骨结核英文七年制培训课件

IntroductionIntroduction1Introduction

EpidemiologyandEtiology(流行病学及病因学)

Pathology(病理)DiagnosisandDifferentialDiagnosis(诊断与鉴别诊断)

ProphylaxisandTreatment(预防与治疗)

Introduction2TuberculosisofbonesandjointsGenerallytobeachronicinflammatoryandinfectiousdiseasecausedbyMyobacterium

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

Thesusceptiblepopulation

withthisdisease

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

最常见的肺外继发性结核Tuberculosisofspineisthemostcommonsite,thenextinorderoffrequencybeingtheknee,hip,ankle,sacroiliac,shoulder,andwristjoints.

脊柱结核最常见

InSummaryTuberculosisofbone6EtiologyPathogen(致病菌)

Acid-fastbacilliMycobacteriumtuberculosisHumantuberclebacilli

（人型结核杆菌）commonBovinetuberclebacilli(牛型结核杆菌)rareThefluorescentstainingofacid-fastbacilli

EtiologyPathogen(致病菌)Thef7TheanteriorlesionCriterionofCure治愈标准Psoasabscess腰大肌脓肿起床活动已达1年，仍保持上述4项指标formingsequestruaandcavities.granulomasorcaseation(orcheesy)necrosisarea:43%LocalswellingJointfunction:insidethejointoroutsidethejointIntroductionTheanteriorlesionIftheoriginalfocusremainsactiveanduntreated,thelesionwillexacerbate,involvedbone,cartilageandsynovia,developingtotuberculouspanarthritis（全关节结核）.PositiveRateofPathologicalexam:70-80%(Langerhansgiantcells)TBoftheCancellousBoneEpidemiology最常见的肺外继发性结核withoutformingsequestrumSystemicandregionallymphnods:singleratherthanmultipleappearanceEpidemiologyEffectiveTBControlGravitationabscessEtiologyOnMarch24,1882,RobertKochannouncedhisdiscoveryofthetuberclebacillus.HediscoveredastainingtechniquethatenabledhimtoseeMycobacteriumtuberculosis.

（结核杆菌）

Dr.RobertKochTheanteriorlesionEtiologyOn8EtiologyTransmissionRoutesHematogenousdissemination

（血液传播）tolongbonesandvertebraeDirectspreadtobonefromadjacenttuberculouslymphadenitis

（结核性淋巴腺炎）Singleormulticentric（单发或多中心），particularlyinAIDSPredilectionforsynovium

（偏好滑膜）-higheroxygenpressureEtiologyTransmissionRoutes9Pathology(病理)Initialpathologicalchangesaretuberculous

osteomyelitis

(结核性骨髓炎,单纯骨结核)andsynovialtuberculosis(滑膜结核)。Thearticularcartilagesremainintactatthisstage.Thelesionwillbehealedthroughpropertreatmentintime,andjointfunctionwillbereservedthoroughlyorpartially.Iftheoriginalfocusremainsactiveanduntreated,thelesionwillexacerbate,involvedbone,cartilageandsynovia,developingtotuberculouspanarthritis（全关节结核）.Pathology(病理)Initialpatholog10PathologyBasicPathologyChanges:

Exudation

渗出

Deterioration

变质

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(干骺端结核）

formingsequestrua(死骨片）

(cancellousbone)newboneformationofperiosteum

（骨膜）

(compactbone)Pathology(SimpleSkeletalTB)16Pathology

(TBoftheSynovialmembrane滑膜结核)Earlystage:Hyperaemia充血Synovialhypertrophy肿胀Exudateincreasing渗出增多Pannusformation（血管翳）&Ricebodies米粒体(small,freewhitebodiescomposedofcompactmassesoffibrin,necroticsynovialvilli,orcartilagefragments)Latestage:hyperplasiaofsynovium

