Spinal Tuberculosis Treatment: An Enduring Bone of Contention

Rehabilitation management of patients with spinal tuberculosis (Review)

Spinal tuberculosis (ST) is a serious condition and a global health concern, accounting for a significant portion of musculoskeletal tuberculosis cases. It can lead to sever spinal and neurological complications. The management of ST involves a multidisciplinary approach, including medical treatment, surgery and rehabilitation. Rehabilitation is crucial through the course of the disease's and is tailored for each stage according to the patients' complaints, and clinical and functional complications. In the case of neurological issues due to spinal compression, rehabilitation aims at overcoming bed confinement complications, involving mobilization techniques, strengthening exercises and related vesico-sphincter disorders (urodynamics, catheterizing). The role of rehabilitation for the management of pain in patients with ST is based on bracing (restricting movements and relieving the pressure on harmed structures), and analgesic physical means (electrical stimulation and massage techniques). Several rehabilitation options may be used to address musculoskeletal complications. Range of motion exercises, muscle strengthening, and posture and balance correction using sensory perception and proprioception techniques, are commonly involved. Cardiorespiratory reconditioning is required to improve respiratory function, walking ability and cardiovascular endurance. Ultimately, rehabilitation allows for the minimization of disability and the prevention of the loss of autonomy, particularly in elderly patients. The advantage of the rehabilitation approach is its multi-optional characteristics including physical therapy, occupational therapy, ergonomic advices and assistive equipment. Despite its crucial role, rehabilitation remains understudied in the management of ST. Thus, the present mini-review aimed to address the rehabilitation options for the clinical features and complications of ST, according to the course of the disease.

Healing Assessment of Spinal Tuberculosis: A Systematic Review

OBJECTIVE

Deciding the healing end point in spinal tuberculosis (STB) remains a controversial topic. The current systematic review aims to address the controversy existing in the literature to find a comprehensive method to assess healing in STB.

METHODS

A thorough literature search was carried out for studies with the assessment of healing parameters in STB. Data extraction was carried out manually, which included study characteristics and healing criteria evaluated in each study.

RESULTS

Qualitative analysis of 8 included studies showed that healing parameters were described in 3 domains: clinical, hematologic, and radiologic response of the patient to antitubercular chemotherapy. Each domain included various individual parameters, with clinical and radiologic assessment criteria being used in most of the studies. Improvement in terms of pain, constitutional symptoms, weight gain, neurology; variation in erythrocyte sedimentation rate and C-reactive protein; and changes in radiography, magnetic resonance imaging, and positron emission tomography/computed tomography were found to be promising predictors in the assessment of healing.

CONCLUSIONS

Radiologic response parameters emerged as the maximally used criteria to assess healing in STB. However, in the absence of any statistical analysis and an observed lag in radiologic response, the cumulative effect of all the parameters in 3 domains (clinical, hematologic, and radiologic) can be used to declare a spinal tubercular lesion nonhealing, healing, or healed.

Spine tuberculosis with an intercurrent active pulmonary location in a high incidence country: A rare case report

Spinal tuberculosis usually presents as destroyed contiguous vertebral bodies associated with intervertebral discs and paravertebral or psoas abscesses. Atypical forms are uncommonly reported. Vertebral involvement without disk destruction is a rare form that improves satisfactorily after appropriate medical management. We report the case of a 36-year-old male who had spine tuberculosis without disk involvement, associated with intercurrent active pulmonary location with good clinical improvement after treatment and follow-up imaging showing spectacular regression of bone lesions. By reporting this case, we also review the literature on this rare form of tuberculosis.

A validated liquid chromatography-tandem mass spectrometry assay for the analysis of isoniazid and its metabolite acetyl-isoniazid in urine

Introduction

Isoniazid (INH) is one of the most effective and potent first-line anti-tubercular drug. INH is also effectively administered as a preventative monotherapy and has been shown to significantly reduce TB incidence. INH is primarily metabolised to acetyl-isoniazid (AcINH) in the liver. AcINH is mainly excreted in urine presenting as a target for monitoring adherence to INH therapy.

Objective

The study aimed to develop and fully validate a bioanalytical method using liquid chromatography-tandem mass spectrometry for the quantification of INH and AcINH in human urine.

