Chemotherapeutic agents remain the cornerstone of treatment for spinal tuberculosis. The arguments that surgery is necessary for biopsy and to allow for removal of infection and its byproducts have been usurped by advanced biopsy techniques and trials demonstrating resolution of infection and most abscesses using chemotherapy. Although chemotherapy alone has been demonstrated to be effective for some neurologic deficits, those lesions that may be safely treated without surgery remain to be fully defined. Modern imaging techniques have allowed more precise diagnosis and identification of neural compression and the extent of bony involvement. Refinement and popularization of anterior surgical techniques have made decompression and reconstruction relatively safe in experienced hands. Lesions that possess a propensity towards kyphosis are more readily identifiable. The use of instrumentation in the face of active disease appears to be promising, though at present there is a relative paucity of supporting data. Despite these advances in treatment, it must be borne in mind that ultimately, the diagnosis of this relatively uncommon disorder must precede the treatment.