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

(TBoftheSynovial17Pathology(Tuberculous

panarthritis)全关节结核DuetoSimpleTB

DuetosynovialTBPathology(Tuberculouspanart18ComplicationsofLateStageTBofBonesandJointsAbscess脓肿Pathologicalsubluxation,dislocationorfracture病理性半脱位、脱位或骨折Articulardeformityorstiffness关节畸形强直Shorteningofextremities肢体短缩

(epiphyseserosion)骨骺受损Paraplegia(spinalcordcompressed)截瘫ComplicationsofLateStageTB19ComplicationsofLateStageTBofbonesandjointsAbscess(ColdAbscess)寒性脓肿Paraspinalabscess椎旁脓肿Gravitationabscess流注脓肿Psoasabscess腰大肌脓肿Lumbertrangleabscess腰三角脓肿OtherabscessComplicationsofLateStageTB20Paraspinalabscess椎旁脓肿Paraspinalabscess21最常见的肺外继发性结核15~35岁男性，多发，（脊柱、髋、膝），对称性，无脓无死骨，HLAb27（+）Tuberculinskintest:TB-Controversy&tendencyHediscoveredastainingtechniquethatenabledhimtoseeMycobacteriumtuberculosis.X线片检查（胸部和患肢）;MRI脊柱结核最常见Thesechangesareduetosynovitisandarenonspecific.anorexia厌食DifferentialDiagnosisColdabscess:withoutruborandcalorSynovialhypertrophy肿胀Polymerasechainreaction（多聚酶链反应）–PCRExtrapulmonarysecondarydiseasesSpecialStandingstancePrincipleofTreatment（人型结核杆菌）common骨与关节结核的发展阶段和分型及其X线特点全身情况良好，体温正常，食欲（orexia）良好Tendernessatthert.lowfever低热Calcificationoftheparaspinalabscessisessentiallypathognomonicfortuberculosis椎旁脓肿钙化是结核的基本特征

Normalshadowofpsoasmajor正常腰大肌影Psoasabscess腰大肌脓肿最常见的肺外继发性结核Calcificationofth22Deepgravitationabscessofgroin

腹股沟深部流注脓肿Deepgravitationabscessofg23Articularstiffnessanddeformity

关节强直畸形Articularstiffnessanddeform24LimbShortening肢体短缩LimbShortening25

Kyphosis（脊柱后凸）

Paraplegia（截瘫）Kyphosis（脊柱后凸）26掌握要点骨与关节结核的发展阶段和分型及其X线特点松质骨结核：中心型坏死型边缘型溶骨型密质骨结核：层状骨膜增生，梭型膨大干骺端结核：兼有松质骨和密质骨结核特性滑膜结核：无特殊。仅骨质疏松全关节结核：早期；晚期骨与关节结核晚期并发症：不同部位的寒性脓肿关节畸形、强直掌握要点骨与关节结核的发展阶段和分型及其X线特点27Diagnosisand

DifferentialDiagnosisDiagnosisand

DifferentialD28ExtrapulmonarysecondarydiseasesCalcificationoftheparaspinalabscessisessentiallypathognomonicfortuberculosisTBofthemetaphysis:Polymerasechainreaction（多聚酶链反应）–PCRLimbShorteningfartherstudyingenelevel:(HLAallele,ethnicdifferance;IL-6,IL8,IL-10,TNF-a)Earlydiagnosisandtheuseofantituberculousdrugshaveradicallyimprovedtheprognosisoftuberculousarthritis.Indicationsofoperation手术适应证Synovialhypertrophy肿胀anemia贫血Thesechangesareduetosynovitisandarenonspecific.lowfever低热Lumbertrangleabscess腰三角脓肿TBoftheCancellousBonePathology(SimpleSkeletalTB)Hematogenousdissemination（血液传播）tolongbonesandvertebraeParaplegia（截瘫）Skintractiontopreventionformingcontracturehip(bendingdeformity)thenfixwithhipspicafor3months.Jointfunction:insidethejointoroutsidethejointTreatment?Diagnosis