Methods

The samples were prepared using solid phase extraction, with the internal standards isoniazid-d4 and acetyl-isoniazid-d4 being used. The extracts were chromatographed on an Atlantis T3 analytical column with an isocratic mobile phase. For detection, a AB Sciex™ API 5500 triple quadrupole mass spectrometer was used at unit resolution in the multiple reaction monitoring mode, following positive electrospray ionization.

Results

The analytical method demonstrated sufficient sensitivity, as indicated by average signal-to-noise ratios of 7.07 and 6.23 at the lower limit of quantification for INH and AcINH, respectively. Validation was performed over three consecutive batches, demonstrating accuracy, precision, and overall robustness based on peak area ratios within the analytical range of 0.234-30.0 µg/mL for both INH and AcINH. All required validation experiments were assessed and met the acceptance criteria guidelines of the US Food and Drug Administration and European Medicines Agency. The validated method was utilized to measure concentrations of AcINH in urine as a means of assessing adherence to the intake of isoniazid in order to prevent TB infection during a phase III open-label multicenter trial.

Conclusion

A bioanalytical method was developed and fully validated for quantifying isoniazid (INH) and acetyl-isoniazid (AcINH) in 100 µL of human urine.

IL-10 and TGF-β1 may weaken the efficacy of preoperative anti-tuberculosis therapy in older patients with spinal tuberculosis

Spinal tuberculosis is a common extrapulmonary type that is often secondary to pulmonary or systemic infections. Mycobacterium tuberculosis infection often leads to the balance of immune control and bacterial persistence. In this study, 64 patients were enrolled and the clinicopathological and immunological characteristics of different age groups were analyzed. Anatomically, spinal tuberculosis in each group mostly occurred in the thoracic and lumbar vertebrae. Imaging before preoperative anti-tuberculosis therapy showed that the proportion of abscesses in the older group was significantly lower than that in the younger and middle-aged groups. However, pathological examination of surgical specimens showed that the proportion of abscesses in the older group was significantly higher than that in the other groups, and there was no difference in the granulomatous inflammation, caseous necrosis, inflammatory necrosis, acute inflammation, exudation, granulation tissue formation, and fibrous tissue hyperplasia. B cell number was significantly lower in the middle-aged and older groups compared to the younger group, while the number of T cells, CD4+ T cells, CD8+ T cells, macrophages, lymphocytes, plasma cells, and NK cells did not differ. Meaningfully, we found that the proportion of IL-10 high expression and TGF-β1 positive in the older group was significantly higher than that in the younger group. TNF-α, CD66b, IFN-γ, and IL-6 expressions were not different among the three groups. In conclusion, there are some differences in imaging, pathological, and immune features of spinal tuberculosis in different age groups. The high expression of IL-10 and TGF-β1 in older patients may weaken their anti-tuberculosis immunity and treatment effectiveness.

Successful Empirical Treatment of Suspected Spinal Tuberculosis: A Case Report

Spinal tuberculosis is an uncommon extrapulmonary manifestation of tuberculosis infection, known as a great masquerade that often mimics other pathologies, such as pyogenic and non-pyogenic infection, bone metastasis, haematological malignancy, and metabolic bone disease. It presents great challenges in establishing a diagnosis, deciding on treatment, and monitoring the response to treatment. A tissue-proven diagnosis is the cornerstone of a definitive diagnosis before initiating medical antitubercular therapy, leading to successful treatment. Here, we present a distinct and rare instance of spinal tuberculosis with an atypical presentation of upper thoracic myelopathy. It involved the cervicothoracic junction, exhibiting minimal axial symptoms but intensive destruction of the affected levels radiologically, along with an incomplete neurological deficit and the possibility of catastrophic neurological complications. The ultimate distinctiveness of this case lies in the diagnostic challenge it posed. Despite undergoing three separate tissue biopsies, tuberculosis infection could not be established, as all results returned negative for cellular, molecular, and histopathological markers, leading to a delay in initiating empirical medical therapy. Nonetheless, the patient responded well to empirical antitubercular therapy, resulting in favourable outcomes. To the best of our knowledge, a case of spinal tuberculosis with numerous negative tissue diagnoses has not been previously reported.

