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The treatment of complicated forms of tuberculous spondylitis in patients with impaired motor function of the gastrointestinal tract
Tuychiev Nuriddin Nazarovich, Junior scientific fellow, Republican Specialized Scientific and Practical Medical Center of Tuberculosis and Pulmonology
Nazirov Primkul Hodjamovich, Leading scientist, MD PHD, professor Republican Specialized Scientific and Practical Medical Center
of Tuberculosis and Pulmonology E-mail: [email protected]
The treatment of complicated forms of tuberculous spondylitis in patients with impaired motor function of the gastrointestinal tract
Abstract: Impairment of motor function of gastrointestinal tract occurs in 35.0% of patients with complicated forms of tuberculous spondylitis. Severity of the impairment depends on duration and localization of the specific tubercular process in the spine. Therapeutic correction of gastrointestinal motor function disorder during treatment of the main (tubercular) process before and after surgery improves the efficiency of the treatment of tuberculous spondylitis.
Keywords: tuberculosis, tuberculous spondylitis, gastrointestinal tract, motor function.
Tuberculosis of joints and bones, especially tuberculosis promid (Reglan, raglan) 10 mg 2 times a day № 20, bisocodyl of the spine, is one of the leading problems of TB care, and occurs in 45.2 to 82.4% of cases [1; 5]. Chemotherapy and surgical procedures play a critical role in treatment of tuberculosis of this localization [3]. Efficacy of etiologic therapy, especially during the preoperative stage of the treatment may be reduced due to the large number of concomitant pathology of vital organs and systems. Almost 35.0% of patients with spinal tuberculosis have dysfunction of the gastrointestinal tract, whereby they develop intolerance to intake the antibacterial drugs [1]. Therefore, the intensive phase of etiologic and pathogenetic therapy does not lead to a regress of the specific process [2; 3; 4], and surgical treatment becomes method of choice in this patients, but surgery itself can cause gastrointestinal complications, especially in early postoperative period. These disorders are developed apparently due to spinal cord edema or irritation of the peritoneum.
However, we have not found any data regarding the effectiveness of surgical and complex pathogenetic therapy based on the nature and severity of the motor disorders of the stomach in patients with tuberculous spondylitis with neurological disorders in the available literature.
Purpose of the study was to analyze surgical treatment outcomes of patients with tuberculous spondylitis and gastrointestinal motor function disorder.
Material and methods: Treatment outcomes of 103 TB spondylitis patients with neurological and functional gastrointestinal disorders between the ages of17 and 60 years (mean age 40,5 ± 2,1), 59 (57.3%) male and 44 (42.7%) female patients were analyzed.
One group (main group) of 52 (51,5%) patients with TB spondylitis with neurological disorders and functional gastrointestinal disorders were administered antibacterial therapy as well as therapy correcting function of gastrointestinal system. As a pathogenetic therapy drugs were prescribed: metoklo-
(dulkolaks) 2 suppositories daily № 15, neostigmine methylsulfate (neostigmine) 0,05 mg daily № 20, Doprokin (dom-peridone) 10 mg 2 times a day № 20. Second group of 51 (49,5%) patients without functional gastrointestinal disorders were treated by a standard method. All patients underwent clinical, biochemical, ultrasound, X-ray, CT, and MRI examinations, and functional evaluation of the cardiovascular and respiratory systems.
The severity of neurological impairment was assessed by the scale proposed by H. L. Frankel et al. (1969) and modified by A.Yu.Mushkin et al. (1989). [1] Evaluation of motor function of the stomach was carried out by a modified method of F. Tympner with 400 ml of 0.9% NaCl solution of room temperature on the unit Interscan-250 (Germany) with 3.5-5 MHz linear transducer [1]. All patients underwent esophagogastroduodenoscopy as well with Olympus (Japan) machine by a standard method.
Results and discussion: 69 (67.0%) patients were diagnosed with active and progressive spine tuberculosis, that patients had relatively acute onset of symptoms of the specific process like intoxication, febrile body temperature, and weakness, loss of appetite and significant weight loss. In 34 (33.0%) patients the course of the specific process was torpid, that were presented with moderate intoxication symptoms, subfebrile body temperature, and insignificant weight loss.
According to X-ray and MRI (CT) studies tubercular process was localized at the cervical spine in 3 (2.9%) patients (one patient from I group and two patients from II group), at the thoracic spine -17 (16.5%) (9 and 8 patients from I and II group accordingly), thoracolumbar spine — 21 (20.4%) patients (10 (I group) and 11 (II group)), lumbar spine — 38 (36.9%) (21 (I group) and 17 (II group)) and lumbosacral spine — 24 (23.3%) (11 (I group) and 13 (II group)).
