Treatment of Cervical TB Spondylitis with Retropharyngeal Extension and Scrofula
For cervical TB spondylitis extending to the retropharyngeal space with scrofula, initiate the standard 6-month four-drug regimen (2 months of isoniazid, rifampin, pyrazinamide, and ethambutol followed by 4 months of isoniazid and rifampin) under directly observed therapy, with surgical intervention reserved for spinal cord compression or instability. 1
Initial Medical Management
Standard Anti-TB Regimen
Intensive phase (2 months): Administer isoniazid 5 mg/kg (max 300 mg daily), rifampin 10 mg/kg (max 600 mg daily), pyrazinamide 35 mg/kg daily for patients <50 kg or 2.0 g daily for patients >50 kg, and ethambutol 15 mg/kg daily 1, 2
Continuation phase (4 months): Continue isoniazid and rifampin after completing the intensive phase 1, 2
Total duration: 6 months is effective for cervical spine TB, including cases with retropharyngeal extension 1
Pyridoxine supplementation: Add 25-50 mg daily to prevent isoniazid-induced neuropathy, particularly important in patients with HIV, diabetes, or chronic renal failure 1
Critical Treatment Principles
Directly observed therapy (DOT): Strongly recommended for all TB patients to ensure treatment completion and prevent drug resistance 1, 2
Drug susceptibility testing: Must be performed on all initial isolates; discontinue ethambutol once susceptibility to isoniazid and rifampin is confirmed 1, 2
Modify regimen appropriately: If drug resistance is identified, follow drug-resistant TB guidelines with at least 5 effective drugs including fluoroquinolones and bedaquiline 2, 3
Management of Scrofula (Cervical Lymphadenitis)
Surgical Approach for Lymph Nodes
Excisional surgery is the primary treatment for tuberculous cervical lymphadenitis (scrofula), with approximately 95% success rate 2
Avoid incisional biopsy alone or anti-TB drugs without macrolides as sole treatment, as these approaches frequently result in persistent disease, sinus tract formation, and chronic drainage 2
Fine needle aspiration can be performed for diagnosis before definitive excisional surgery 2
For recurrent disease: Perform second surgical procedure or consider clarithromycin-based multidrug regimen if surgical risk is high 2
Surgical Indications for Spinal Disease
When to Operate on the Spine
Spinal cord compression: Immediate surgical decompression indicated for patients with myelopathy or progressive neurological deficits 1, 4, 5
Spinal instability: Surgery required for atlantoaxial dislocation or significant bony destruction causing mechanical instability 1, 4, 5
Persistent reducible atlantoaxial dislocation: Direct posterior fusion after adequate ATT trial 4, 5
Fixed atlantoaxial dislocation with severe deficits: Transoral decompression combined with posterior fusion 4, 5
Surgical Timing and Approach
All surgery performed under cover of anti-tuberculous therapy administered for 18 months total 4, 5
Transoral approach provides excellent access for biopsy, abscess drainage, and anterior decompression of the cervicomedullary junction 6, 4, 5
Conservative management with external orthosis appropriate for patients with minor deficits (neck pain without pyramidal tract involvement) who respond to ATT within 3 months 4, 5
Monitoring and Follow-up
Response Assessment
Clinical evaluation: Monitor for improvement in neck pain, neurological function, and systemic symptoms 4, 5
Radiological follow-up: Serial imaging to assess bony healing, abscess resolution, and spinal stability 4, 5
Sputum cultures: If pulmonary involvement present, obtain monthly cultures until conversion 2
Critical Pitfalls to Avoid
Do not delay surgical intervention in patients with severe neurological deficits or spinal cord compression, as even patients with spinal cord signal changes on MRI can show significant improvement with timely decompression 4, 5
Never treat scrofula with incisional biopsy alone or standard anti-TB drugs without surgical excision, as this leads to chronic drainage and sinus tract formation 2
Avoid premature discontinuation of ATT; complete the full 6-month course for standard disease or 18 months if surgical intervention was required 1, 4, 5
Do not add only one drug to a failing regimen if drug resistance is suspected, as this rapidly leads to acquired resistance 3
Ensure external stabilization (halo jacket or cervical orthosis) is properly fitted and monitored, as cardiorespiratory arrest has been reported in patients with severe cervical disease 6, 7