Spinal tuberculosis (TB), a destructive form of extrapulmonary TB, is uncommon in the United States. It is more common among immigrants from TB-endemic countries. Typically, the infection spreads to the vertebrae from a primary site elsewhere. Spinal TB commonly presents with an insidious onset of nonspecific back pain and can be the first presenting symptom of underlying TB. Because it presents in a similar fashion to a metastatic disease, which is more common in the United States, a diagnosis of spinal TB is often delayed, resulting in long-term disability. A high clinical suspicion coupled with appropriate imaging studies helps in prompt diagnosis and the rapid institution of treatment. Anti-TB drugs are effective to treat spinal TB, but surgery is required in refractory disease, abscess formation, vertebral collapse, and/or nerve compression. We present 2 cases of spinal TB: one responded very well to medical treatment; the other required adjunct surgery.