Spinal cord compression, one of the most dreaded complications of malignancy, is usually caused by metastatic bone disease compressing the spinal cord and/or nerve roots. If not recognized and treated promptly, it can have potentially catastrophic outcomes. As patients live longer due to newer treatments, the incidence of malignant spinal cord compression may increase, and the types of presentation or behavior of tumors may change. Spinal cord compression must be considered in all patients who have a cancer diagnosis presenting with back or neck pain and/or neurological symptoms or signs. In this chapter, the terminology used in the diagnosis and treatment of spinal cord compression will be defined and the epidemiology and pathophysiology described. Given that spinal cord compression is a true emergency, it must be diagnosed and managed promptly by a multidisciplinary team. Early detection and effective treatment can make the difference between independent living and being bed bound. This chapter will explore the many factors that should be considered in determining the most appropriate care plan and highlight how the ultimate goals of care and care plan need to be continually reassessed to ensure the best outcome for the patient. Surgical intervention and radiotherapy treatment decisions are complex and will be explained in detail, within the context of these above considerations. Technical aspects and illustrations to clarify treatment options will be provided. Predicted outcomes will be discussed; however it is important to note that the best outcomes occur when the degree of premorbid neurological deficit is minimal and the diagnosis and treatment initiated within 24–48 h of presentation.