MedicalhistoryInsidiousonset隐匿起病Symptoms:

pain疼痛

lowfever低热

nightsweats盗汗

anorexia厌食

anemia贫血

weightloss体重减轻

localswelling局限肿胀morbidnightcryingofbabies夜啼contacthistory接触史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松质骨结核：中心型坏死型leg,6monthswithhippainClearanceoffocallesion（病灶清除术）March2,2007Diagnosis?granulomasorcaseation(orcheesy)necrosisarea:43%Labtest:Wbcnormal,CRP,ESRGravitationabscesslocalswelling局限肿胀74yrs,female,formingsequestrua(死骨片）松质骨结核：中心型坏死型anorexia厌食CastfixationimmunologicresearchneedtobegofartherTBofthemetaphysis:tendernessandpercussingpainThesedimentationrate:non-pathognomonicfortuberculosisbutaltersearlythanX-ray(male<15mm/h;femal<20mm/h)lowfever低热MethodofJointAspirationforTB松质骨结核：中心型坏死型Method35DifferentialDiagnosisRheumatoidArthritis:

20~55岁女性，多关节、小关节，对称性。RF因子（+）

AnkylosingSpondylitis:

15~35岁男性，多发，（脊柱、髋、膝），对称性，无脓无死骨，HLAb27（+）

Septicarthritis:关节穿刺

SepticOsteomyelitis:

全身中毒症状重。细菌学和病理检查

BoneTumor:脊柱结核早期侵犯椎间盘，椎间隙狭窄消失DifferentialDiagnosisRheumat36急性骨髓炎(以破坏和增生为主）X线见骨质广泛破坏，大量死骨及大量骨膜新骨形成骨结核（破坏、疏松、萎缩为主）髓腔内溶骨性破坏,无死骨；骨干周围有广泛新骨形成急性骨髓炎(以破坏和增生为主）X线见骨质广泛破坏，大量死骨及37慢性骨髓炎破坏与增生并存;骨质硬化；大量死骨、包壳发生骨结核以破坏、疏松、萎缩为主;很少硬化；死骨少、小(沙粒状）慢性骨髓炎骨结核38掌握要点骨与关节结核的诊断要点：分四步骤：病史与临床表现结菌素皮肤实验X线片检查（胸部和患肢）;MRI细菌学检查（痰培养、脓肿穿刺液培养）主要鉴别的疾病：结缔组织病骨关节感染性疾病骨肿瘤掌握要点骨与关节结核的诊断要点：39ProphylaxisandTreatmentProphylaxisandTreatment40EffectiveTBControlTheWHO-recommendedtreatmentstrategyfordetectionandcureofTBisDOTS.EffectiveTBControl41TreatmentEarlydiagnosisandtheuseofantituberculousdrugshaveradicallyimprovedtheprognosisoftuberculousarthritis.Othermeasuresadoptedareresttotheaffectedjointinfunctionalposition,tractionwhenneededanddietaryimprovement.Treatmentconsistsofgeneralmedicalmeasures,chemotherapy,localconservativeorthopediccare,andsurgery.TreatmentEarlydiagnosisandt42CriterionofCure治愈标准全身情况良好，体温正常，食欲（orexia）良好局部症状消失，无疼痛，窦道闭合血沉3次结果正常X线显示脓肿缩小乃至消失或钙化，无死骨，病灶边缘轮廓清晰起床活动已达1年，仍保持上述4项指标CriterionofCure治愈标准全身情况良好，体43Indicationsofoperation手术适应证骨关节结核有明显的死骨忽而大脓肿形成窦道流脓经久不愈脊柱结核引起脊髓受压Indicationsofoperation手术适应证44骨干周围有广泛新骨形成Earlydiagnosisandtheuseofantituberculousdrugshaveradicallyimprovedtheprognosisoftuberculousarthritis.Polymerasechainreaction（多聚酶链反应）–PCRGeneprobetechnic（基因探针技术）,March2,2007GenerallytobeachronicinflammatoryandinfectiousdiseasecausedbyMyobacteriumtuberculosis.TBofthemetaphysis:SearchingmoreidealdrugforTBwithlesssideeffectIftheoriginalfocusremainsactiveanduntreated,thelesionwillexacerbate,involvedbone,cartilageandsynovia,developingtotuberculouspanarthritis（全关节结核）.thequantityofnewboneformationofanorexia厌食weightloss体重减轻periosteumisdeterminedbytheage.(arthroscopy/locallesion,open/extensivelesion)Labtest:Wbcnormal,CRP,ESRThomastestHipTuberculosispain疼痛immunologicresearchneedtobegofartherSpinalTuberculosisClinicalManifestationCervical:NeckPain(mildtosever)NumbnessofarmduetoneuralcompressionObstructingbreathingandswallowingwithPostpharyngealabscess骨干周围有广泛新骨形成SpinalTuberculosis45TuberculosisofSpine