Challenges and Triumphs: Unusual Presentation of Tuberculosis in the Cuboid Bone Successfully Managed Through Surgical and Medical Intervention

This case report describes the unusual presentation of tuberculosis (TB) affecting the cuboid bone in a 16-year-old male patient. The patient presented with a one-year history of progressive foot pain, a discharging sinus, evening rise of temperature, weight loss, and loss of appetite. Clinical examination revealed soft tissue swelling and the presence of caseous material oozing from the sinus. Emergency debridement and curettage were performed, and bone cementing was carried out. An intraoperative sample was sent for a culture sensitivity test, histological analysis, and cartridge-based nucleic acid amplification test (CBNAAT). Histopathological examination, CBNAAT, and culture and sensitivity tests confirmed the diagnosis of Mycobacterium tuberculosis infection. Post-operatively, anti-tuberculous treatment was started. The patient fully recovered from TB of the cuboid.

A, Kis L, Király K, Varga S, Marcsik A, Schütz O, Török T, Hunt DR, Tihanyi B. White plague among the "forgotten people" from the Barbaricum of the Carpathian Basin-Cases with tuberculosis from the Sarmatian-period (3rd-4th centuries CE) archaeological site of Hódmezővásárhely-Kenyere-ér, Bereczki-tanya (Hungary)

Tuberculosis (TB) is a bacterial infection that is well-known in the palaeopathological record because it can affect the skeleton and consequently leaves readily identifiable macroscopic alterations. Palaeopathological case studies provide invaluable information about the spatio-temporal distribution of TB in the past. This is true for those archaeological periods and geographical regions from when and where no or very few TB cases have been published until now-as in the Sarmatian period (1st-5th centuries CE) in the Barbaricum of the Carpathian Basin. The aim of our paper is to discuss five newly discovered TB cases (HK199, HK201, HK225, HK253, and HK309) from the Sarmatian-period archaeological site of Hódmezővásárhely-Kenyere-ér, Bereczki-tanya (Csongrád-Csanád county, Hungary). Detailed macromorphological evaluation of the skeletons focused on the detection of bony changes likely associated with different forms of TB. In all five cases, the presence of endocranial alterations (especially TB-specific granular impressions) suggests that these individuals suffered from TB meningitis. Furthermore, the skeletal lesions observed in the spine and both hip joints of HK225 indicate that this juvenile also had multifocal osteoarticular TB. Thanks to the discovery of HK199, HK201, HK225, HK253, and HK309, the number of TB cases known from the Sarmatian-period Carpathian Basin doubled, implying that the disease was likely more frequent in the Barbaricum than previously thought. Without the application of granular impressions, the diagnosis of TB could not have been established in these five cases. Thus, the identification of TB in these individuals highlights the importance of diagnostics development, especially the refinement of diagnostic criteria. Based on the above, the systematic macromorphological (re-)evaluation of osteoarchaeological series from the Sarmatian-period Carpathian Basin would be advantageous to provide a more accurate picture of how TB may have impacted the ancestral human communities of the Barbaricum.

Anterior and posterior fusion via a posterior and costotransversectomy approach for thoracic spinal tuberculosis: A case report

INTRODUCTION AND IMPORTANCE

Left untreated, spinal tuberculosis can lead to irreversible neurological deficit in patients, lowering quality of life. Combination of antitubercular drugs and surgical approach is important in managing spinal tuberculosis. We report a case of thoracic spinal tuberculosis treated by anterior and posterior fusion via a posterior and costotransversectomy approach.

PRESENTATION OF CASE

A 38 years-old woman diagnosed with paraplegia due to spinal tuberculosis of the thoracic vertebra (Th8) with Frankel A grade for spinal function. Pre-op kyphotic angle was 27.2°. Antitubercular drugs prescribed did not improve paraplegia symptom. Thoracal X-ray and MRI showed pathological fracture on Th8 and paravertebral abscess along anterior corpus of the Th6-9. We performed Sapardan's alternative VI approach that consists of debridement and abscess evacuation, decompression by laminectomy of the Th8, flavectomy and costotransversectomy of the Th8, posterior stabilization of the Th6-7 and Th9-10, and interbody fusion of the Th8. One month postoperative follow up showed improvement on motor function and sensory function. Post op kyphotic angle was 26.7°.

CLINICAL DISCUSSION

Adequate debridement followed by costotransversectomy, interbody fusion and surgical stabilization relieves pain, improves neurologic function, and prevents deformity of spinal tuberculous patient.

CONCLUSION

Although costotransversectomy approach is rarely used in surgical management of spinal TB, it is beneficial in cases with massive abscess involvement since it provides better view to collect and drain massive abscess.

