A patient with thoracic Pott's disease has been on appropriate four-drug antitubercular therapy for 4 weeks. Which finding now mandates surgical decompression rather than continued conservative treatment?

• A Persistence of a large paravertebral abscess on repeat MRI
• B Increase in kyphotic angle measured on serial radiographs
• C Persistent elevation of erythrocyte sedimentation rate
• D Progressive worsening of motor weakness despite compliant chemotherapy ✓

Explanation

Tuli classifies progressive neurological deficit despite 3 to 4 weeks of adequate chemotherapy, sphincter disturbances, and complete cord compression as absolute indications for surgery. Abscess size, ESR trends, and modest progression of deformity are relative considerations managed conservatively in the absence of deficit, so options A, C, and B are plausible but do not compel operation.

Reference: Tuli's Textbook of Tuberculosis of the Skeletal System, 5th ed.

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