Thoracolumbar spinal tuberculosis (TLSTB) remains a significant health burden in developing countries. Although anterior approaches have traditionally been considered the standard, posterior-only surgery has emerged as a promising alternative due to advantages including effective deformity correction, reduced surgical invasiveness, and shorter hospitalization. However, evidence regarding its long-term outcomes and complication profile remains limited. This retrospective case series evaluated the clinical and radiological outcomes, as well as perioperative complications, of posterior-only surgery for TLSTB. A total of 83 patients underwent posterior-only long- segment pedicle screw fixation with debridement and anterior column reconstruction using structural autograft, an anterior distraction device, or a titanium mesh cage over a five-year period. Clinical outcomes were assessed using the Visual Analog Scale (VAS), American Spinal Injury Association (ASIA) impairment scale, and Oswestry Disability Index (ODI), while radiological outcomes included kyphotic Cobb angle, fusion status based on Bridwell criteria, and implant failure. All parameters were evaluated preoperatively, postoperatively, and at final follow-up. Multivariable regression analysis was performed to identify predictors of poor outcomes, and intraoperative and postoperative complications were systematically recorded. The mean patient age was 41.6 ± 5.3 years, with a mean follow-up of 28 ± 6.1

months. VAS improved from 7.1 ± 1.84 to 1.8 ± 0.52. Neurological recovery was achieved in 92% of patients, with 73% showing improvement of at least two ASIA grades. ODI decreased from 64.2 ± 10.74 to 24.6 ±

6.23. The kyphotic Cobb angle improved from 47.4°

± 23.94° to 16.7° ± 4.78°. Solid fusion (Bridwell grade I–II) was achieved in 87% of patients, while hardware failure occurred in 7.2%. Disease recurrence was observed in 2.4%, and the overall complication rate was 13.2%. Severe preoperative neurological deficit, delayed-onset paralysis, and greater baseline kyphosis were identified as predictors of poorer outcomes. Posterior-only surgery resulted in substantial improvements in pain, neurological function, and deformity correction in TLSTB, supporting its role as an effective alternative to conventional approaches; however, implant-related complications and nonunion highlight the importance of appropriate patient selection and long-term follow-up.