Pubic Symphysis Tuberculosis Recurrence - A Rare Case Report and Literature Review

Introduction

Tuberculosis (TB) of pubic symphysis is an extremely uncommon condition accounting <1% of all musculoskeletal TB. Further recurrence of TB of symphysis pubis is a rare clinical scenario requiring a high level of suspicion for diagnosing the condition. Recurrence of tuberculosis can occur either be due to relapse of the original infection or reinfection due to exogenous Mycobacterium tuberculosis strain. There have only been nine case reports on TB of the pubic symphysis in the last three decades and only 40 patients were identified in English language medical literature so to the best of our knowledge this is the first case report on the recurrence of TB of pubic symphysis.

Case Report

A 26-year-old female patient presented with pain over symphyseal area for 2 months. Laboratory and radiological investigations were suggestive of TB of symphysis pubis. She was started on oral, category I anti-tubercular therapy (ATT) from DOTS center. Patient on improvement in symptoms discontinued taking ATT after 6 months. About 7 months after stopping ATT, she again presented with pain over symphyseal area and difficulty in walking. Laboratory, radiological investigation, and biopsy were obtained to rule out multidrug-resistant (MDR) TB. The patient improved on 12 months' oral daily ATT regime (HRZES2+HRZE4+HRE6). She was followed up for another 1 year with clinical examination and laboratory investigation after stopping ATT. At present, she is asymptomatic with no signs of recurrence after 1 year of completion of treatment.

Conclusion

ATT intake should be continued for 12 months for musculoskeletal TB for preventing recurrence. The biopsy needs to be taken from the affected region in recurrence TB to rule out MDR.

Current Therapeutic Delivery Approaches Using Nanocarriers for the Treatment of Tuberculosis Disease

Tuberculosis is a major health issue globally and a leading cause of death due to the infective microorganism Mycobacterium tuberculosis. Treatment of drug resistance tuberculosis requires longer treatment with multiple daily doses of drugs. Unfortunately, these drugs are often associated with poor patient compliance. In this situation, a need has been felt for the less toxic, shorter, and more effective treatment of the infected tuberculosis patients. Current research to develop novel anti-tubercular drugs shows hope for better management of the disease. Research on drug targeting and precise delivery of the old anti-tubercular drugs with the help of nanotechnology is promising for effective treatment. This review has discussed the status currently available treatments for tuberculosis patients infected with Mycobacterium alone or in comorbid conditions like diabetes, HIV and cancer. This review also highlighted the challenges in the current treatment and research on the novel anti-tubercular drugs to prevent multi-drug-resistant tuberculosis. It presents the research highlights on the targeted delivery of anti-tubercular drugs using different nanocarriers for preventing multi-drug resistant tuberculosis. Report has shown the importance and development of the research on nanocarriers mediated anti-tubercular delivery of the drugs to overcome the current challenges in tuberculosis treatment.

Multiple CD59 Polymorphisms in Chinese Patients with Mycobacterium tuberculosis Infection

Background and Objective. Tuberculosis (TB) is a major threat to human health, especially in developing countries. Its susceptibility and progression depend on interactions between mycobacterium tuberculosis, host immune system, and genetic and environmental factors. Up to now, many studies have presented the association between TB susceptibility and host genetic polymorphisms, but never regarding CD59 gene, which is an essential complement regulator. This study investigated the relationship between multiple CD59 single nucleotide polymorphisms (SNPs) and susceptibility to TB among Chinese patients. Methods. A case–control study was conducted to investigate the SNPs at CD59 rs1047581, rs7046, rs2231460, rs184251026, rs41275164, rs831633, rs704700, rs41275166, and rs10768024 by sequence-specific primer-polymerase chain reaction (SSP-PCR) in 900 tuberculosis patients and 1,534 controls. Results. The minor allele frequencies at rs2231460, rs184251026, rs41275164, and rs41275166 were extremely low both in the Cases (0.00%–0.61%) and in the Controls (0.07%–0.43%), comparatively at rs1047581, rs7046, rs831633, rs704700, and rs10768024 were notably higher both in the Cases (8.23%–48.39%) and in the Controls (8.57%–47.16%). Among the nine SNPs, only homozygous CC genotype at rs10768024 showed a significant protective effect against TB than homozygous TT genotype (OR(95% CI) = 0.59(0.38, 0.91), χ2 = 5.779, $P=0.016$ ), and homozygous TT and heterozygous CT genotypes showed a significant risk of TB infection in the recessive model (OR(95% CI) = 1.68(1.10, 2.56), χ2 = 5.769, $P=0.016$ ). Further analysis verified that rs10768024 CC genotype independently related to TB susceptibility (OR(95% CI) = 0.60(0.39, 0.91), Wald χ2 = 5.664, $P=0.017$ ) in multivariate logistic regression analysis, and its genetic mutation was independent of the other SNPs (r2 = 0.00–0.20) in haplotype analysis. Conclusions. The first investigation of the CD59 gene and susceptibility to TB suggests a significant risk with homozygous TT and heterozygous CT genotypes at rs10768024 loci. The homozygous CC mutation at rs10768024 loci showed a significant protection against TB susceptibility.

