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SPONDYLODISKITIS: MODERN APPROACHES TO DIAGNOSIS
Gafarov Jakhongir Sobirovich
https://doi.org/10.5281/zenodo.13989801
Resume; restart. At the same time,
the diagnosis of spondylodiscitis is
difficult and often occurs with a significant delay after the appearance of the first
symptoms, which is due to the rarity of the disease, the non-specificity of its
manifestations , and therefore the lack of disease . awareness of doctors on
issues of infectious lesions of the spine. The current problem with determining
the etiology of the disease leads to irrational antibiotic therapy, long-term
treatment and increased costs. Surgical treatment of spondylodiscitis is delayed
due to the lack of strict guidelines. Key words: spondylodiscitis , infection,
diagnosis, biopsy, treatment, surgery.
Diagnostics
Clinical presentation of DM Clinical symptoms of DM are not specific. The
onset of the disease, as a rule, is ignored, and the alarm signal is constant back
pain, which increases at night, when walking, and general intoxication
symptoms increase. This condition can last in different ways: from 10 days to a
month, depending on the severity of the process. The most common symptom of
diabetes is back pain, but up to 15% of patients may not experience back pain.
Pain syndrome depends on the localization and degree of the pathological
process in the spine. The most common localization of pain and, accordingly,
injuries are in the lumbar region, less often in the chest region, and very rarely
in the cervical region. Pain in the thoracic spine can be similar to pneumonia or
pleurisy, in the lower thoracic and lumbar spine it mimics acute abdomen,
dynamic obstruction, paranephritis and osteochondrosis. This leads to incorrect
diagnosis or even unnecessary surgery. Fever is a less common symptom,
occurring in half of patients. Fever rarely occurs in diabetes with tuberculosis
etiology. The spread of the infectious process to the spinal canal is accompanied
by the development of radicular syndrome with limitation of motor activity,
signs of irritation or fading of reflexes, and sensory disturbances in the areas of
the affected roots. As the disease progresses, symptoms of spinal cord
compression appear with a frequency of 10 to 64%: plegia with the development
of paresis of the limbs, increased neurological deficit , pelvic dysfunction with
delayed urination and defecation. Spinal deformities in the form of kyphosis are
common with tuberculosis. Cervical DM may present with dysphagia or
torticollis. Acute pain during palpation of vertebral tumors of the spine and
paravertebral region at the level of the lesion is the most common symptom
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detected during examination of the patient (in 78-97% of cases), which is often
associated with a limited range. movement and spasm of paravertebral muscles .
The lack of characteristic symptoms of the disease leads to late diagnosis and
poor treatment results. On average, the period between the onset of the disease
and the diagnosis lasts from 8 weeks to 3 months.
Laboratory diagnostics
a sensitive but non-specific indicator of infection. In many studies, this
indicator increases in more than 90% of cases, its average value is from 43 to 87
mm per hour. A decrease in ESR of 25% or more is a good prognostic sign of
therapy. C-reactive protein is elevated in more than 90% of patients with
diabetes. A rapid decrease in the level of C-reactive protein indicates the correct
choice of therapy and allows injectable forms of antibiotics to be administered
orally. Leukocytosis is detected only in 30-50% of patients and is the least
sensitive inflammatory sign of the disease.
Microbiological diagnosis
It is very important to determine the etiological factor that caused the
infectious process in the diagnosis of diabetes. This is due to the wide range of
possible pathogens and the increase in resistance to antibiotics. Empirically
prescribed antibiotic therapy often leads to the development of complications,
expansion of indications for surgical treatment, as well as prolongation of the
patient's stay in the hospital and increased costs of treatment. The simplest
method of microbiological research is blood culture . However, this method has
diagnostic value only in 25-33% of cases and is positive only in cases of infection
due to a highly virulent strain. In this case, blood should be taken for culture at
the height of the fever and before the start of antibacterial therapy, which is
rarely possible. It is recommended to carry out three cultures with the
determination of sensitivity to antibiotics. Early detection of the tuberculosis
process in the spine allows identifying patients with diabetes of tuberculosis
etiology, which reduces the spread of infection, and also allows early initiation of
anti-tuberculosis therapy in a specialized hospital. Exclusion of diabetes caused
by mycobacteria tuberculosis , use several methods. Diaskintest is a test that
determines whether a patient has tuberculosis. The Mantoux test is less
important today, because it only detects the active process of tuberculosis, and
also gives a high frequency of false results. These methods are the simplest and
cheapest. Pathogenic DNA detection methods: LPA (Hain test), GenExpert .
