Spondylodiscitis refers to infection of the intervertebral disc and adjacent vertebral bodies, a condition that can destroy the structural architecture of the spine and compress the spinal cord. In tuberculosis-endemic regions, spinal tuberculosis, also known as Pott’s disease, is a leading cause of this syndrome. The bacterium responsible, Mycobacterium tuberculosis, typically reaches the spine through hematogenous dissemination from a primary focus, most often the lungs. Once seeded in the richly vascularized anterior portion of a vertebra, the infection erodes bone and disc tissue, producing collapse, deformity, and potential neurological catastrophe. Because the clinical presentation overlaps substantially with pyogenic and other infectious causes, laboratory confirmation is critical whenever feasible, though in resource-limited settings this is often easier said than done.

The research team, led by Hussein Salad Yusuf of the hospital’s Department of Neurosurgery, reviewed medical records of all eligible patients diagnosed with spinal infection between 1 August 2023 and 31 July 2024. Using total-enumeration sampling, they identified 121 patients with radiological evidence of spondylodiscitis on MRI, CT, or x-ray. The study was designed as a record-based analysis of routinely collected clinical data, with no additional research-specific laboratory testing performed. Ethical approval was obtained from the hospital’s Ethics Committee, and the requirement for informed consent was waived because the study used anonymized routinely collected hospital data.

The demographic profile showed a mean age of 48.8 years with a standard deviation of 18.1, and a median of 50 years, with the largest age group being 46 to 60 years at 31.4 percent of the cohort. Males comprised 53.7 percent of patients, showing only a modest male predominance. Most patients were urban residents, and the majority fell into low or middle socioeconomic categories, reflecting the recognized association between socioeconomic disadvantage and tuberculosis risk. The authors note that this distribution should not be interpreted as causal because the study did not include a population-based control group.

Clinically, back pain was nearly universal, documented in 92.6 percent of patients, while radicular pain, pain radiating along a nerve root distribution, affected 82.6 percent. Constitutional symptoms such as fever, weight loss, and night sweats were present in only half of the cohort, emphasizing that their absence does not exclude spinal infection. Neurological deficit was documented in 46.3 percent of patients, and spinal deformity in 38.0 percent. Among the 56 patients with neurological deficit, muscle-power grades ranged from grade 4, indicating mild weakness, to grade 0, indicating complete paralysis, with six patients at the most severe end of the spectrum.

Radiologically, the lumbar spine was the most frequently involved region at 48.8 percent, followed by the thoracic spine at 25.6 percent. Anterior-column involvement, the classic pattern of tuberculous spondylodiscitis, was present in 97.5 percent of patients, while middle-column involvement occurred in 72.7 percent and posterior-column involvement in 21.5 percent. Epidural abscess, a collection of pus within the spinal canal that can compress neural structures, was identified in 69.4 percent of patients. Associated disc herniation was present in 39.7 percent. The strong correlation between epidural abscess and middle-column involvement, with a Spearman coefficient of 0.762, is clinically coherent, as destruction of the middle column creates a pathway for infectious material to extend into the epidural space.

Microbiological or histopathological testing was performed in only 46 of the 121 patients, representing 38.0 percent of the cohort. Among those tested, 30 were positive for tuberculosis, yielding a positivity rate of 65.2 percent among tested patients and a confirmed tuberculosis proportion of 24.8 percent in the total cohort. The authors stress that these two denominators answer different questions and should not be conflated. Four patients had non-tuberculous organisms identified, including gram-positive cocci, Klebsiella species, mucormycosis, and Staphylococcus epidermidis, one case each. Drug-susceptibility results were available for 29 of the 30 tuberculosis-positive patients, with 25 showing no documented resistance and 4 showing monoresistance. No multidrug-resistant tuberculosis was identified among the tested confirmed cases, though the authors caution that this finding should be interpreted in light of the small number tested and incomplete susceptibility data.