Tuberculosis of the Spinal Cord

Tuberculosis involving the spinal cord is associated with high mortality and disabling long-term sequelae. Although tuberculous radiculomyelitis is the most frequent complication, pleomorphic clinical manifestations exist. Diagnosis can be challenging among patients with isolated spinal cord tuberculosis due to diverse clinical and radiological presentations. The principles of management of tuberculosis of the spinal cord are primarily derived from, and dependent upon, trials on tuberculous meningitis (TBM). Although facilitating mycobacterial killing and controlling host inflammatory response within the nervous system remain the primary objectives, several unique features require attention. The paradoxical worsening is more frequent, often with devastating outcomes. The role of anti-inflammatory agents such as steroids in adhesive tuberculous radiculomyelitis remains unclear. Surgical interventions may benefit a small proportion of patients with spinal cord tuberculosis. Currently, the evidence base in the management of spinal cord tuberculosis is limited to uncontrolled small-scale data. Despite the gargantuan burden of tuberculosis, particularly in lower and middle-income countries, large-scale cohesive data are surprisingly sparse. In this review, we highlight the varied clinical and radiological presentations, performance of various diagnostic modalities, summarize data on the efficacy of treatment options, and propose a way forward to improve outcomes in these patients.

Diagnosis, Management, and Prognosis of Spinal Tuberculosis: A Case Report

Spinal tuberculosis (TB) is a condition that affects numerous people around the world. The incidence of TB prior to the pandemic was decreasing by about 1.8% per year; however, COVID-19 has complicated this incidence rate leading to an increase of 4.5% in 2020 and 2021. Spinal TB is a rare event in all TB patients. The management could be multifactorial including location, severity, and symptom, and this case demonstrates an example of issues to consider in the diagnosis and management of patients. This is a case of a patient presenting with back pain which was subsequently diagnosed as spinal TB. We will review this patient's presentation and consideration for multifactorial opinions in the literature. This literature review demonstrates that there is no one treatment option available. Providers need to tailor treatment to each individual case. This is an example of a case that illustrates that diagnosis of spinal TB is not straightforward and clinicians may have to make a judgment call and treat prophylactically to prevent a poor prognosis.

Lumbosacral tuberculosis, a rare manifestation of Pott's disease - How identified human skeletons from the pre-antibiotic era can be used as reference cases to establish a palaeopathological diagnosis of tuberculosis

The macromorphological examination of identified human osteological collections from the pre-antibiotic era (e.g., Terry Collection) can provide invaluable information about the skeletal manifestations of tuberculosis (TB) in individuals who did not receive pharmaceutical therapy. With analysis of such collections, new diagnostic criteria for TB can be recognised which can be used in palaeopathological interpretation. The aim of our paper is to provide a reference and aid for the identification of TB in past populations by demonstrating and discussing in detail the vertebral alterations indicative of one of its rare skeletal manifestations, lumbosacral TB. These changes were detected in two individuals from the Terry Collection (Terry No. 760 and Terry No. 1093). These two case studies furnish palaeopathologists with a stronger basis for diagnosing lumbosacral TB in skeletons which exhibit similar vertebral lesions from osteoarchaeological series. To illustrate this, an archaeological case from Hungary (KK146) is also presented, displaying vertebral alterations resembling that of the two cases from the Terry Collection. Through the demonstrated case studies, we can derive a better insight into the disease experience of people who lived in the past and suffered from TB.

