Clinical and radiological outcomes after conservative treatment of TB spondylitis: is the 15 years' follow-up in the MRC study long enough?

INTRODUCTION: Tuberculosis of the spine is a still a common disease entity, not only in developing countries but is also returning in developed countries especially in the immune-compromised patients. Conservative treatment with chemotherapy is still the main stay of treatment. This article focuses on the clinical and radiological outcomes, and problems with conservative treatment.

METHOD: The available literature of anti-tuberculosis chemotherapy in managing spinal tuberculosis was reviewed. Data sources included relevant literature of the English language identified through Medline search from 1946 to 2011. Personal experience and unpublished reviews from the authors' institution were also included.

RESULTS: Although majority of patients respond well to anti-tuberculosis chemotherapy, about 15 % of them develop paradoxical response. The Medical Research Council (MRC) studies have shown that for patients without significant neurological deficits, operative and conservative treatment could produce the same clinical outcome at 15 years follow-up. Patients treated operatively with debridement and spinal fusion with strut graft had faster bony fusion and less kyphotic deformity. In contrast, those treated with drugs alone or with simple debridement without fusion may result in disease reactivation, severe kyphosis or late instability, which in turn may lead to late-onset Pott's paraplegia, back pain, sagittal imbalance and compromised pulmonary function that are difficult or risky to treat.

CONCLUSION: Recognition of the clinical and radiologic features of these late sequels is important for the management. Prevention of deformity in the early disease has been added to the modern standard of treatment of TB spine.