Changing trends in duration of treatment of musculoskeletal and spinal tuberculosis- long term experience in a tertiary care teaching hospital

Abstract

Duration of antitubercular therapy (ATT) for musculoskeletal (MSK) tuberculosis (TB) is a challenge, particularly if pain persists at the end of therapy. WHO recommends 6–9 months therapy, index TB guidelines of India recommends 12 months ATT extendable to 18 months, yet many surgeons in India continue to prescribe 18–24 months ATT in all cases of MSK TB. To address this controversy, two studies were conducted to assess the adequacy of 6 months ATT for MSK TB, the third study to evaluate results of 9–12 months of ATT and fourth study to assess residual back pain in spinal TB after ATT of different duration.

In the 1st study (2006–09), after 6 months of ATT, all 9 cases of spinal and all 25 cases of extraspinal MSK TB had healed clinically and with a negative ciprofloxacin-labelled technetium 99 scan and among them, even as early as 3 months, 2 spinal and 4 extra-spinal cases had negative scans.

In the 2nd study (2010–2013), after 6 months ATT, Gadolinium enhanced MRI scans in 50 cases of MSK TB depicted complete resolution in 6 cases (12%), partial resolution in 36 cases (72%) and no resolution in 8 cases (16%). Irrespective of the MRI findings at 6 months, in 44 clinically healed cases ATT was stopped at 6 months and they remained healed at more than 5-year follow up. In 6 cases, who had no clinical healing, ATT was prolonged in 3 patients and the category of ATT was changed in remaining 3 patients (2 spinal TB and one Hip TB).

In the 3rd study (2019–2022), all 51 patients of spinal TB who took 9–12 months of ATT had fever subsidence within 1–6 months (mean 3.52 months), appetite improvement within 1–7 months (mean 3.5 months) and weight gain by 1–8 months (mean 4.45 months). Intermittent back pain continued in 23/51 patients (41%) even after 2 years of stoppage of 9–11 months ATT, among them 20 patients (96.4%) had radiological bony fusion. Persistent back-pain (mean VAS 6.33) occurred in 3 cases who took 12 months ATT; 2 reported after 10 months of whom 1 was detected as MDR, 3rd patient reported after 7 years and recovered after 1 year of ATT.

In the 4th study (2020–2023), 88 of 300 MSK TB (non-resistant cases, managed non-operatively) patients responded telephonically, 48 visited the hospital and 40 patients were telephonically interviewed regarding back pain after ATT. After various duration of ATT, 6–9 months (13.6% cases); 10–12 months (26.1% cases); 13–18 months (53.4% cases) and 19–24 months (6.8% cases) all had clinically healed with no fever, loss of appetite or weight loss. Majority (45/48) of patients (93.8%) had bony healing yet back pain was present in 28 patients (31.8%); intermittent pain in 19 patients and continuous pain in nine.

Stopping ATT at 6 months may be considered in cases with complete clinical healing with normal ESR. Patients with no progressive signs of clinical healing by 6 months should be investigated for drug resistance rather than empirical extension of treatment beyond 6–9 months.