Management of Spinal Tuberculosis
The standard management of spinal tuberculosis consists of a six-month regimen of rifampicin, isoniazid, and pyrazinamide for the first two months, followed by rifampicin and isoniazid for four months, supplemented with ethambutol in the initial phase when drug resistance is a concern. 1
Medical Treatment
First-line Regimen
Initial phase (first 2 months):
- Rifampicin (10 mg/kg, max 600 mg daily)
- Isoniazid (5 mg/kg, max 300 mg daily)
- Pyrazinamide (35 mg/kg, max 2 g daily)
- Ethambutol (15 mg/kg daily) - may be omitted in previously untreated patients with low risk of isoniazid resistance 1
Continuation phase (next 4 months):
- Rifampicin and isoniazid at the same doses 1
Dosing Options
- Daily dosing throughout
- Daily for 2 months followed by 2-3 times weekly for 4 months
- Three times weekly from the start for 6 months 1
Special Considerations
- If pyrazinamide cannot be tolerated, extend treatment to 9 months with ethambutol for the initial 2 months 1
- For drug-resistant TB, treatment must be individualized based on susceptibility testing 2
- Directly Observed Therapy (DOT) is recommended to ensure compliance and prevent drug resistance 3
- Add pyridoxine (vitamin B6) for malnourished patients and those predisposed to neuropathy (e.g., alcoholics, diabetics) 3
Surgical Management
Surgery may be required in specific situations:
- Spinal cord compression
- Spinal instability
- Large abscess formation
- Progressive neurological deficit despite medical treatment
- Failure to respond to medical therapy 1
Surgical options include:
- Anterior debridement and fusion
- Posterior stabilization
- Combined approaches depending on the extent of disease and location 4
The timing of surgery is important - patients with paraplegia may recover more quickly with surgical intervention (average 3 days) compared to conservative management (gradual recovery over 14 days) 4
Monitoring and Follow-up
- Regular clinical assessment for treatment response
- Monitor for drug toxicity, especially hepatotoxicity
- Liver function tests should be performed at baseline and monitored if symptoms develop 1
- Radiological follow-up to assess healing and progression of deformity
- In children, kyphosis may progress despite treatment 4
Drug Resistance Considerations
- Multi-drug resistant TB (MDR-TB) is increasingly common in spinal TB (78.3% in one study) 5
- Highest resistance rates are seen with isoniazid (92.7%) and rifampicin (81.9%) 5
- Obtain tissue for culture and drug sensitivity testing whenever possible 5
- Consult with TB specialists for management of drug-resistant cases 3
Potential Complications
- Progressive kyphosis, especially in children
- Neurological deficits
- Drug toxicity, particularly hepatotoxicity
- Treatment failure due to poor drug penetration into sclerotic bone 6
- HIV co-infection may complicate management 2
The six-month regimen has been shown to be highly effective for spinal TB, with ambulatory chemotherapy being sufficient for most cases without neurological compromise 1. Surgery plus chemotherapy provides faster neurological recovery in patients with spinal cord compression 4.