Tuberculosis is the most common infectious disease in the world. Every year 10 million new people are infected (WHO 1991). While tuberculosis commonly infects the lungs, there is a tuberculous process outside the lungs in 15% of affected people. Of all these extrapulmonary lesions, 10% are located in the skeleton with half in the spine and half in the other bones and joints (Watts 1996).

Tuberculosis of the spine is potentially serious. The infection can destroy the bone and cause pain and deformities of the spine (such as a hump). Sometimes the damage to the spine results in trapped nerves causing a lot of pain and loss of feeling and muscle control; even complete paralysis can occur. If there is a sharp angle in the spine (kyphosis) due to the bony destruction, loss of neurological function may manifest only after years, even if the tuberculosis has been cured adequately (Hsu 1988; Rajeswari 1997; Luk 1999). This is the result of chronically irritated and malnourished spinal marrow (myelopathy) or a local reactivation. Late paraplegia due to affected spinal marrow is an almost insolvable problem because an operation at this stage is very difficult and prone to major complications without subsidence of the neurological deficit (Moon 1997). If the bone has fully fused in a normal position after the primary illness period, this late consequence is thought not to occur (Leong 1993). Most experts believe that a kyphosis over 30 degrees is likely to deteriorate and lead to back pain and neurological deficit (Kaplan 1952; Wimmer 1997; Rajeswari 1997; Parthasarathy 1999). Another study reports that progression of the deformity can be predicted based on the initial amount of vertebral body bone loss and is independent of the initial angle of kyphosis (Rajasekaran 1987).

Tuberculosis in general is curable. The mainstay of treatment is chemotherapy with at least isoniazid, rifampicin, and pyrazinamide. The American Thoracic Society recommends 6 months of chemotherapy for spinal tuberculosis in adults but 12 months in children because reliable data are lacking on shorter treatment duration (ATS 1994). The British Thoracic society recommends 6 months of treatment irrespective of age (BTS 1998). In their recent review of the literature, Van Loenhout‐Rooyackers and colleagues found that 6 months of treatment is probably sufficient for everyone (Loenhout 2002).

In tuberculosis, treatment is considered to be successful when the person is cured, is no longer infectious, and does not suffer relapse. However, some unique problems are encountered in spinal tuberculosis: spinal deformity and neurological problems. Treatment in spinal tuberculosis is directed toward restoring normal neurology, controlling the deformity to prevent pain and late paraplegia, local elimination of the disease to prevent recurrence, and to achieve early bony fusion to prevent deterioration of deformity and pain. You want the people to resume their normal lives.

In the presence of comorbidity that affects the immunocompetence of people (diabetes mellitus, liver cirrhosis, renal failure, cancer, corticosteroid therapy, transplantation, HIV infection, alcoholism, intravenous drug use, malnutrition) it has been shown that there is a relative increase in tuberculosis manifestations outside the lungs (extrapulmonary tuberculosis) compared to pulmonary tuberculosis (Antony 1995; Iseman 2000). HIV increases the risk of reactivation of a latent focus and progression of the primary infection to a more atypical and disseminated extrapulmonary manifestation. Survival rates were worse for people with HIV and extrapulmonary tuberculosis compared to people with HIV and pulmonary tuberculosis. Survival for people with HIV and both pulmonary and extrapulmonary tuberculosis was even shorter (Whalen 1997). Other studies report comparable survival curves for both groups, with a more complicated medical course for the extrapulmonary group (Wohl 2000). Ethnic background is also suspected to play a role in the expression of extrapulmonary tuberculosis in people with AIDS (Braun 1990). There are also reports of high incidences of extrapulmonary tuberculosis in the absence of HIV infection (Cowie 1997). Studies directed specifically at spinal tuberculosis and HIV conclude that good clinical outcomes can be expected irrespective of the HIV status and the availability of antiretroviral therapy (Leibert 1996; Govender 2000). Another report mentions that people with HIV are not a homogeneous group, and that results − especially complications like wound infections − worsen during the end stage of the disease (Jellis 1996). In conclusion regarding HIV and immunosuppression, it can be stated that a good clinical outcome is generally expected from treating spinal tuberculosis, but this may depend on how far the HIV/AIDS has progressed.

