Unraveling the masquerade: Decoding mimics of spinal tuberculosis

Spinal tuberculosis (TB) is the most common form of skeletal TB and a significant cause of morbidity in endemic regions. Although culture, histopathology, and molecular assays provide definitive diagnosis, empirical anti-tubercular therapy is frequently initiated due to cost and accessibility constraints. While convenient, this practice risks serious consequences, including toxicity, emergence of drug resistance, and delayed recognition of alternative conditions that radiologically resemble TB. A wide spectrum of disorders can mimic spinal TB, which include a myriad of infective etiologies include pyogenic and fungal spondylodiscitis and brucellosis, as well as non-infective mimics, such as inflammatory disorders, degenerative changes, and neoplastic processes. Atypical manifestations of TB itself further complicate interpretation, reinforcing the limitations of relying solely on imaging. In such contexts, empirical therapy not only masks critical alternative diagnoses but also fosters multidrug-resistant and extensively drug-resistant strains of Mycobacterium tuberculosis . Tissue diagnosis, preferably through computed tomography-guided biopsy, remains the cornerstone of accurate characterization and should precede therapy whenever feasible. This review article aims to highlight the diverse spectrum of spinal TB mimickers, emphasizing their radiological features, diagnostic challenges, and the indispensable role of tissue confirmation in guiding appropriate management.