Treatment patterns reflected the diagnostic constraints of the setting. Eighty-five patients, representing 70.2 percent of the cohort, received empirical anti-tuberculosis treatment regardless of microbiological confirmation. The authors emphasize that this proportion represents presumptive treatment exposure and cannot be used as confirmation of tuberculosis prevalence. Forty-six patients underwent an operative or procedural intervention, with instrumentation combined with biopsy being the most common procedure, reflecting the dual need for spinal stabilization and tissue diagnosis in selected patients. Percutaneous biopsy was appropriately classified as a diagnostic procedure rather than a therapeutic intervention.

Outcome data were available for only 65 patients, or 53.7 percent of the cohort. Among these, 15 achieved complete recovery, 31 achieved partial recovery, and 19 had no recovery, yielding a favorable-outcome proportion of 70.8 percent among patients with documented follow-up. The authors explicitly caution that this estimate applies only to patients with documented follow-up and should not be generalized to the entire cohort, because 46.3 percent of patients lacked any documented outcome data, creating potential attrition bias whose direction and magnitude remain uncertain. In bivariate analysis, a history of tuberculosis exposure was significantly associated with clinical outcome, with a p-value of 0.003, while operative or procedural intervention was not significantly associated with outcome, with a Fisher’s exact p-value of 0.399. Economic status also showed an association, though the authors note this should be interpreted cautiously because only five patients were classified in the high-status category.

The study’s limitations are substantial and openly acknowledged. The retrospective single-center design limits generalizability and introduces potential selection and information bias. Microbiological confirmation was available in only 38 percent of patients, limiting accurate determination of the etiological spectrum and creating potential misclassification, particularly because empirical anti-tuberculosis treatment was common. Systematic testing for Brucella, an important differential diagnosis in Somalia whose spondylodiscitis can closely mimic spinal tuberculosis both clinically and radiologically, was not documented, so the contribution of brucellar infection cannot be assessed. ASIA and Frankel neurological grades were not consistently available or linked to outcomes at the patient level, preventing granular neurological recovery analysis. Because only 19 unfavorable outcomes were available among the 65 patients with documented follow-up, multivariable logistic regression was not retained in the final analysis, meaning all outcome comparisons are unadjusted and may be affected by confounding.

Despite these constraints, the study provides valuable local data from a setting where published descriptions of spondylodiscitis have been scarce. The authors conclude that improved microbiological diagnosis, consideration of alternative infections such as brucellosis, systematic neurological grading, and prospective multicenter follow-up are needed to better define the etiological spectrum and outcomes of spinal infection in Somalia. Until such studies are conducted, clinicians in tuberculosis-endemic settings must continue to navigate the difficult balance between treating presumed spinal tuberculosis empirically and pursuing the laboratory confirmation that would allow more precise diagnosis and targeted therapy.

Subject of Research: Epidemiology, clinical presentation, radiological findings, and outcomes of spondylodiscitis in a tuberculosis-endemic setting in Somalia

Article Title: Spondylodiscitis in a tuberculosis-endemic setting in Somalia: epidemiological, clinical, radiological, and outcome findings from a retrospective study

Article References: Salad Yusuf, H., Abukar, A. A., Adan, M. S., Mohamed, A. S., Mohamed, Z. Y., Ulusow, M. A., Alasow, M. O. D., Ibrahim, A. A., & Dahir, N. A. (2026). Spondylodiscitis in a tuberculosis-endemic setting in Somalia: epidemiological, clinical, radiological, and outcome findings from a retrospective study. Frontiers in Tuberculosis, 4, Article 1971442. https://doi.org/10.3389/ftubr.2026.1971442

Image Credits: AI Generated

DOI: 10.3389/ftubr.2026.1971442

Keywords: spondylodiscitis, spinal tuberculosis, Somalia, Mogadishu, tuberculosis, epidural abscess, neurological deficit, retrospective study, Frontiers in Tuberculosis, diagnostic gaps, empirical anti-TB treatment, spinal deformity