Medical therapy of bone and joint tuberculosis in 1998

Some measure of agreement and no little debate continue to surround the management of bone and joint tuberculosis. There is a consensus that the first phase of antituberculous chemotherapy should consist of three drugs (isoniazid, rifampin, and pyrazinamide) or four drugs (plus ethambutol) given for two to three months. When neither resistance nor side effects occur, isoniazid and rifampin should be continued as maintenance therapy. Patient compliance is well-recognized as requiring special attention because of its large impact on treatment outcomes. Provided strict patient selection criteria and close medical supervision are used, spinal cord compression can be treated nonsurgically with four antituberculous drugs, immobilization and, in many cases, a glucocorticoid. In spinal tuberculosis without neurological signs, immobilization is not always necessary, except when the cervical spine is involved. The optimal duration of antituberculous chemotherapy required for complete recovery of bone and joint tuberculosis is still debated. Twelve months is the duration currently recommended by most experts. Shorter durations, of six to nine months, have been advocated in adults. A critical analysis of the literature shows that proof is still lacking of the equivalence between six- to nine-month and 12- to 18-month treatments. In particular, trials conducted under the aegis of the Medical Research Council of the United Kingdom failed to resolve this issue because of methodological inadequacies regarding sample size and statistical analysis. The large sample size and long follow-up needed to obtain conclusive data would probably require a multicenter international study.