Steroid Therapy in TB Spine

Indication and Dosing

The American Thoracic Society recommends adjunctive corticosteroids for TB spine with spinal cord compression, using dexamethasone 12 mg/day for adults (or 8 mg/day for children <25 kg) for 3 weeks, followed by a gradual taper over the subsequent 3 weeks, for a total duration of 6 weeks 1
Corticosteroids are specifically recommended when there is evidence of spinal cord compression in patients with TB spine, with the primary goal of reducing inflammation and preventing or reversing neurological deficits associated with cord compression 2, 3

The initial dose of dexamethasone for adults is 12 mg/day, and for children <25 kg is 8 mg/day, with a total duration of 6 weeks 1
If using prednisone or prednisolone instead of dexamethasone, the equivalent initial dose would be approximately 60 mg/day for adults, tapered over the same 6-week period 3
The WHO guidelines advocate for either dexamethasone or prednisone during the first 6-8 weeks for spinal TB with cord compression 2

Steroids are not routinely indicated for uncomplicated TB spine without neurological involvement, and the evidence for steroid use in TB spine is based primarily on expert opinion and extrapolation from other forms of extrapulmonary TB 3, 1, 2
Corticosteroids have demonstrated clear mortality benefit in TB meningitis and pericarditis, which provides the rationale for their use in TB spine with cord compression 4

Monitor liver function given the hepatotoxic potential of concurrent anti-TB medications 4
Steroids do not replace surgical intervention when indicated, and surgery should be considered for failure to respond to medical therapy, progressive neurological deficits despite treatment, or spinal instability 3