Case Presentation

A 26-year-old man presented with a six-month history of severe, progressive lower back pain. Over the past 15 days, he was unable to stand due to worsening pain. He also reported bilateral radicular leg pain for the past month.

On physical examination, there was tenderness over the L4 and L5 spinous processes. Neurological assessment revealed normal motor power (5/5) at the hips and knees, and reduced power (4/5) at the ankles and extensor hallucis longus (EHL) bilaterally. Sensation was intact, and deep tendon reflexes were preserved (++).

The patient was constipated but had no complaints of urinary urgency, hesitancy, or retention. Perianal sensation was intact, and the bulbocavernosus reflex was present. The straight leg raise (SLR) test was bilaterally positive at 40°.

He also exhibited constitutional symptoms suggestive of TB, including malaise, weight loss, and loss of appetite. There was no personal or family history of TB or known TB contact. The patient belonged to a low socioeconomic background.

Treatment

Tuberculosis is a medical disease, and its successful treatment primarily depends on antitubercular therapy (ATT). However, in cases of spinal TB, surgical intervention becomes necessary when there is gross spinal instability due to tuberculous destruction, significant spinal canal stenosis caused by abscess formation, or the presence of neurological deficits.

Surgery facilitates debridement and reduction of disease burden, enhances the penetration of chemotherapeutic agents through fresh bleeding surfaces, and provides tissue for definitive diagnosis. In this case, surgical intervention was planned based on clinical and radiological findings.

Under general anesthesia, a posterior approach was used to perform segmental fixation at two levels above and below the affected segments. S2-alar-iliac (S2AI) screws were inserted for added stability. Due to the absence of pedicles at L4 and L5, these levels were excluded from the construct.

Following decompression, bilateral L4 and L5 nerve roots were released, and samples of pus and granulation tissue were sent for histopathological examination and TB GeneXpert testing. A lordotically contoured rod was applied, and the wound was closed as per standard protocol over a drain.

Limitations

This report describes a single, rare presentation of spinal tuberculosis; therefore, the findings cannot be generalized to all cases of skeletal or extrapulmonary TB. The absence of comparative cases or a control group limits the ability to draw conclusions regarding optimal timing of surgery or treatment duration.

Nevertheless, the report highlights an unusual radiological and surgical presentation that adds meaningful insight to the existing literature.

Conclusion

Atypical presentations of lumbar spinal TB, particularly those involving complete pedicle resorption, are rare and present significant diagnostic and therapeutic challenges. This case highlights several key points: first, atypical presentations must be considered in endemic regions; second, radiological and histopathological evaluations should be thorough; and third, timely and well-executed surgical intervention can be both lifesaving and limb-saving.