ClinicalManifestationThoracic:BackpainGibbousdeformityLumbar:SpecialStandingstancePick-uptest(+)GravitationabscessTuberculosisofSpine

46OsseousdestroyanddecreaseinoneormorediscspacesColdAbscess:Cervical:

Lumbar

ThoracicTuberculosisofSpine

RoentgenographicFindings

Osseousdestroyanddecrease47PrincipleofTreatmentCastfixationSurgicaltreatmentEvacuationorexcisionofsofttissueabscesses（切开排脓）

Clearanceoffocallesion（病灶清除术）

Osteotomy,Arthrodesisandarthroplasty.

（矫形手术）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（基因探针技术）,Polymerasechainreaction（多聚酶链反应）–PCRNucleicacidamplification(核酸扩增）invitro…TB-Controversy&tendencyEarl60TB-Controversy&tendencySearchingmoreidealdrugforTBwithlesssideeffectTB-Controversy&tendencySear61ThanksThanks62Earlydiagnosisandtheuseofantituberculousdrugshaveradicallyimprovedtheprognosisoftuberculousarthritis.Pick-uptest(+)SkeletalTB最常见的肺外继发性结核Gravitationabscess流注脓肿Coldabscess:withoutruborandcalorTheabovechangesarefollowedbyperipheralerosionoftheboneanddestructionofthesubchondralbone,withthejointspacenarrowing.Hyperaemia充血Centrallesion:bonenecrosisHematogenousdissemination（血液传播）tolongbonesandvertebrae(arthroscopy/locallesion,open/extensivelesion)Localheatandrednessareusuallyabsent,andtendernessisminimal.About5%oftuberculosisismusculoskeletal.Pathology

(TBoftheSynovialmembrane滑膜结核)骨与关节结核的发展阶段和分型及其X线特点起床活动已达1年，仍保持上述4项指标ArticularstiffnessanddeformityChemotherapyAcid-fastbacilliTheanteriorlesionDeterioration变质EtiologyOnMarch24,1882,RobertKochannouncedhisdiscoveryofthetuberclebacillus.HediscoveredastainingtechniquethatenabledhimtoseeMycobacteriumtuberculosis.

（结核杆菌）

Dr.RobertKochEarlydiagnosisandtheuseof63Pathology(SimpleSkeletal

TB)TBoftheCancellousBone

Peripheraltypeabundantbloodsupplylocalbonedefectwithoutformingsequestrum

Pathology(SimpleSkeletalTB)64Diagnosis

MedicalhistoryInsidiousonset隐匿起病Symptoms:

pain疼痛

lowfever低热

nightsweats盗汗

anorexia厌食

anemia贫血

weightloss体重减轻

localswelling局限肿胀morbidnightcryingofbabies夜啼contacthistory接触史DiagnosisMedicalhistory65DiagnosisClinicalexamination

Systemicandregionallymphnods:singleratherthanmultipleappearanceLocalswellingColdabscess:withoutruborandcalorLocalheatandrednessareusuallyabsent,andtendernessisminimal.

