Thoracic spine tumors present significant challenges due to their complex anatomical location and the involvement of critical structures. These tumors can be primary or metastatic, often requiring a multidisciplinary approach to treatment. Surgical management plays a pivotal role, with various approaches, including posterior, anterior, and lateral techniques tailored to the tumor’s location. This chapter provides a comprehensive overview of common thoracic spine tumors, the risks to surrounding structures, and the techniques used in surgical resection. It also emphasizes the importance of neuromonitoring and positioning considerations in order to minimize risks.