Expression and Clinical Significance of lncRNA NEAT1 in Patients with Spinal Tuberculosis

Background

Spinal tuberculosis (STB) often leads to irreversible neurological injury, resulting in serious social and economic problems. With the emergence of drug resistance, the management becomes even more challenging, given the treatment courses are generally longer for skeletal than pulmonary tuberculosis (PTB). The development and validation of nonsputum biomarkers for diagnosis and tailoring of treatment duration to enable personalized and evidence-based management of such diseases to improve treatment outcomes is being called for globally. Studies have demonstrated that lncRNA NEAT1 was highly expressed in pulmonary tuberculosis (TB) and was related to its progression and recovery. However, the expression and clinical significance of lncRNA NEAT1 in STB remains unclear.

Methods

The relative expression of lncRNA NEAT1 was quantified by relative real-time reverse transcription PCR (RT-PCR). The prognostic value was assessed by receiver-operating characteristic (ROC) curve analysis. Pearson and Spearman correlation coefficient and chi-square test were used to analyze the correlation between the lncRNA NEAT1 expression and the clinical characteristics. Univariate and multivariate logistic regression analyses were used to analyze independent predictors of STB recurrence.

Results

Compared with normal healthy individuals, the expression level of lncRNA NEAT1 in peripheral blood and granulomatous tissues of STB patients was significantly increased. The results of the in vitro Mycobacterium tuberculosis- (Mtb-) infected cell model showed that the expression level of lncRNA NEAT1 was significantly upregulated in macrophages infected with Mtb, and the difference was statistically significant compared with Mtb-uninfected group. The expression level of lncRNA NEAT1 in granulomatous tissue of STB was significantly higher than that in peripheral blood. The expression of lncRNA NEAT1 was related to segments of the lesions, paraspinal abscesses, anti-TB treatment, drug resistance, interleukin-6 (IL-6), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). Multivariate analysis results showed that relatively high expression of lncRNA NEAT1_1, the shorter transcript of the NEAT1 gene, was an independent prognostic factor of STB outcome.

Conclusion

LncRNA NEAT1 was highly expressed in peripheral blood mononuclear cells (PBMCs) and granulomatous tissue from patients with STB, as well as in Mtb-infected THP-1 cell lines. LncRNA NEAT1 expression was significantly associated with clinical characteristics (paraspinal abscesses, segments of the lesions and anti-TB treatment, IL-6, CRP, and ESR) of patients in STB. Increased expression of lncRNA NEAT1_1 predicted good prognosis of STB and might become a prognostic biomarker for STB.

Imaging update in spinal tuberculosis

Tuberculosis is ancient disease known to mankind. Diagnosis and management of spinal tuberculosis has immensely improved in last few decades. Imaging, particularly MRI, plays important role in diagnosis of spinal tuberculosis and its complications. Four common imaging patterns of spinal tuberculosis include paradiscal type, central type, Anterior subligamentous type, and posterior type. Imaging also plays important role in differentiation of spinal tuberculosis from its mimics, particularly pyogenic spondylitis, and metastasis. Radiological interventions, such as CT guided vertebral biopsy, and percutaneous drainage of cold abscess, are commonly used in management of spinal tuberculosis. Monitoring of therapeutic response is often based on clinical evaluation and imaging. MRI is most common imaging modality used. Signs of healing include bony ankylosis, resolution of marrow edema, decrease in contrast enhancement, and fatty change with in bone marrow. PET CT is recently evaluated for response assessment with promising results. This review summarizes pathophysiology, clinical presentation, imaging features, radiological interventions, and response assessment in spinal tuberculosis.

Tuberculosis of the spine and drug resistance: a review article

Pott's spine is tuberculosis of spine caused due to hematogenous spread of mycobacterium from a primary focus. It constitutes about 50% of skeletal tuberculosis cases. Paradiscal type is the most common type of spinal tuberculosis. Untreated cases can lead to complications like a cold abscess, paraplegia, and deformity which may require surgical intervention. Rapid molecular methods have made the diagnosis of spinal tuberculosis and drug resistance faster and easier but it still remains a problem due to difficulties in sample collection and the paucibacillary nature of the Pott spine. Antitubercular drug therapy forms the mainstay of management. The emergence of MDR TB and XDR TB has posed a big challenge in the management of spinal tuberculosis. The literature regarding drug resistance in spinal tuberculosis and its management is lacking. We conducted a literature review of 29 studies and presented information on pathogenesis, diagnosis, and management of spinal tuberculosis and drug resistance. New shorter regimens for MDR and XDR TB are under trial in different parts of the world. We believe this article will provide information on spinal tuberculosis and drug resistance and help clinicians outline important research areas.