Paradoxical reactions in spinal tuberculosis: A case series

Introduction: Clinical or radiological worsening of pre-existing tubercular lesions or appearance of new lesions in patients who have shown initial improvement following antitubercular chemotherapy (ATT) is termed as a paradoxical reaction (PR). The appearance of these lesions after spine surgery raises the possibilities of drug resistance, treatment failure, and surgical site infection. This retrospective case series aims to describe the presentation of PRs in spinal tuberculosis (TB), identify risk factors, and propose a treatment plan for PRs within the spine. Materials and Methods: Nine patients (2 males and 7 females; mean age 31.2 years), who underwent posterior transpedicular decompression and instrumented fusion for spinal TB, presented 4–7 weeks later with a soft, large swelling at the surgical site. In one patient, the swelling had burst through the skin resulting in a discharging wound. Two patients had screw pullout with local kyphosis. All patients had been started on ATT only after index surgery and had experienced improvement in constitutional symptoms, pain, and neurology. Magnetic resonance imaging showed large fluid collection at the surgical site without any new bony lesions. Results: All patients underwent surgical debridement with two patients requiring revision instrumentation. Examination of tissue and fluid revealed caseating granulomas and mycobacteria. Continuation of the same ATT led to uneventful healing. Conclusion: PRs in patients with spinal TB presented with a cold abscess at the surgical site between 4 and 7 weeks after starting ATT. Surgical drainage with debridement and continuation of ATT without changes to the regimen led to uneventful healing in all patients. Young age, female sex, thoracic lesions, and patients virgin to ATT prior to surgery were risk factors.