Background <p>Spinal tuberculosis (TB) remains a significant health burden in endemic regions. Its diagnosis is frequently delayed due to non-specific early symptoms and radiological findings that can mimic other inflammatory spinal pathologies, leading to severe complications such as kyphosis and neurological deficit.</p> Case presentation <p>A 71-year-old woman from Southeast China presented with a 1-year history of progressive low back pain, initially misdiagnosed as axial spondyloarthritis. She experienced temporary relief with symptomatic treatment, including secukinumab. One year later, her symptoms recurred severely. Advanced imaging (computed tomography/magnetic resonance images) revealed destruction of the L1 and L2 vertebral bodies with a paravertebral abscess. Microbiological confirmation was obtained via a positive T-SPOT.TB test and metagenomic next-generation sequencing detecting Mycobacterium tuberculosis complex. The patient successfully underwent posterior debridement, spinal canal decompression, fusion, and instrumentation, followed by a standard anti-tuberculosis regimen. Her symptoms significantly improved, and she resumed return to work within 2&#xa0;months.</p> Conclusion <p>This case highlights the potential for spinal TB to masquerade as seronegative spondyloarthritis, leading to dangerous diagnostic delays. Clinicians should maintain a high suspicion for TB in endemic areas and employ specific diagnostic tests early. Timely surgical intervention for instability or neurological compromise, combined with appropriate chemotherapy, is crucial for optimal outcomes.</p>