Metastatic epidural spinal cord compression (MESCC) is becoming a more common clinically encountered entity as advancing systemic antineoplastic treatment modalities improve survival in cancer patients. Although treatment of MESCC remains a palliative endeavor, emerging surgical techniques, in combination with imaging modalities that detect spinal metastatic disease at an early stage, are resulting in improved outcomes. Here, we review the clinical presentation, diagnostic work-up and management options in the management of MESCC. A treatment paradigm is outlined with emphasis on early circumferential surgical decompression of the spinal cord with concomitant spinal stabilization. Radiation therapy has a clearly defined role in the treatment of patients with MESCC, particularly those with radiation-sensitive tumors in the setting of non-bony spinal cord compression and those with a limited life expectancy. Spinal stereotactic radiosurgery, vertebroplasty, and kyphoplasty, are emerging treatment options that are beginning to be used in selected patients with MESCC.