The thoracic spine is a structurally unique region that renders it uniquely susceptible to thoracic disc herniation. Surgical management strategies are complicated, in part, by the regional anatomical and biomechanical nuances. Surgical approaches include posterior, posterolateral, and anterior routes. Each is associated with specific indications and contraindications. The biomechanical principles and safe anatomical trajectories must be considered in the surgical decision-making process. These issues are discussed in the pages that follow.