Traditional surgical treatment for tuberculous spondylodiscitis with significant vertebral destruction (vertebral height loss >50 percent), kyphosis and neurological deficit consist of midline decompression (bilateral laminectomy), debridement and anterior column reconstruction with cage.Cage subsidence with loss of surgical correction is often observed following surgery resulting in suboptimal outcomes. We describe a midline preserving decompression (unilateral laminectomy), debridement and anterior column reconstruction as a safe and effective alternative to the traditional surgical approach. We did a retrospective analysis of prospectively collected data (from January 2021 to November 2025) on 54 patients with thoracolumbar spinal tuberculosis who underwent either midline decompression and cage reconstruction (MDC group, n=26) or midline preserving decompression and reconstruction with autograft (MPDG group, n=29) with a minimum two-year follow-up. We compared the operative time, intraoperative blood loss, radiological outcomes (preoperative vs postoperative sagittal alignment, loss of surgical correction at final follow-up, cage position and fusion status), clinical outcomes (VAS and ODI scores) and complications between the two groups. The mean operative time was significantly less in the MPDG group (130.7+/-10.1min, range 120 – 150 min) vs MDC group(182.7+/-13.5min, range 160 – 210 min), p<0.05.The intraoperative blood loss was significantly less in the MPDG group (325.2+/- 56.3 ml, range 250 – 420 ml) vs MDC group(463.2+/-74.2 ml, range 350 – 600ml), p<0.05. The loss of kyphosis correction at final follow-up was slightly higher in the MPDG group (9.3+/- 2.1 degrees) vs MDC group (7.7+/-1.5 degrees). The mean VAS and ODI scores at final follow-up were comparable in both the groups. There were 5 cases of cage malposition in the MDC group. No cases of neurological worsening were observed in both groups. Fusion was observed earlier in the MPDG group (8 months) compared to the MDG group (10 months). Midline preserving unilateral decompression and anterior column reconstruction with autograft is a feasible, effective and safer approach in treating thoracolumbar spinal tuberculosis with kyphosis and neurodeficit as compared to the traditional MDC technique.