Q: My father had met with a road accident 11 months ago. He had suffered a head injury in the accident and remained in coma for about 20 days. During the course of the treatment he developed various complications i.e. pleural effusion in the left lung, hypothyroidism, and Potts Spine in L4 & L5. My question relates mainly to the treatment that is being given for Tuberculosis of the spine in L4 & L5. The anti-tubercular treatment was started 9 months ago with a four drug regime comprising Rifampicin (600 mg), Isoniazid (300 mg), Pyrazinamide (1000 mg) and Ethambutol. After a month, Isoniazid and Ethambutol were discontinued for about a week and were thereafter resumed. After 4 months, Ethambutol was discontinued because there were indications of toxicity in the eyes. Rest of the three drugs viz. Rifampicin (600 mg), Isoniazid(300 mg) and Pyrazinamide (1000 mg) are continuing till date. The neurosurgeon who is looking after his case is of the view that these three medicines will continue throughout the course of the treatment which we have been told is 18 months form the start of the same. However, the medicine doctor and an orthopaedic surgeon, whom I had consulted for this case, are of the opinion that Pyrazinamide has been administered for a fairly long period of time and should be discontinued now. Only Rifampicin (600 mg) and Isoniazid (300 mg) will continue for the rest of the treatment. I would like to inform you that the MRIs are showing good improvement. Please inform me what should be the course of future treatment and how long shall it continue ? I would also like to know that whether there is any difference in the treatment of Spinal TB and Pulmonary TB.

A:Yes, there is a difference. It takes longer to cure Spinal TB. I would give drugs for 18 months. 6 months may be enough for treating Pulmonary TB. As to the choice of drugs, I would agree with your neurosurgeon that all three drugs should continue for the entire 18 months. The reason for giving so many drugs is the possibility of multiple drug resistance organisms. Here, the genetic information is such that resistance to Rifampicin is generally accompanied by resistance to INH. As yet, identifying bacteria which are drug resistant is difficult, expensive or simply impractical. The negative aspect of giving multiple drugs is the risk of toxicity, but as long as there is no toxicity it is wiser to give more rather than less. Never change a winning game.