Background: Spinal tuberculosis (STB) is a major cause of spinal deformity, instability, and neurological deficits. While antitubercular therapy (ATT) is the primary treatment, surgery is indicated in advanced disease or complications. This study evaluates surgical management and outcomes in cervical, thoracic, and thoracolumbar STB at a single Indian center. Methodology: Retrospective review of 84 patients (cervical 17, thoracic 37, thoracolumbar 14, and lumbar 16) who underwent surgery from 2015 to 2023. Data included demographics, clinical presentation, neurological status (American Spinal Injury Association ASIA scale), pain (Visual Analogue Scale VAS), surgical approach, fusion technique, complications, and postoperative outcomes. Surgical strategy was individualized based on lesion location, vertebral involvement, and deformity. Results: Mean age ranged from 36.5 (cervical) to 49.3 (lumbar) years; males predominated. Pain (90%), fever (80%), and fatigue (66%) were common; neurological deficits occurred in 51%. Anterior approaches were used in cervical (76%) and thoracic (59%) cases, posterior in thoracolumbar (86%) and lumbar (100%), with combined anterior–posterior in 4%. Operative time and blood loss were lowest for cervical (96 ± 15 min; 70 ± 23 mL) and highest for thoracolumbar cases (156 ± 40 min; 264 ± 81 mL). Postoperatively, most patients improved neurologically (ASIA D/E), with significant pain reduction (VAS 7.1–7.6 → 2.2–2.9) and functional recovery (ODI 49–63 → 19–27). Complications were infrequent and manageable. Conclusion: Tailored surgical intervention for STB, guided by anatomical site and disease severity, achieves excellent neurological, functional, and radiological outcomes. Early, appropriately planned surgery remains essential for patients with progressive deficits, instability, or inadequate response to ATT.
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