A 42-year-old man with thoracic spinal tuberculosis started on four drug antitubercular therapy six weeks ago now has increasing weakness of both legs, deteriorating from MRC grade 4 to grade 2 power. Repeat MRI shows enlarging epidural granulation tissue compressing the cord despite documented adherence to treatment. What is the appropriate next step?

• A Urgent surgical decompression of the cord ✓
• B Add corticosteroids alone and observe closely
• C Change empirically to second line antitubercular drugs
• D Continue current chemotherapy and reassess after 3 months

Explanation

Progressive neurological deficit while the patient is receiving adequate antitubercular chemotherapy is a well established indication for surgical decompression, since continued medical management alone risks irreversible cord damage. Empirical switching to second line drugs is reserved for microbiologically confirmed resistance, and steroids do nothing to remove mechanical compression. Waiting three months in the face of a deteriorating deficit would be unsafe.

Reference: Campbell's Operative Orthopaedics, 14th ed.

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Written and medically reviewed by the StethoPrep medical team.