates and ankylosing of the arcuate joints, which leads to the formation of typical X-ray symptoms of the "bamboo stick" and "tramway rails".

The peculiarity of clinical forms, the fuzziness of early clinical manifestations and the inevitable progression of Bekhterev's disease led many authors to repeatedly try to identify those signs whose presence would allow us to establish a diagnosis with the initial manifestations of the disease. In the literature, these signs are described as "diagnostic criteria," indicating in the name of those places where the conferences at which they were held were held.

Bekhterev Diagnostic Criteria

Criteria	Clinical signs
"Roman" diagnostic criteria (1961)	Pain and stiffness in the sacroiliac region, lasting more than 3 months and not diminishing at rest; pain and stiffness in the thoracic spine; restriction of movements in the lumbar spine; limitation of the motor excursion of the thorax; in the anamnesis - irit, iridocyclitis and their consequences; X-ray signs of bilateral sakroileitis.
The New York Diagnostic Criteria (1966)	Limitation of mobility of the lumbar spine in three directions (flexion, extension, lateral inclinations); pain in the thoracolumbar and lumbar spine in anamnesis or during examination; restriction of chest excursions during breathing, less than 2.5 cm (measured in the region of 4 intercostal spaces).
"Prague" diagnostic criteria (1969)	Pain and stiffness in the sacroiliac region; pain and stiffness in the thoracic spine; restriction of movements in the lumbar spine; restriction of the chest excursion; iritis in the anamnesis or now.
Additional signs of initial manifestations (Chepy VM, Astapenko MG)	Pain on palpation of the symphysis area; defeat of the sternoclavicular joints; a urethritis in the anamnesis.

[1], [2], [3], [4], [5]