Pediatric Tuberculosis of the L4 Lumbar Vertebra Successfully Managed with Posterior-Only Reconstruction Spinal tuberculosis in children is usually managed conservatively with anti-tubercular therapy. However, children differ from adults because their spine continues to grow. Even a small deformity can progressively worsen, eventually leading to severe kyphosis, spinal cord compression, and late neurological deficits. Case Summary A 7-year-old girl presented with severe back pain for one month and difficulty standing and walking. MRI demonstrated extensive destruction of the L4 lumbar vertebra with localized kyphotic deformity. Considering the child’s age, remaining growth potential, vertebral destruction, and progressive deformity, surgical intervention was recommended. Surgical Procedure Dr. Pramod Saini, Associate Director, Spine Surgery, Max Super Speciality Hospital, Noida, performed: • Posterior pedicle screw fixation using pediatric pedicle screws • Transpedicular decompression • Partial L4 corpectomy • Anterior column reconstruction using an expandable TLIF cage through a posterior-only approach The availability of expandable cages has made it possible, in selected patients, to reconstruct the anterior spinal column through a single posterior approach, avoiding the need for traditional retroperitoneal surgery for lumbar lesions. Outcome The patient was mobilized on the second postoperative day. Biopsy confirmed tuberculosis, and GeneXpert detected rifampicin-sensitive Mycobacterium tuberculosis. Standard first-line anti-tubercular therapy was initiated. Importance of Long-Term Follow-Up Children have substantial spinal growth remaining. As growth continues, increased stress on implants may occasionally lead to screw loosening or implant failure after healing. Elective implant removal may then be considered. Regular follow-up also helps detect any recurrence or progression of spinal deformity during growth. Key Learning Points • Most pediatric TB spine cases can be treated without surgery. • Extensive L4 vertebral destruction and progressive deformity may require early surgical stabilization. • Posterior-only reconstruction using expandable TLIF cages has reduced the need for anterior lumbar approaches in selected patients. • Long-term follow-up is essential until skeletal maturity to monitor spinal growth and maintain alignment. Keywords: Pediatric TB Spine, Lumbar Spinal Tuberculosis, L4 Vertebral Tuberculosis, Pediatric Spine Surgery, Expandable TLIF Cage, Lumbar Kyphosis, Spine Surgeon Noida, Dr. Pramod Saini, Max Super Speciality Hospital Noida.