Routine surgery in addition to chemotherapy for treating spinal tuberculosis

Background Tuberculosis is generally curable with chemotherapy, but there is controversy in the literature about the need for surgical intervention in the one to two per cent of people with tuberculosis of the spine. Objectives To compare chemotherapy plus surgery with chemotherapy alone for treating people diagnosed with active tuberculosis of the spine. Search strategy We searched the Cochrane Infectious Diseases Group Specialized Register (October 2005), CENTRAL (The Cochrane Library 2005, Issue 4), MEDLINE (1966 to October 2005), EMBASE (1974 to October 2005), LILACS (1982 to October 2005), conference proceedings, and reference lists. Selection criteria Randomized controlled trials with at least one year follow up that compared chemotherapy plus surgery with chemotherapy alone for treating active tuberculosis of the thoracic and/or lumbar spine. Data collection and analysis Two authors independently assessed trial eligibility, methodological quality, and extracted data. We analysed data using odds ratio with 95% confidence intervals. Main results Two randomized controlled trials (331 participants) met the inclusion criteria. They were conducted in the 1970s and 1980s with follow-up reports available after 18 months, three years, and five years; one trial also reported 10 years follow up. Completeness of follow up varied at the different time points, with less than 80% of participants available for analysis at several time points. There was no statistically significant difference for any of the outcome measures: kyphosis angle, neurological deficit (none went on to develop this), bony fusion, absence of spinal tuberculosis, death from any cause, activity level regained, change of allocated treatment, or bone loss. Neither trial reported on pain. Of the 130 participants allocated to chemotherapy only, 12 had a neurological deficit and five needed a decompression operation. One trial suggested that an initial kyphosis angle greater than 30 degrees is likely to deteriorate, especially in children. Authors' conclusions The two included trials had too few participants to be able to say whether routine surgery might help. Although current medication and operative techniques are now far more advanced, these results indicate that routine surgery cannot be recommended unless within the context of a large, well-conducted randomized controlled trial. Clinicians may judge that surgery may be clinically indicated in some groups of patients. Future studies need to address these topics as well as the patient's view of their disease and treatment.