Spinal cord compression (SCC) is a well-known complication in cancer patients, with an enormous potential impact on quality of life. In most cases, treatment is palliative, but a prompt diagnosis and immediate treatment is essential to preserving neurological function. Whereas steroids and radiation have been the mainstay of therapy for many years, the role and timing of surgery has remained controversial. However, class I evidence now exists to support the benefit of pre-irradiation surgical decompression in a carefully selected subpopulation of patients with SCC. A multidisciplinary approach is required to maximize the therapeutic and functional outcome of these patients.