Abstract
This article presents an important status check on the more recent literature regarding the continuing global health care concern about tuberculosis (TB), as related to its spinal manifestations in the form of Pott’s disease.
In the big picture, TB remains one of the top 10 causes of death globally, with 1.8 million deaths reported in 2015. 1 The gold-standard TB treatment remains long-term antibiotic therapy with spine surgical indications essentially unchanged since the MRC trials (1940-1949). 2 The optimism towards medical eradication of TB, with a reported annual decline of about 1.5% per year since 2000, has been tempered by the emergence of multidrug-resistant (MDR) variants in regards to treatability, affordability, and likely further disease spread. In 2015, the World Health Organization (WHO) reported 10.4 million new cases with about 480 000 of them MDR cases. 1 Multidrug-resistant cases are noteworthy for their much increased burden of care requirements, including much higher treatment costs (US$18 000 for a 6 month course of treatment for conventional TB versus US$134 000 for MDR to US$430 000 for extensively resistant variants), and more common inpatient care and lost productivity over the 2 year treatment period needed. 3 These circumstances bode poorly for future disease containment efforts. While this review article does not address the changing resistance patterns of TB, it does reflect the global presence of the disease in its publication profile. Sixty percent of new TB cases occur in India, Indonesia, China, Nigeria, Pakistan, and South Africa, as reflected by the publications list. 1 As the graphic representations show, China increasingly dominates the world literature over the last 2 years (with no publications on surgical treatment of Pott’s disease from the United States since 2000, despite approximately 10 000 new TB cases per year). 2 Extensive representation of medical literature from one cultural sphere may be problematic, as experiences from one country may not translate to the sociocultural norms and resources available in another part of the world.
In general, the authors could not answer the question of if there is a change in surgical treatment indications for Pott’s disease and overall prevalence of surgery. Based on the summary findings, it appears that posteriorly based surgery is becoming the preferred approach for adults. In terms of outcomes and results reporting, there remains a high degree of uncertainty. The authors present an inventory list of key deliverables, which would seem to be of interest for all spinal TB related studies, yet only a paucity of studies actually address these parameters. Most importantly, perhaps, length of follow-up and longer-term assessment of recurrence in these patients is still mostly unknown.
Given these limitations, it is hard to gauge the present-day outcomes of spine surgery for TB and if there have been tangible improvements for patients. Hopefully, authors on the topic of Pott’s disease will include these key variables in their studies going forward to allow for greater comparability of results across centers and regions of the world.