Section 7. Medical science
The severity of the specific process was determined by numbers of affected vertebras as well as abscess formation, which was presented in 75 (72.8%) patients (39 (I group) and 36 (II group). Instability of the vertebral column was determined in 78 (75.7%) cases (40 (I group) and 38 (II group)).
Neurological symptoms were presented as radicular pain syndrome, muscle paresis, and sensory loss, as well as pelvic organs function impairment and vegetative nerve system disorders.
52 (50.5%) patients of the main group were diagnosed with gastrointestinal motor function disorder. Gastroparesis (weakening of the motor function of the stomach) was in 31 (59.6%) patients, gastric dysrhythmia (a violation of cyclic activity of the stomach in the interdigestive period) was in 19 (36.5%) patients. No gastrointestinal disorder was found in the control group patients. Clinically, all patients of the main group had discomfort at epigastric area (Fig № 1). Patients often had difficulties to localize the pain, noting that the pain arises from the upper abdomen, and sometimes about umbilical region. 18 (34.6%) patients had constant aching pain, and its intensity varied from moderate — in 8 (44.5%) cases, to mild — in 6 (33.3%) cases. In 4 (22.2%) cases the pain was sharp or cutting in nature. 12 (23.0%) patients noted a clear correlation between pain and food intake. 9 (17.3%) patients had fasting pains, 3 (33.3%) of them had nocturnal pain. In 6 (11.5%) patients the pain did not depend on food intake. 11 (21.2%) patients had dyspeptic syndrome: loss of appetite, nausea, heartburn, belching, meteorism and epigastric pain.
On admission 27 (51.9%) patients from the group I and 23 (45,1%) from group II were assigned to HRSZE regimen. Due to the intolerance of antibacterial drugs in 23 (44,2%) cases (group I) isoniazid and rifampicin were administered intramuscularly or intravenously. Remaining patients were assigned to HRSE regimen. Spinal cord compression on MRI and neurological deficit were indications for surgery at an early stage of treatment.
Surgical intervention aimed to remove necrotic tissues and sequesters with spinal cord decompression by resection of the affected vertebras. Bone autografting was usually performed to fill bone defects, stabilizing the spine and inducing bone fusion. In 33 (32,0%) patients used autografts from a rib (2 to 4 fragments), which was resected as a part of surgical approach. In 70 (68,0%) patients with tuberculosis of the cervical, thoracolumbar, lumbar, lumbosacral spine, autograft was taken from iliac crest. Postoperatively, all patients continued their antibiotic therapy regimen for 2-3 months.
In 1-2 days after surgery, 9 (17,3 ± 1,0) patients in group I and 11 (21,5 ± 0,7) patients in group II (which did not have any clinical signs preoperatively) manifested with stomach motor function symptoms, which were presented clinically as belching, vomiting, abdominal distension, regurgitation.
During the first 2-3 months after surgery 46 (88,5%) patients from the main group showed clinical improvement, which was presented as improvement of intoxication symptoms in 46 (88,5%) patients, relief of pain in 43 (82,7%) patients. 45 (88.2%) patients in the same period showed significant improvement of intoxication symptoms and 44 (86.3%) patients improvement of pain in second group. All patients showed stable position of the bone grafts in both groups. No residual or recurrent abscess was found in 44 (84,0%) patients from group I and in 33 (91,6%) patients from group II. Acute coronary syndrome occurred in 1 patient on the sixth day after surgery. Exudative pleurisy occurred in another patient in 1 month postoperatively on the operated side of the thorax. Two patients occurred with abnormal liver function (increased transaminase levels) and one patient with allergic dermatitis. Abscess formation occurred in three patients on the opposite side of the operated vertebra revealed on MRI. Body temperature remained 37,0-37,5 within two months after surgery in one patient. Two patients developed toxic hepatitis. All the complications of the cardiovascular system, lungs, and liver were eliminated by adequate pathogenetic therapy.
Restoration of spinal cord function after surgery depends on the severity and duration of the compression. In our study, in 2-3 months after surgery complete resolution of spinal disorders was observed in all 45 (43,8 ± 2,1) patients in both groups with radicular syndrome (ER type), and in 17 (10 from group I, 7 from group II) patients with type D disorder. Significant neurological improvement was indicated in patients with D — and C — type of disorder. Restoration of spinal cord function in patients with A — and B — types require long-term treatment and observation.
Conclusions:
1. Impairment of the gastrointestinal tract in patients with complicated forms of tuberculous spondylitis worsens the course of tubercular process in the spine and makes it difficult to cure.
2. Timely diagnosis and adequate pathogenetic therapy of motor function of the gastrointestinal tract increases the efficiency of treatment of tuberculous spondylitis.
3. Radical and reconstructive surgery on anterior aspect of the spine with complex antibacterial therapy prevents severe spinal deformities, neurological and gastrointestinal disorders.
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