A 40-year-old has Pott's disease at L1–L2 with a psoas abscess tracking to the iliac fossa. Neurological examination shows paraparesis (MRC grade 3/5 in both lower limbs). After confirming drug-sensitive TB on culture, the indication for surgical decompression is best characterised as:

• A All Pott's disease patients require anterior decompression regardless of neurology
• B Any degree of kyphosis requires immediate surgical correction
• C Neurological deficit that fails to improve after 4–6 weeks of appropriate ATT (medical paralysis) OR worsening neurology despite ATT — requiring anterior decompression and instrumented fusion ✓
• D Paraparesis is always managed conservatively with ATT alone

Explanation

The current consensus (MRC Madras trial reanalysis and modern guidelines) is that most Pott's disease — even with mild-moderate neurological deficit — responds well to chemotherapy alone. Surgical decompression is indicated when: (1) neurological deficit fails to improve after 4–6 weeks of adequate ATT ('medical paralysis'); (2) neurology worsens despite ATT; (3) severe deficit at presentation with significant cord compression on MRI; or (4) structural instability with progressive kyphosis. Surgery involves anterior debridement of the caseous material and granulation tissue (compressing the cord), anterior interbody fusion with autograft, and often posterior instrumentation (pedicle screws) for stability — the 'radical surgery' of Hodgson. Psoas abscess alone is not an indication for surgery and can be managed by ATT ± percutaneous drainage.

Reference: Maheshwari Essential Orthopaedics, 6th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.