Sinustracts:multiple

appearance,periarticulartendernessandpercussingpainJointfunction:insidethejointoroutsidethejointSystemicsymptoms:mildexceptforchildDiagnosisClinicalexamination66掌握要点骨与关节结核的诊断要点：分四步骤：病史与临床表现结菌素皮肤实验X线片检查（胸部和患肢）;MRI细菌学检查（痰培养、脓肿穿刺液培养）主要鉴别的疾病：结缔组织病骨关节感染性疾病骨肿瘤掌握要点骨与关节结核的诊断要点：67ProphylaxisandTreatmentProphylaxisandTreatment68Feb.23,2007Feb.23,200769TB-Controversy&tendencyEarlydiagnosis:themolecularbiologytechnicisstilladevelopmentaltendencyofstudy.Geneprobetechnic（基因探针技术）,Polymerasechainreaction（多聚酶链反应）–PCRNucleicacidamplification(核酸扩增）invitro…TB-Controversy&tendencyEarl70IntroductionIntroduction71Introduction

EpidemiologyandEtiology(流行病学及病因学)

Pathology(病理)DiagnosisandDifferentialDiagnosis(诊断与鉴别诊断)

ProphylaxisandTreatment(预防与治疗)

Introduction72TuberculosisofbonesandjointsGenerallytobeachronicinflammatoryandinfectiousdiseasecausedbyMyobacterium

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

Thesusceptiblepopulation

withthisdisease

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

最常见的肺外继发性结核Tuberculosisofspineisthemostcommonsite,thenextinorderoffrequencybeingtheknee,hip,ankle,sacroiliac,shoulder,andwristjoints.

脊柱结核最常见

InSummaryTuberculosisofbone76EtiologyPathogen(致病菌)

Acid-fastbacilliMycobacteriumtuberculosisHumantuberclebacilli

（人型结核杆菌）commonBovinetuberclebacilli(牛型结核杆菌)rareThefluorescentstainingofacid-fastbacilli

EtiologyPathogen(致病菌)Thef77TheanteriorlesionCriterionofCure治愈标准Psoasabscess腰大肌脓肿起床活动已达1年，仍保持上述4项指标formingsequestruaandcavities.granulomasorcaseation(orcheesy)necrosisarea:43%LocalswellingJointfunction:insidethejointoroutsidethejointIntroductionTheanteriorlesionIftheoriginalfocusremainsactiveanduntreated,thelesionwillexacerbate,involvedbone,cartilageandsynovia,developingtotuberculouspanarthritis（全关节结核）.PositiveRateofPathologicalexam:70-80%(Langerhansgiantcells)TBoftheCancellousBoneEpidemiology最常见的肺外继发性结核withoutformingsequestrumSystemicandregionallymphnods:singleratherthanmultipleappearanceEpidemiologyEffectiveTBControlGravitationabscessEtiologyOnMarch24,1882,RobertKochannouncedhisdiscoveryofthetuberclebacillus.HediscoveredastainingtechniquethatenabledhimtoseeMycobacteriumtuberculosis.

（结核杆菌）

Dr.RobertKochTheanteriorlesionEtiologyOn78EtiologyTransmissionRoutesHematogenousdissemination

（血液传播）tolongbonesandvertebraeDirectspreadtobonefromadjacenttuberculouslymphadenitis

（结核性淋巴腺炎）Singleormulticentric（单发或多中心），particularlyinAIDSPredilectionforsynovium

（偏好滑膜）-higheroxygenpressureEtiologyTransmissionRoutes79Pathology(病理)Initialpathologicalchangesaretuberculous

osteomyelitis

(结核性骨髓炎,单纯骨结核)andsynovialtuberculosis(滑膜结核)。Thearticularcartilagesremainintactatthisstage.Thelesionwillbehealedthroughpropertreatmentintime,andjointfunctionwillbereservedthoroughlyorpartially.Iftheoriginalfocusremainsactiveanduntreated,thelesionwillexacerbate,involvedbone,cartilageandsynovia,developingtotuberculouspanarthritis（全关节结核）.Pathology(病理)Initialpatholog80PathologyBasicPathologyChanges:

