最近の脊椎カリエスについて

Tuberculous Spondylitis

　要旨：近年日本では脊椎カリエスの患者数の減少は著しい．そのため脊椎カリエスを診たことのない整形外科医が多くなり，診断と治療が遅れ重篤となる症例が増加している．鑑別診断として結核を常に頭に入れておくべきである．単純X線所見では，椎間板腔の狭小化に椎体上下縁の不整や椎体辺縁の骨欠損を認めたならば，感染特に脊椎カリエスを考えるべきである．CTは診断上非常に有益で，椎体周囲軟部組織の腫脹，椎体後壁の破壊，椎体周囲軟部組織内の石灰化などは脊椎カリエスを強く疑わせる．MRIも重要な所見を与えてくれ，特に病巣椎体の高信号と低信号の混在による不均一な像やGd-DTPAによる造影MRIのrim enhancementは脊椎カリエスを示唆する．Instrumentを使用する報告が増えているが，その使用には慎重であるべきである．いずれれにせよ脊椎カリエスの治療の基本は3剤以上の抗結核薬の投与である．

　There has been a marked decrease in the number of patients with tuberculous spondylitis in Japan in recent years, and as a result only a few orthopaedic surgeons have had experience in treating it. In fact, since hardly any orthopaedic surgeons can quickly make a correct diagnosis, the condition of the patients rapidly deteriorats. Because of this, all orthopaedic surgeons should keep the existence of disease in mind.

　On plain radiographs it is important to check for the signs such as verterbral disc space narrowing, irregularity of the vertebral end-plates, and marginal bone destruction, and if any of these signs is detected, tuberculous spondylitis should be placed at the top of the list of the differential diagnosis. CT scanning is perhaps a more useful method of detecting the disease, and if the scans reveal a paravertebral soft tissue mass, destruction of the posterior wall of a vertebral body, or soft tissue calcification in the mass, tuberculous spondylitis should be suspected. MRI provides important evidence for the diagnosis of this disease, and a heterogeneous pattern of intensity of the bone marrow in the vertebral body involved and rim enhancement with gadolinium-DTPA are valvable clves. Recently there have been many reports of instrumentation surgery for tuberculous spondylitis, but because of the risk of recurrence care should be exercised when using instruments, especially on the vertebral body.

　Use of at least 3 different antitubercular drugs is the basic treatment for tuberculous spondylitis.