Tuberculosis is of the spine is responsible for large percentage of non-traumatic compressive myelopathies resulting in paraparesis and paraplegia in Nigeria, India and Ethiopia and the most common cause death from an infectious disease word wide [17-19,31]. This study presents the largest cache of (432) patients with tuberculosis of the spine in a Nigerian tertiary institution in a 10 year study. In UCH Ibadan 9 cases were reported in period of six years (1966-1972), in Ilorin 50 patients reported in a 10 year (2001-2009). In Kano it constituted 44% of the 98 patients treated within 4 years (2006-2009) as a cause of non-traumatic paraplega in Murtala Mohammed hospital. Even among children in same kano, only26 children were noted in four years (2001-2004). Suffice to state that only 32 patients were admitted and treated in 5 years (1995-2000) in Jos University Teaching Hospital for tuberculous spondilitis [2]. All these show the poor patronage of health facilities by patients despite enormous premium placed on strategies for TB eradication and the fact that these centers lie within endemic area. This also show that progress in prevention of tuberculosis is slow [20]. These large number of patients in Jos is a function of increase in awareness and increased health seeking behaviors of the populace. It also reveals there is a large number of reservoirs of the disease in the communities. Poor patronage of established facilities for treatment and escape in routine diagnosis of extra-pulmonary tuberculosis may be among the reasons for poor patronage in other centers [15,20]. Hence the need for more vigorous health education campaigns and public enlightenment across the country.

Another major reason for the ever-increasing number of patients is the persistence of existing hallmarks and determinants of its prevalence such as poverty, HIV infection, diabetics, under nutrition, and smoking. Others include extreme of age and alcoholism. Out of these smoking and alcoholism are vices common among male young adults. It is worthy of note that Nigeria is responsible for 4.4% and among the 8 countries that contribute three quarters of the world’s tuberculous affliction [20].

The gross preponderance of male gender portrays this infectious disease as one that inflicts the large number of the work force as men constitute majority of outdoor labor force. They are also the major bread winners of the families and are veritable custodians that bore the burden of the communities. Male preponderance could also be trace to their social habits, practices and occupations which make them more vulnerably exposed to outdoor influences [21]. Women tendency to seek early medication is predicated on their caregiver, home maker roles and their tendency to protect their children and themselves. Perhaps the tight schedules of men tend to render them less conscious of their health needs. This is consistent with the findings in our center over 20 years ago and in Kano [2,17]. However, in Ilorin, Port Harcourt and Enugu female preponderance is marginal and almost equal [16,22,32]. Although this may not be explained only on grounds of exposure alone the cumulative stress and economic forces acting takes a great toll on the immune status of most of the men.

The mean age of our patient (47.1±15.5 years) is skewed toward middle age category. In Owerri (South East, Nigeria) however, majority falls among a little younger age with the mean age of 38.5+-4.4. What is peculiar and important to this age groups is that the age group constitute the strongest, most productive ,most vibrant and literate segment of the society. It also signifies that the productive age group are most exposed and made vulnerable to this infectious disease with great antiquity.

This study highlighted a significant association between young adult age group with the preponderance of gibbus, retroviral disease and the most severe stage of the disease, paralysis and pressure sore.

While gibbus provides a lead pointer to diagnosis its presence in the younger age group may be explained by the great amount of action of forces exerted by the para-spinal muscles of the trunk on the disease or weak vertebrae during spasms. This is particularly significant as it is associated with the muscles surrounding the lumbar spine which we found as the most affected segment of the spine. Again, this part of the trunk resides the most powerful group of muscles responsible for keeping an individual upright and explains further the existence of gibbus in the lumbar region than other sections of the spine. The young may also be difficult to confine since they spend a great amount of their time working in pursuit of their livelihood.

The high prevalence of retroviral disease among this group is not strange since they constitute the most sexually active, sociable and outgoing age group with high propensity to engage in risky experimental activity. Most adventures and associations of marriages are often conducted among this age group. In addition true characters of adulthood manifest in these age group too.

It is however surprising that these age group manifest the most severe form of morbidity in form of paralysis. This may be as a result of the impact of the high number of the collapsed vertebrae (gibbus) or the association with retroviral disease among them.

Prolong delay in presentation is unique among patients with tuberculous spondilities as this is also recorded in Enugu (South East Nigeria) where 70.2% patients presented within 24 months of onset of the symptoms [32]. The implication of this prolong duration of symptoms at presentation is that there is significant association between duration of symptoms at presentation and severity of the disease as they constitute the largest number of admissions, highest number of paralyzed patients and development of pressure sores. The large number of admissions among this group reveals the demographic propensity and index of developing the severest form and debility. This prolong delay in presentation may also arise because diagnosis of extrapulmonary tuberculosis can be almost always challenging and could often be delayed [33]. Besides, the most common symptom (back pain) is a confounding feature among other common disease conditions although other multifaceted factors contributing to this delay may suffice.

Tuberculous spondylitis is ever increasing in our setting particularly due to deteriorating socioeconomic status of the citizens, large reservoir of the disease and poor health seeking behaviors. The preponderance of the disease among young adults implies that the prevention and treatment must be targeted among this group carried out concurrently. The frontline physicians must embark on regularly training workshops in order to have a high index of suspicion. From the era of non-routinely done spine surgeries to the present era in which routine surgeries can be performed not much has changed because the cost of spine surgery, absence of readily available minimal access surgical diagnostic tools renders both the patientand the surgeon from accessing the game changing surgical input.