Exudation

渗出

Deterioration

变质

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(干骺端结核）

formingsequestrua(死骨片）

(cancellousbone)newboneformationofperiosteum

（骨膜）

(compactbone)Pathology(SimpleSkeletalTB)86Pathology

(TBoftheSynovialmembrane滑膜结核)Earlystage:Hyperaemia充血Synovialhypertrophy肿胀Exudateincreasing渗出增多Pannusformation（血管翳）&Ricebodies米粒体(small,freewhitebodiescomposedofcompactmassesoffibrin,necroticsynovialvilli,orcartilagefragments)Latestage:hyperplasiaofsynovium

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

(TBoftheSynovial87Pathology(Tuberculous

panarthritis)全关节结核DuetoSimpleTB

DuetosynovialTBPathology(Tuberculouspanart88ComplicationsofLateStageTBofBonesandJointsAbscess脓肿Pathologicalsubluxation,dislocationorfracture病理性半脱位、脱位或骨折Articulardeformityorstiffness关节畸形强直Shorteningofextremities肢体短缩

(epiphyseserosion)骨骺受损Paraplegia(spinalcordcompressed)截瘫ComplicationsofLateStageTB89ComplicationsofLateStageTBofbonesandjointsAbscess(ColdAbscess)寒性脓肿Paraspinalabscess椎旁脓肿Gravitationabscess流注脓肿Psoasabscess腰大肌脓肿Lumbertrangleabscess腰三角脓肿OtherabscessComplicationsofLateStageTB90Paraspinalabscess椎旁脓肿Paraspinalabscess91最常见的肺外继发性结核15~35岁男性，多发，（脊柱、髋、膝），对称性，无脓无死骨，HLAb27（+）Tuberculinskintest:TB-Controversy&tendencyHediscoveredastainingtechniquethatenabledhimtoseeMycobacteriumtuberculosis.X线片检查（胸部和患肢）;MRI脊柱结核最常见Thesechangesareduetosynovitisandarenonspecific.anorexia厌食DifferentialDiagnosisColdabscess:withoutruborandcalorSynovialhypertrophy肿胀Polymerasechainreaction（多聚酶链反应）–PCRExtrapulmonarysecondarydiseasesSpecialStandingstancePrincipleofTreatment（人型结核杆菌）common骨与关节结核的发展阶段和分型及其X线特点全身情况良好，体温正常，食欲（orexia）良好Tendernessatthert.lowfever低热Calcificationoftheparaspinalabscessisessentiallypathognomonicfortuberculosis椎旁脓肿钙化是结核的基本特征

Normalshadowofpsoasmajor正常腰大肌影Psoasabscess腰大肌脓肿最常见的肺外继发性结核Calcificationofth92Deepgravitationabscessofgroin

腹股沟深部流注脓肿Deepgravitationabscessofg93Articularstiffnessanddeformity

关节强直畸形Articularstiffnessanddeform94LimbShortening肢体短缩LimbShortening95

Kyphosis（脊柱后凸）

Paraplegia（截瘫）Kyphosis（脊柱后凸）96掌握要点骨与关节结核的发展阶段和分型及其X线特点松质骨结核：中心型坏死型边缘型溶骨型密质骨结核：层状骨膜增生，梭型膨大干骺端结核：兼有松质骨和密质骨结核特性滑膜结核：无特殊。仅骨质疏松全关节结核：早期；晚期骨与关节结核晚期并发症：不同部位的寒性脓肿关节畸形、强直掌握要点骨与关节结核的发展阶段和分型及其X线特点97Diagnosisand

DifferentialDiagnosisDiagnosisand

DifferentialD98ExtrapulmonarysecondarydiseasesCalcificationoftheparaspinalabscessisessentiallypathognomonicfortuberculosisTBofthemetaphysis:Polymerasechainreaction（多聚酶链反应）–PCRLimbShorteningfartherstudyingenelevel:(HLAallele,ethnicdifferance;IL-6,IL8,IL-10,