Typical features

• Subacute back, radicular, or leg pain
• Progressive leg weakness, numbness, spasticity, or difficulty walking
• Bladder or bowel dysfunction
• Multilevel myelopathy or rapidly ascending weakness
• May coexist with tuberculous meningitis, fever, headache, or evidence of TB elsewhere

Investigations

• Contrast MRI of the spine: meningeal enhancement, thickened/clumped nerve roots, loculated CSF, cord edema, or epidural involvement.
• CSF: often markedly raised protein, sometimes lymphocytic cells and low glucose. A very high CSF protein can suggest a spinal block.
• Seek microbiological proof where possible: CSF mycobacterial PCR/culture and testing of pulmonary, lymph-node, or other accessible TB sites. The CNS TB review describes the clinical pattern and diagnostic clues.

Treatment

• Start standard multidrug anti-tuberculous therapy promptly when CNS TB is strongly suspected, while obtaining diagnostic samples where feasible.
• In adult TB meningitis/CNS TB, WHO-based guidance generally uses a 12-month treatment course. Local national TB protocols and drug-susceptibility results determine the exact regimen.
• Corticosteroids are usually used as adjunct therapy in CNS TB, particularly with spinal block, edema, or neurologic deterioration. The recent TB meningitis guideline supports corticosteroids alongside TB treatment and notes that treatment must be individualized.
• Surgical CSF diversion or decompression may be required for hydrocephalus, severe spinal block, compression, or diagnostic biopsy. Established adhesive scarring can leave residual neurological disability despite microbiological cure.