Objective To investigate the surgical indications by retrospectively analyzing the surgical methods and outcomes in 71 cases with thoracic spinal tuberculosis (TB). Methods Between January 2001 and December 2010, 112 adult patients with thoracic spinal TB were treated with different surgical procedures. We followed up 81 patients (average age 38 years, range 17-68 years), without multiple-level noncontiguous spinal TB, for 17-72 months (mean 37 months), in which 23 patients had neurological deficits. The patients were divided into 5 groups receiving different procedures according to location and extent of the lesion: group A (18 cases) receiving anterior radical debridement and strut grafting with instrumentation by extrapleural approach; group B (21 cases) getting anterior radical debridement and strut grafting with instrumentation by transthoracic approach; group C (10 cases) having posterolateral decompression and strut grafting with posterior instrumentation; group D (27 cases) receiving posterior instrumentation and interlaminar bone grafting with anterior radical debridement and strut grafting in one-stage or two-stage; group E (10 cases) having anterior radical debridement and strut grafting by splitting the manubrium of sternum or the breast bone in the treatment of upper thoracic spinal TB. Results (1) The average operation time and blood loss were 3.5h and 350ml in group A, 3.0h and 350 ml in group B, 3.0h and 300ml in group C, 4.5h and 640ml in group D, and 4.0h and 600ml in group E respectively. (2) The degree of kyphosis was corrected by (47.5±11.8)% in group A, (46.9±10.2)% in group B, (59.9±17.4)% in group C, (61.7±18.6)% in group D, and (44.1±8.7)% in group E respectively. (3) The correction loss at last visit was (64.8±19.3)% in group A, (53.6±15.6)% in group B, (56.9±11.8)% in group C, (54.9±15.4)% in group D, and (44.1±8.7)% in group E respectively. All the 23 cases with neurological deficit were improved at least one grade according to Frankel scoring system. Conclusion These results suggest that all the surgical procedures can obtain good results in correction and maintenance of the deformity, clearance of the foci, decompression of the spinal cord and pain relief in the treatment of thoracic spinal TB, providing that the patients are chosen correctly according to location and extent of the lesions, and patients’ general health status. Posterolateral decompression and strut grafting with posterior instrumentation is recommended for the elderly considering their poor general health condition. Posterior instrumentation may be superior to anterior instrumentation in correction and maintenance of the deformity.