These methods are the fastest and most accurate for diagnosing tuberculosis.
Their important advantage is the possibility of simultaneous detection of drug
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resistance of mycobacteria. Biopsy of the pathological focus Biopsy of the
infected area followed by microbiological examination in different studies
ranges from 19% to 100%. This technique is often used in patients with negative
blood cultures. Biopsies in these patients are positive in 43-78% of cases. Biopsy
material should be grown in a medium diagnostic for aerobic, anaerobic
microorganisms, fungi and mycobacteria. At the same time, the biopsy material
should be subjected to histological examination. Its main role is to distinguish
purulent and granulomatous processes. Biopsy material can also be tested using
PCR. This is a very effective method that allows you to detect microorganisms in
minimal quantities even after the start of antibiotic therapy. Currently, the
methods of identifying the DNA of microorganisms are developing rapidly.
However, the main problem with their use is their high cost. There are closed
(percutaneous) and open methods of biopsy . Among the closed methods for
obtaining material for infectious diseases of the spinal cord, the most suitable is
a puncture biopsy, the varieties of which are fine needle aspiration biopsy and
trephine biopsy. A puncture biopsy is performed under ultrasound kovy ,
fluoroscopic , CT or MRI control. Ultrasound examination is ineffective in
diagnosing diseases of the spinal cord. Its capabilities are limited to the
detection of superficial lesions of the cervical spine. Biopsy under fluoroscopic
control is the simplest, cheapest, short-term method that allows monitoring the
process in real time. The disadvantage of this method is its inability to image the
surrounding soft tissues. Computed tomography visualization of the procedure
is standard in many developed countries. CT control allows you to plan the
trajectory of the needle, avoid lung damage, and access hard-to-reach areas.
Disadvantages include the duration of the procedure and the effect of ionizing
radiation. The advantage of CT control over fluoroscopy is the ability to see soft
tissues as well as bone, as well as more accurate visualization of the needle,
especially for small pathological lesions. MRI control is used only in large
specialized neurosurgery centers. Its advantages include strong contrast
between soft and bony tissues, absence of ionizing radiation , and
multidimensional imaging capabilities. An open biopsy is performed during
surgery. For the spine, if the area of pathological formation is removed for
research purposes, cross-sectional biopsy is more important. An open biopsy is
diagnostic in about 80% of cases.
Instrumental diagnostics
subchondral sclerosis, loss of definition of the vertebral endplates, and
decreased intervertebral disc height. Late changes include destruction of the
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opposite end plate and a decrease in vertebral height. However, 2-8 weeks after
the onset of symptoms, symptoms do not begin to develop, and false positive
results can lead to the development of degenerative changes in the spine.
Different isotopes are used for radionuclide diagnosis of diabetes. Technetium-
99m has high sensitivity - up to 90%, but less specificity - 78%. Gallium-67 is
used in combination with radiography, and the sensitivity of this method
reaches 90%, specificity - 100%, and accuracy - 94%. CT is one of the best ways
to diagnose bone lesions. CT can detect changes such as early destruction of the
endplate (before it can be seen on radiography), later sequestration, and
pathological calcification found in tuberculosis. Changes in the intervertebral
disc appear as hypodense areas. MRI is the method of choice in the instrumental
diagnosis of diabetes. It has a sensitivity of approximately 96%, a specificity of
93%, and an accuracy of 94%. Its advantage over other methods is the high
ability to visualize the epidural space and the spinal cord. Characteristic changes
include decreased signal intensity from the intervertebral disc and adjacent
vertebral bodies on T1, increased signal on T2, and loss of endplate definition on
T1. Gadolinium contrast increases the accuracy of the study (especially in early
diagnosis, there may be no other changes), and also helps distinguish infectious
lesions from degenerative changes and neoplasms. With tuberculosis lesions of
the spinal cord, there are usually no changes in the intervertebral disc, but
paravertebral abscesses, changes in the back structures of the vertebrae can be
detected, and long vertebrae are also involved in the process and their
destruction is detected. In the presence of purulent diabetes, MRI changes
during treatment often indicate a lack of dynamics or even a worsening of the
process. This leads to unnecessary surgical interventions. Positive dynamics of
MRI Pictures may be absent during the first 4-8 weeks of therapy. Accordingly, it
is not recommended to rely on MRI data to evaluate the effectiveness of
treatment
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