Medical therapy of bone and joint tuberculosis in 1998

Some measure of agreement and no little debate continue to surround the man agement of bone and joint tuberculosis. There is a consensus that the first phase of antituberculous chemotherapy should consist of three drugs (Isoni azid, rifampin, and pyrazinamide) or four drugs (plus ethambutol) given for two to three months, When neither resistance nor side effects occur, Isoni azid and rifampin should be continued as maintenance therapy, Patient compl iance is well-recognized as requiring special attention because of its larg e impact on treatment outcomes. Provided strict patient selection criteria and close medical supervision are used, spinal cord compression can be trea ted nonsurgically with four antituberculous drugs, immobilization and, in m any cases, a glucocorticoid. In spinal tuberculosis without neurological si gns, 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, Twe lve months is the duration currently recommended by most experts, Shorter d urations, of six to nine months, have been advocated in adults. A critical analysis of the literature shows that proof is still lacking of the equival ence between six- to nine-month and 12- to 18-month treatments. In particul ar, trials conducted under the aegis of the Medical Research Council of the United Kingdom failed to resolve this issue because of methodological inad equacies regarding sample size and statistical analysis. The large sample s ize and long follow-up needed to obtain conclusive data would probably requ ire a multicenter international study.