What is the recommended steroid dosage for the treatment of tuberculosis (TB) spine?

Steroid Dosage for TB Spine

For TB spine with spinal cord compression, adjunctive corticosteroids should be administered using dexamethasone 12 mg/day for adults (or 8 mg/day for children <25 kg) for 3 weeks, followed by a gradual taper over the subsequent 3 weeks, for a total duration of 6 weeks. 1

Indication for Steroids in TB Spine

• Corticosteroids are specifically recommended when there is evidence of spinal cord compression in patients with TB spine 1
• The primary goal is to reduce inflammation and prevent or reverse neurological deficits associated with cord compression 1

Dosing Regimen

Adults and Children ≥25 kg:

• Initial dose: 12 mg/day dexamethasone (or equivalent prednisolone/prednisone dose) 1
• Continue at full dose for 3 weeks 1
• Then taper gradually over the following 3 weeks 1
• Total duration: 6 weeks 1

Children <25 kg:

• Initial dose: 8 mg/day dexamethasone 1
• Same tapering schedule as adults 1

Alternative Corticosteroid Equivalents

• If using prednisone or prednisolone instead of dexamethasone, the equivalent initial dose would be approximately 60 mg/day for adults, tapered over the same 6-week period 1
• The WHO guidelines advocate for either dexamethasone or prednisone during the first 6-8 weeks for spinal TB with cord compression 1

Critical Context and Caveats

• Steroids are not routinely indicated for uncomplicated TB spine without neurological involvement 1
• The evidence for steroid use in TB spine is based primarily on expert opinion and extrapolation from other forms of extrapulmonary TB (particularly TB meningitis and pericarditis), rather than high-quality randomized trials specific to spinal TB 1
• Corticosteroids have demonstrated clear mortality benefit in TB meningitis and pericarditis, which provides the rationale for their use in TB spine with cord compression 1, 2

Monitoring During Steroid Therapy

• Monitor for hyperglycemia, particularly in patients with diabetes or HIV co-infection 2
• Watch for gastrointestinal bleeding and consider gastroprotection 2
• Assess for invasive bacterial infections, especially in immunocompromised patients 2
• Monitor liver function given the hepatotoxic potential of concurrent anti-TB medications 1

Surgical Considerations

• Steroids do not replace surgical intervention when indicated 1
• Surgery should be considered for: failure to respond to medical therapy, progressive neurological deficits despite treatment, or spinal instability 1
• The decision for surgery should be made in consultation with experienced spine surgeons 1

Common Pitfalls to Avoid

• Do not use steroids for uncomplicated TB spine without cord compression—this exposes patients to unnecessary risks without proven benefit 1
• Do not extend steroid therapy beyond 6-8 weeks without compelling indication, as prolonged use increases adverse effects without additional benefit 1
• Do not delay or substitute steroids for adequate anti-TB chemotherapy—the foundation of treatment remains appropriate antimicrobial therapy 1