Reply to the Letter to the Editor: Minimally Invasive Surgical Approaches in the Management of Tuberculosis of the Thoracic and Lumbar Spine

To the editor,

We appreciate the comments from Ekinci and colleagues. We agree that medical therapy is the mainstay of treatment and surgery is called for only in specific conditions. The Gulhane Askeri Tip Akademisi [GATA] classification [1] mentioned by the authors gives some guidelines regarding patient and surgical management. This is similar to the “middle path regimen” described by Tuli [2] and followed by us. As per this regimen, surgery is considered in those patients with persistent disabling pain due to collapse and/or severe deformity (Type III), neurological deficits (Type II, III), or clinical and radiological progression of disease in spite of antituberculous therapy (Type IA). Those with only abscess without any deficits and/or deformity (Type IB) underwent ultrasound-guided or CT-guided drainage and were not considered as surgical cases by us in this study. In the GATA classification, the only difference between Type II and III is in the extent of deformity irrespective of neurological deficit. As per this classification, almost all patients with tuberculosis of the spine would meet reasonable surgical indications. The GATA classification needs more clarity between the Type II and Type III regarding management options.

In our opinion, we have considered deformity and neurological deficits as separate entities independent of each other with more importance being given to neurological deficits, no matter how subtle the deficits may seem. Those with less severe deformities and no deficits can be managed conservatively with medical therapy alone.