Spinal tumors and spinal tuberculosis are two types of diseases that are common in spinal surgery clinics and often require differential diagnosis. Most of their clinical symptoms are non-specific symptoms such as low back pain, radiating pain in the limbs, low fever, chills, poor appetite, and wasting. Even though there may be symptoms of the primary lesion, it cannot be said that the spinal lesion is its secondary lesion, and definitive evidence is needed for tumor metastasis or extrapulmonary tuberculosis. In contrast, the specialist signs are mostly positive for spinal destruction, loss of spinal stability and involvement of soft tissues such as periosteum, nerve roots, and paravertebral muscles; in fact, as long as something is in there destroying the spine and invading the soft tissues, it is the same presentation. The specificity of conventional laboratory tests is low, and the specificity of tumor markers may be of some significance in suggesting secondary spinal tumors, but is of little significance in primary spinal tumors, and the rate of false negatives for such results is high. Current laboratory tests for tuberculosis are very ineffective, and the sensitivity and false-negative rate of the PPD test and TB-Ab are problematic. Preoperatively, spine surgeons often determine which disease is present by the typical imaging differences between the two: a lesion that invades and destroys the intervertebral space, often with a paravertebral abscess, is often judged to be spinal tuberculosis; a lesion that invades along the pedicle is generally judged to be a spinal tumor. Of course, this is only a basic judgment, and no matter how experienced a doctor is, he or she would not dare to determine a disease based on imaging alone, and the final decision must rely on histopathological findings. Here, we will discuss the imaging differences between these two types of diseases, that is, why spinal tumors and spinal tuberculosis have the above-mentioned imaging differences on MRI. Many of you may say that this is what the textbooks have been saying since you were in school, as a legal standard for imaging decisions. Now, let’s think about it. In fact, tumor and tuberculosis are two diseases with completely different pathological bases, which naturally have different histobiological manifestations. How exactly does that relate to the difference in imaging presentation? Let’s analyze the pathology of the progression of the two diseases: the development of tumor invasion is based on the mutation and destruction of homologous cells, which means that the first victims are the bone cells similar to its tissue origin, and therefore the histobiological manifestations are firstly intraosseous destruction along the vertebral body – cancellous root of the vertebrae, and only then may they invade the extraosseous tissue. Tuberculosis is a specific inflammatory disease, and its invasion and destruction are based on the collapse of surrounding tissues by the inflammatory process, therefore, wherever it is close and easy to be invaded, it will be destroyed first, and the first to suffer is the adjacent cartilage endplates and intervertebral discs and other soft tissues, and then penetrate to the paravertebral muscle space. Tumor is firstly a “nest”, but the destruction is all hard bone tissue, so it often shows bone destruction in the direction of vertebral body and pedicle; while tuberculosis is a “soft”, so it often invades the intervertebral space and paravertebral space where the soft tissue exists. and the paravertebral space. Based on these histobiological characteristics, it is not difficult to relate the imaging differences between these two diseases. However, spinal tuberculosis and tumors may present differently at different stages of disease progression and may be atypical in particular cases, as tumors may also disrupt the intervertebral space and tuberculosis may not necessarily disrupt the vertebral arch. The diagnosis of any disease needs to be combined with clinical symptoms, physical signs, and laboratory and imaging tests. The above is only an analysis and consideration of the differences in imaging manifestations to histopathology in the early and middle course of these two types of diseases in routine situations.