Spinal tuberculosis is the most common form of skeletal tuberculosis. Tuberculous involvement of the lower spine is rare. Sacral tuberculosis is very rare; most reported cases in the literature are case reports. Spinal tuberculosis may present atypically: neural arch involvement, skip lesions, sacral involvement, or as extradural tuberculosis. Diagnostic bone biopsy is an integral part of patient work-up. Patients may be infected by a variety of micro organisms, especially patients who are HIV positive or those who have AIDS. The gold standard technique for biopsy of the sacrum is CT-guided percutaneous biopsy. The technique has a very low complication rate in experienced hands. We describe a simple, safe and fast percutaneous biopsy technique we used to obtain biopsy of the upper sacrum. The details are stated in this report. Background Tuberculous infection of the musculo-skeletal system constitutes about 1% of all tuberculous infections. Spinal tuberculosis constitutes about one quarter to two-thirds of musculo-skeletal tuberculosis[1]. The distribution of spinal tuberculosis(TB) varies widely according to the literature: the commonest affected site is the thoraco-lumbar region, followed by the thoracic and then the lumbar area. The lumbo-sacral area is affected in less than 5% of cases[2, 3]. Isolated sacral TB is extremely rare[4]. The high prevalence of HIV and AIDS has caused an increase in the incidence of not only TB in general, but also an increase in spinal tuberculosis, especially in developing countries. HIV positive patients can be infected by a variety of organisms; spinal biopsy becomes an important part of patients' diagnostic work-up. We present a case of a young HIV positive male patient who had sacral tuberculosis. We describe a technique called percutaneous trans ilio-sacral biopsy. To the best of our knowledge, this technique has not been described in the English literature.We detail the presentation, physical examination, and the percutaneous trans ilio-sacral biopsy technique. Case presentation A 31 year-old HIV positive male patient was referred to our spinal clinic because of chronic progressive lower backache. The pain started spontaneously about one year before presentation. He has been treated conservatively at the local clinic where he received anti-retroviral therapy. He had no complaint of bladder or rectal sphincter dysfunctions. He was complaining of pain in the lower limbs and it was getting progressively worse. There were no complaints relating to neurology. Family history was unremarkable. On physical examination, he was a well and healthy-looking young man. There were no findings generally. Local findings of the lower back showed deformity in the S1/S2 area, localized tenderness, no local signs of inflammation or abscess formation, and he had tenderness on both sacro-iliac joints. Neurological examinations showed; decrease sensation to light touch and pinprick bilaterally in the S2- S4 dermatomes, normal motor power bilaterally, and normal reflexes. He had normal rectal sphincter tone and function. There were no any other significant findings. A clinical diagnosis of spinal tuberculosis was made. Plain radiographs of the spine were requested. The X-rays showed destruction of the upper sacral spine( S1/S2) with possible involvement of the sacro-iliac joints. Computed tomography scan ( CAT-SCAN) was requested. CAT SCAN with contrast was done: it showed extensive S1 and S2 destruction with disc space narrowing, There was an extensive pre-vertebral soft tissue mass measuring 7.0cm x 8.0cm stretching from the inferior border of L5/S1 disc space proximally to the superior border of S4 inferiorly. The mass extended into the vertebral canal thus displacing the neural tissue posteriorly. The mass was well-encapsulated. There were areas of calcifications within the mass (Figure 1).
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