More than 230 years after the characteristic clinical features of tuberculosis spondylitis were first described, this serious infection can still present diagnostic dilemmas in clinical practice. Atypical presentations of spinal tuberculosis mimicking malignancy have been described. We report a 50-year-old woman with abdominal pain as a presenting symptom of lumbar spinal tuberculosis. She presented with chronic intermittent abdominal pain of 6 months' duration, without low-grade fever and weight loss. There were no bowel/bladder complaints, vomiting, or worm infestation. Magnetic resonance imaging of the lumbar spine showed the L3, L4, and L5 vertebrae bodies had been destroyed and disease had invaded the lumbar spinal canal. There was a giant abscess in the right musculus psoas major. The C-reactive protein level was 130 g/L, and the erythrocyte sedimentation rate was 165 mm/h. A diagnosis of lumbar spinal tuberculosis with abdominal pain was made. After 3 weeks of antituberculosis treatment, an operation was performed to debride the necrotic tissues and reconstruct the L3 vertebrae through an anterior approach combined with a posterior approach to establish the spine stability. On 6-month follow-up, the patient had recovered from the operation and had no focal neurologic deficit.