A 35-year-old man with HIV presents with back pain, vertebral collapse, and a large paraspinal swelling at the L2 level. CT shows a psoas abscess with calcifications. Neurological examination is normal. The first-line management is:
- A Emergency spinal decompression and stabilisation surgery
- B Anti-tubercular therapy for 6 months as per the standard DOTS short-course regimen
- C Anti-tubercular therapy (ATT) for 9–12 months; abscess drainage only if >100 mL or no response after 4 weeks of ATT ✓
- D Immediate CT-guided percutaneous drainage of the psoas abscess with no ATT until culture results
Correct answer: C. Anti-tubercular therapy (ATT) for 9–12 months; abscess drainage only if >100 mL or no response after 4 weeks of ATT
Explanation
In spinal TB (Pott's disease) without neurological deficit, conservative management with anti-tubercular therapy (HRZE for 2 months, then HR for 7–10 months — total 9–12 months) is the primary treatment; most lesions heal with chemotherapy alone. Psoas abscess responds to ATT; percutaneous drainage is indicated for very large collections (>100 mL), failure to respond at 4 weeks, or abscess causing pressure symptoms. Surgical decompression is reserved for neurological deficit, instability, or chemotherapy failure. HIV co-infection prolongs treatment.
Reference: Maheshwari Essential Orthopaedics, 6th ed.
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Written and medically reviewed by the StethoPrep medical team.