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The recent article by Sadiq *et al*.\[[@CIT1]\] has been of much concern and has caught the attention of the surgical community, both in India as well as abroad. Sadiq *et al*. have reported a “high incidence of tuberculous meningitis” in patients with cervical spine tuberculosis. We would like to point out that the reported incidence of tuberculous meningitis in the cervical spine is probably higher than originally envisaged. The two most important factors that have contributed to this misinterpretation are the diagnostic criteria and the use of magnetic resonance imaging (MRI) as a screening tool for asymptomatic tuberculous meningitis.
In the current report, MRI is used to identify the meningeal lesions and to provide a road map for accurate surgical planning. However, it is difficult to over emphasize the importance of making the diagnosis of tuberculous meningitis as early as possible. The two diagnostic criteria for tuberculous meningitis, recommended by CDC, are, firstly, positive smear for acid-fast bacilli and, secondly, a positive response to anti-tubercular treatment (ATT).\[[@CIT2]\] The presence of an intracranial tuberculoma on MRI, as used by Sadiq *et al*. for the diagnosis of tuberculous meningitis, has a good sensitivity (90-100%), but its specificity is considerably low (50-75%).\[[@CIT3][@CIT4]\] Lumbar puncture (LP) is a useful non-invasive investigation for the diagnosis of tuberculous meningitis. However, it may be difficult to perform LP in patients with advanced pulmonary tuberculosis and prophylactic antibiotics need to be used for LP in such cases. Therefore, LP should be the preferred diagnostic tool for tuberculous meningitis in the lateralized form of the disease. It has been estimated that approximately 50% of the patients with tuberculous meningitis have clinical signs of lateralization.\[[@CIT5]\]
The clinical presentation of tuberculous meningitis depends upon the presence of lateralization. When lateralization is not clinically evident, diagnosis of tuberculous meningitis may be delayed. It is estimated that “uncontrolled” spinal tuberculosis is the second most common form of active tuberculosis after pulmonary tuberculosis.\[[@CIT6]\]