Defining the end point of drug therapy in tuberculosis of the spine

Abstract

Background: Tuberculosis (TB) of the spine (Pott's disease) remains one of the most common forms of skeletal tuberculosis and is an important cause of pain, neurological deficits, spinal deformity, and long-term disability, particularly in developing countries. Although antitubercular therapy (ATT) is the cornerstone of treatment, the optimal endpoint for discontinuing therapy remains controversial because clinical recovery, laboratory improvement, and radiological healing often occur at different stages. This study evaluated the clinical, laboratory, and radiological parameters used to determine the endpoint of ATT in patients with spinal TB.

Methods: A retrospective observational study was conducted in the Department of Orthopaedics at Padmini Care Hospital, Tangi, Cuttack, Odisha, India, between October 2022 and May 2024. Medical records of 50 patients with spinal TB who completed standard first-line ATT were reviewed. Clinical improvement, neurological status, inflammatory markers (erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]), and serial radiological findings were analyzed to identify reliable indicators for treatment completion. Statistical analysis was performed using paired Student's t-test and Chi-square test, with p<0.05 considered statistically significant.

Results: The mean age of the patients was 42.8±13.1 years, with males comprising 62.0% of the study population. Significant clinical improvement was observed during treatment, with mean visual analogue scale pain scores decreasing from 7.8±1.1 to 2.1±0.9 (p<0.001). Neurological improvement occurred in 75.0% of patients with baseline neurological deficits. Mean ESR decreased from 63.5±17.2 mm/hour to 18.9±8.4 mm/hour, and mean CRP declined from 31.4±11.8 mg/l to 5.8±3.1 mg/l (both p<0.001). Although complete radiological healing was observed in 38.0% of patients, 94.0% demonstrated radiological stability without disease progression. No clinical relapse was documented during follow-up after discontinuation of ATT.

Conclusions: Clinical recovery, normalization of inflammatory markers, and radiological stability together provide a practical and reliable basis for determining the endpoint of antitubercular therapy in spinal TB. Complete radiological resolution should not be considered mandatory before treatment discontinuation. A multidisciplinary assessment may help prevent unnecessary prolongation of therapy while maintaining favorable clinical outcomes.