What is the management of spine tuberculosis?

Management of Spine Tuberculosis

The standard treatment for spine tuberculosis consists of a 6-month regimen of rifampicin and isoniazid, supplemented with pyrazinamide and ethambutol for the first 2 months, with surgical intervention reserved for cases with neurological compromise, spinal instability, or significant kyphosis. 1

Diagnosis

• Image-guided aspiration biopsy should be performed to confirm the diagnosis and determine drug susceptibility 1
• Bacteriological confirmation and drug susceptibility testing should be sought whenever possible due to rising incidence of drug resistance 2
• Samples should be obtained during any drainage procedures for microbiological confirmation 3

Medical Treatment

First-line Treatment Regimen

• Standard 6-month short-course chemotherapy is the mainstay of treatment for spine tuberculosis 2, 1:
  • Initial phase (first 2 months): Isoniazid, rifampicin, pyrazinamide, and ethambutol
  • Continuation phase (next 4 months): Isoniazid and rifampicin
• Daily dosing is strongly recommended over intermittent regimens 1
• Recommended dosages 2:
  • Isoniazid: 5 mg/kg (up to 300 mg) daily
  • Rifampicin: 10 mg/kg (< 50 kg: 450 mg; > 50 kg: 600 mg) daily
  • Pyrazinamide: 35 mg/kg (< 50 kg: 1.5 g; > 50 kg: 2.0 g) daily
  • Ethambutol: 15 mg/kg daily

Special Considerations

• For tuberculous meningitis or cerebral tuberculoma, extend treatment to 12 months 4
• If pyrazinamide is omitted or cannot be tolerated, treatment should be extended to 9 months 4, 1
• Fixed-dose combinations (e.g., Rifater, Rifinah) should be used whenever possible to aid compliance and prevent accidental monotherapy 2
• For pregnant patients, streptomycin and pyrazinamide should be avoided; the initial regimen should consist of isoniazid and rifampicin with ethambutol added if primary isoniazid resistance is suspected 5

Surgical Management

Surgery is indicated in the following situations:

• Neurological compromise or spinal cord compression 1, 6
• Spinal instability or significant kyphosis 1
• Large abscess formation requiring drainage 1, 3
• Failure to respond to medical therapy 1
• Progressive deformity despite medical treatment 6

Surgical approaches may include:

• Anterior debridement and fusion for cases with significant anterior column involvement 6
• Posterior stabilization with instrumentation to prevent kyphosis, particularly when both anterior and posterior elements are involved 6
• Abscess drainage when indicated 3

Drug-Resistant Tuberculosis Management

• For multidrug-resistant TB (MDR-TB), treatment should be guided by drug susceptibility testing 1
• The WHO recommends a shorter, 6-month all-oral, bedaquiline-containing regimen for eligible patients with MDR/RR-TB 2
• This regimen includes: bedaquiline (6 months), levofloxacin/moxifloxacin, clofazimine, pyrazinamide, ethambutol, high-dose isoniazid, and ethionamide 2
• Never add a single new drug to a failing regimen to prevent further acquired resistance 1

Monitoring and Follow-up

• Regular clinical assessment and radiographic evaluation to monitor response to treatment 1
• Monitor for drug-related adverse effects, especially hepatotoxicity 2, 3
• If AST/ALT levels rise to five times normal or bilirubin rises, rifampicin, isoniazid, and pyrazinamide should be temporarily discontinued 2
• Long-term follow-up is essential, particularly for children, as spinal growth can exaggerate deformities 1

Adjunctive Therapies

• Directly Observed Therapy (DOT) is recommended to ensure adherence to the treatment regimen 5, 7
• Nutritional support is essential, especially for malnourished patients 1
• Physiotherapy and rehabilitation are important for improving function and preventing complications 1
• Orthotic devices may be needed to support the spine during healing 1

Common Pitfalls and Caveats

• Affected vertebrae may continue to show radiographic changes during treatment without indicating treatment failure 1
• Inadequate duration of therapy or poor compliance can lead to treatment failure and drug resistance 8, 7
• Spinal TB without unsightly kyphosis and neurologic symptoms is primarily a medical, rather than surgical, condition 6
• Concomitant administration of pyridoxine (B6) is recommended in malnourished patients and those predisposed to neuropathy (e.g., alcoholics and diabetics) 5