[Objective] To compare the clinical effect of anterior surgery and posterior surgery in the treatment of thoracolumbar tuberculosis and analyze the reasons. [Methods] From January 2015 to October 2020, 103 cases of thoracolumbar spinal tuberculosis treated by surgery in our hospital were retrospectively analyzed, including 39 cases of anterior surgery and 64 cases of posterior surgery. Preoperative age, gender, JOA score, ODI score, ASIA neurological function rating and imaging examination of Cobb Angle were recorded in the two groups. The perioperative conditions such as incision length, intraoperative blood loss, operation time, intraoperative and postoperative complications were recorded. ASIA neurological function rating, JOA score and ODI score were recorded before and after operation to evaluate the clinical effect. Cobb Angle and bone graft fusion were examined by imaging. [Results] All patients completed the operation successfully. Perioperative period, the operation time, intraoperative blood loss, incision length and postoperative bed rest time of the anterior approach group were significantly longer than those of the posterior approach group, and the differences were statistically significant (P < 0.05). The patients were followed up for 21-48 months, with an average of (29.56±10.35) months. At the last follow-up, the ASIA neurological function rating, JOA score, ODI score and Cobb Angle of imaging examination in the two groups were improved compared with those before operation, and the differences were statistically significant (P < 0.05). At last follow-up, there was no significant difference in ASIA neurological function rating, JOA score and Cobb Angle between the two groups (P > 0.05). The ODI score was compared between the two groups at the last follow-up, and the difference was statistically significant (P < 0.05). [Conclusion] Both anterior surgery and posterior surgery are effective treatment options for thoracolumbar tuberculosis. Anterior surgery is more traumatic and has more thorough lesion removal. Compared with the anterior approach, the posterior approach has advantages of less trauma and less bleeding.