Multidrug-Resistant and Extensively Drug-Resistant Skeletal Tuberculosis: Systematic Review of Clinical Profile, Management, and Outcomes

Background: Multidrug-resistant (MDR), pre-extensively drug-resistant (pre-XDR), and extensively drug-resistant (XDR) strains are associated with delayed diagnosis, protracted therapy, and increased morbidity. This article aims to systematically review the clinical spectrum, diagnostic strategies, drug resistance profiles, therapeutic regimens, surgical interventions, and outcomes of drug-resistant skeletal TB. Methods: A systematic search of PubMed, Scopus, and Embase up to September 2025 identified studies reporting ≥ 5 culture- or molecular-confirmed MDR, pre-XDR, or XDR skeletal TB cases. Data extraction included demographics, clinical features, diagnostics, drug susceptibility, treatment protocols, surgical management, and outcomes. Results: Twenty studies reported 1,242 drug-resistant cases: 1,032 spinal and 210 osteoarticular. MDR TB predominated, while pre-XDR/XDR cases ranged from 1.2 to 20%. Treatment success was 76-100% for MDR TB and 50-80% for pre-XDR/XDR TB; adverse events occurred in 33-55%. Recurrence and mortality were low (< 5-19%). Conclusions: MDR TB dominates drug-resistant skeletal TB, but pre-XDR/XDR cases demand complex management. Early molecular diagnosis, tailored multidrug regimens, and judicious surgical intervention are pivotal for optimal outcomes. A multidisciplinary strategy is essential to improve prognosis and limit long-term morbidity.