Whilst thoracic myelopathy secondary to degenerative disease is relatively uncommon, left untreated it carries significant morbidity. It is thus of critical importance that patients are correctly diagnosed and managed expediently and effectively. Unfortunately, the management of thoracic myelopathy can be challenging, not least due to the technical difficulty accessing the site of compression and indeed optimum management is also debated. In this Element the authors present background, clinical features, diagnosis, and pitfalls and then a handy management algorithm for this critical neurosurgical condition.