Study DesignRetrospective cohort study.ObjectiveTo describe the clinical characteristics and surgical outcomes of non-ambulatory patients with thoracic ossification of the posterior longitudinal ligament (T-OPLL), and to identify predictors of independent walking recovery.MethodsThis retrospective study analyzed 70 non-ambulatory T-OPLL patients treated with either circumferential decompression (CD) or posterior decompression with fusion (PDF) surgery at a single center over 10 years (2012-2022). Outcomes included neurological recovery rate, independent walking recovery, and complications.ResultsOverall, 71.4% of patients regained independent walking. The CD group showed superior functional outcomes (90% vs 64% walking recovery, = 0.030) but higher complication rates (70% vs 38% CSF leakage, = 0.015). Shorter disease duration ( = 0.018) and lower BMI ( = 0.027) independently predicted better walking recovery.ConclusionsFor non-ambulatory T-OPLL patients, CD surgery provides better functional recovery while PDF surgery offers a safer alternative. Early surgical intervention and individualized approach selection based on disease duration and BMI are critical for optimizing outcomes.