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Background: The most commonly encounter tumor of the spine is metastasis, and thoracic spine is the most commonly metastatic spine. Controversy exists regarding the optimal surgical approach for this kind of patient. The author conducted a study to assess the differences between anterior thoracotomy and posterior approach in patients with malignant epidural cord compression in the thoracic spine. Methods: Between January 2003 and December 2015, patients with metastatic thoracic lesion underwent surgery at our department were stratified into two groups according to different approach method to the lesion site. Group A mean anterior thoracotomy, decompression and fixation. Group P represented posterior decompression and fixation. Survival was defined as months since surgery to last tractable times. American Spinal Injury Association grade was used to assess preoperative and postoperative neurologic status. Days at intensive care unit (ICU) were compared. Every complication by surgery or during admission was documented. Results: Group A had 25 patients and Group P had 67 patients. Lung cancer was ther most commonly origin cancer in both groups. The most commonly surgical level was the 9th thoracic vertebrae in Group A and the 10th thoracic vertbrae in Group P. Both gropus had a similar preoperative neurologic (p=0.959). One patients in Group A and two in the Group P sustained neurologic deterioation immediately after surgery. Group A took more operation time (213.0 vs 199.2 minutes, p=0.380) and had more blood loss (912.5 vs 834.4 ml, p=0.571). 6 patients in Group A (24%) and 10 patients in Group P (13.9%) developed complications immediately or postoperatively. Patients in Group A need more days of care at ICU (2.36 vs 0.19 days, p<0.001). The longer survival was seen in the goup P (15.4 vs 11.2 months) but without significant differnce. Conclusion: Patients in Group P required significantly less days of care at ICU. Besides, posterior approach also took a shorter surgical time, and had a less blood loss during surgery, although without statistically significant difference. According to the results, the author would prefer posterior approach by decompression and fixation for those with thoracic metastatic tumor with epidural compression. Keywords: Thoracic spine; metastatic epidural spinal cord compression; anterior thoracotomy; posterior approach; survivorship; neurologic status; complications.