Comment on “Pediatric tuberculous spondylitis – A study of the relationship of neurological status to different variables at tertiary centers in a developing country”

Dear Editor,

We read with great interest the article by Khomariyah et al.^[1] which examined pediatric tuberculous spondylitis and its association with neurological status in tertiary care centers in Indonesia. The authors should be commended for conducting such a large-scale, multicenter study on conditions like tuberculous spondylitis, which are underreported in the pediatric literature. This study provided clinically relevant data on clinical profiles, comorbidities, complications, nutritional status, and neurological deficits in pediatric spinal tuberculosis (TB), thereby enriching the pediatric literature. We aim to incorporate considerations that may enhance the clinical and public health relevance of these findings.

First, the strong association reported between malnutrition and severe neurological deficits underscores the importance of nutrition in immunity, growth, and healing. The authors could have expanded the discussion to include the “double burden” of malnutrition, since both under- and overnutrition can worsen disease outcomes. In many low- and middle-income countries, overweight and obesity coexist with undernutrition, and obesity-related inflammation^[2] may aggravate TB progression, while undernutrition weakens immune response and delays recovery. A study from Ethiopia found severe acute malnutrition to be a major predictor of TB incidence in children, with risk factors including poor appetite, lack of micronutrient supplementation, and co-morbid infections.^[3] These findings underscore the importance of comprehensive nutritional screening and support in preventing neurological complications and the onset of disease.

Second, diagnostic limitations remain a major barrier. As reported in the article, only 42.5% of children underwent magnetic resonance imaging (MRI), primarily due to cost and accessibility issues. As the gold standard for detecting early spinal involvement and cord compression, limited access to MRI can delay diagnosis and result in deformities or neurological deficits.^[4] Expanding access to affordable imaging and applying structured diagnostic algorithms that combine clinical suspicion, laboratory markers, and plain radiography, where MRI is unavailable, may provide cost-effective solutions.

Third, the high prevalence of complications such as paraparesis and decubitus ulcers highlights the need for preventive community strategies in addition to hospital care. Awareness campaigns for parents, teachers, and primary health workers to recognize persistent back pain, neurological signs, or unexplained fever could promote earlier referral. Nutritional support, micronutrient fortification, and integrating spinal TB screening into routine child health checks may help reduce both the incidence and severity of the disease.^[5]

Finally, we emphasize the necessity of a multidisciplinary approach. Pediatric spinal TB is not solely an orthopedic or infectious disease issue. Collaborative care involving pediatricians, orthopedists, radiologists, nutritionists, and rehabilitation specialists is critical. Early physiotherapy and rehabilitation, combined with pharmacological treatment, may help reduce disability and improve quality of life. Equally important is systematic follow-up, as treatment discontinuation is common in socioeconomically disadvantaged regions.^[4,6]

Overall, the study by Khomariyah et al. ^[1] makes a valuable contribution. We support the authors’ call for early detection, while emphasizing the importance of nutrition, diagnostic access, prevention, and multidisciplinary care to reduce morbidity and improve outcomes in children with this debilitating disease.