Optimal evaluation of tubercular spondylodiscitis before starting anti-tubercular treatment: A narrative review

Tubercular spondylodiscitis, a common form of extrapulmonary tuberculosis, presents significant diagnostic challenges due to its insidious onset, nonspecific symptoms, and overlap with other spinal pathologies such as pyogenic infections and metastases. Delayed or inaccurate diagnosis can lead to severe neurological complications, and empirical anti-tubercular therapy without definitive evidence risks mismanagement. This review emphasizes the importance of comprehensive diagnostic evaluation—including clinical, radiological, and microbiological assessment—before initiating treatment. A narrative review was conducted using literature published between 2010 and 2025 from databases including PubMed, Scopus, Web of Science, and Google Scholar. Keywords included "spinal tuberculosis," "tubercular spondylodiscitis," "MRI," "GeneXpert," "biopsy," and "diagnosis." The review included original articles, systematic reviews, and clinical guidelines focusing on diagnostic strategies, imaging, laboratory tests, and biopsy techniques. Articles were selected based on relevance to diagnosis and excluded if they lacked methodological clarity or focused solely on treatment outcomes. MRI was identified as the most sensitive imaging modality, with scoring systems improving specificity in differentiating tubercular from pyogenic spondylodiscitis. GeneXpert MTB/RIF demonstrated high diagnostic accuracy (85–95% sensitivity; 96–100% specificity) and enabled early detection of rifampicin resistance. CT-guided percutaneous biopsies offered a safe approach for tissue sampling, though diagnostic yield was higher with open biopsy. Histopathology and conventional cultures remain essential, particularly for drug susceptibility testing, though limitations exist due to the paucibacillary nature of spinal TB. Integrated diagnostic models combining clinical, laboratory, and imaging features provided high diagnostic accuracy in differentiating spinal TB from mimics. A multimodal approach—combining clinical evaluation, advanced imaging (particularly MRI), targeted tissue sampling, and rapid molecular diagnostics—is essential for the accurate diagnosis of tubercular spondylodiscitis. No single test is definitive; combining complementary methods enhances diagnostic precision, supports early initiation of appropriate therapy, and reduces the risk of overtreatment. Molecular diagnostics, especially GeneXpert, have transformed early detection and resistance profiling, but must be integrated with conventional methods and institutional protocols to ensure optimal outcomes.