There is controversy in the literature about the necessity of additional surgical intervention in spinal tuberculosis. This difference of opinion goes back to 1960 when Hodgson and Stock advocated surgical treatment (Hodgson 1960) and Konstam and colleagues advocated the conservative treatment (Konstam 1958; Konstam 1962). Conservative treatment consists of medication and additional non‐operative measures (physical therapy, orthosis, and bedrest). Surgery can basically be divided into two procedures. The first is a debridement. This is a procedure that comprises surgicaldrainage or curettage of the infected material without spinal reconstruction. The second form, which is more extensive, is a debridement with spinal reconstruction aimed at immediate restoration of spinal alignment and stability. The reconstruction can be done with bone grafts and/or artificial materials like steel, carbon fibre, or titanium.

The British Medical Research Council Working Party on Tuberculosis of the Spine performed a series of trials to investigate the various methods of treatment. They concluded that chemotherapy on an outpatient basis is sufficient to treat the majority of people (MRC 1973a; MRC 1973b; MRC 1974a; MRC 1974b; MRC 1976; MRC 1978; MRC 1982; MRC 1985; MRC 1987; MRC 1993; MRC 1998). This is an attractive conclusion because tuberculosis is common in countries with limited resources. It means we can cure people without surgery. However, their reports also reveal a quicker bony fusion and less deformity for the group that received surgery, especially with the radical operation in which the whole lesion is resected and stabilized with a bone graft. So perhaps the addition of surgery is preferable in regions where resources are available. However, these trials only included people with milder forms of spinal tuberculosis, and they excluded people who were paralysed severe enough to prevent them from walking across a room and people with a total destruction of more than three vertebral bodies − two groups likely to benefit from surgery.

Many authors consider the following indications for surgical intervention: (1) neurological deficits (with an acute or non‐acute onset) caused by compression of the spinal cord; (2) spinal instability caused by destruction or collapse of the vertebrae, destruction of two or more vertebrae, or kyphosis of more than 30 degrees; (3) no response to chemotherapeutic treatment; (4) non‐diagnostic biopsy; (5) large paraspinal abscesses (Vidyasagar 1994; Chen 1995; Nussbaum 1995; Rezai 1995; Boachie‐Adjei 1996; Watts 1996; Moon 1997). Some authors even advocate surgery in mild cases of spinal tuberculosis (Leong 1993; Luk 1999; Turgut 2001). Their concern is the development of late myelopathic paraplegia as a result of residual kyphosis. An unpublished case series from Hong Kong of 60 conservatively treated patients with severe kyphotic deformities revealed 25 cases of late onset paraplegia (Luk 1999).

Potential benefits of surgery are quicker relief of pain, immediate relief of compressed nerve tissue, restoration of normal anatomic delineation, less kyphosis, a higher percentage of bony fusion, quicker bony fusion, earlier resolution of sinus tracts and abscesses, shorter hospitalization, and less relapse. It may also prevent late neurological problems due to the sharp angle of the spine as long as the bone is not fused, further deterioration of the kyphos angle can occur (Leong 1993; Hsu 1988).

Surgery requires a lot of expertise, good anaesthesia, and excellent peri‐operative care. It requires hospitalization, is expensive and potentially dangerous. Complications can occur during the operation or postoperatively. Complications of spinal surgery can be divided into several groups: material related, vascular, neurological, visceral, and wound related. Material failures consist of breakage of the screws and rods, loss of correction, and failure of fusion (Jutte 2002). Graft displacement, collapse, and resorption can occur. Vascular problems can be massive bleeding, haematoma formation, and thromboembolism. Neurological damage consists of nerve root impingement or lesion, dura tears, spinal cord infarction, and plexus lesions. Visceral damage, especially ureter lesions, can occur. Wound infections happen in 1 to 6% of spinal surgeries (Fardon 2002). Nutritional status is considered to be a major factor in results of operative treatment as well. The risk of postoperative wound infection was 15 times greater in malnourished people (Fardon 2002). So if there is no real benefit of surgery, it should not be performed.