A patient with Pott's spine at L4-L5 develops sudden worsening of lower limb weakness and bladder disturbance despite 4 months of anti-TB therapy. MRI shows a retropulsed osseous fragment compressing the cauda equina. What is the best next step?

• A Add corticosteroids to existing anti-TB regimen and reassess in 2 weeks
• B Switch anti-TB regimen assuming drug-resistant TB and continue conservative management
• C Urgent surgical decompression (anterior decompression and fusion) to relieve mechanical cord/cauda equina compression ✓
• D CT-guided aspiration of residual abscess and reassessment

Explanation

A retropulsed bony fragment causing progressive neurological deficit is a MECHANICAL cause of compression and will not respond to antibiotics or steroids. Urgent surgical decompression — anterior decompression (corpectomy) with strut grafting and stabilisation — is mandatory to prevent irreversible cauda equina injury. Anti-TB drugs address the biological disease; steroids are used for paradoxical reactions or cord oedema but not mechanical bony compression. CT aspiration drains abscess but cannot remove bony fragments.

Reference: Maheshwari Essential Orthopaedics, 6th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.