Malignant spinal cord compression is one of the most dreaded complications of cancer. If untreated, it can lead to worsening neurologic function culminating in paralysis and sphincter incontinence. The most challenging aspect in the management of this complication is early diagnosis because the single most important factor determining outcome is the level of neurologic function at initiation of therapy. Magnetic resonance imaging is the diagnostic modality of choice. Steroids have a proven role in the treatment. Radiation therapy has been the standard of care, with surgery reserved for special cases. A recent randomized trial has proven that in appropriately selected patients initial surgery, followed by radiation, provides better functional and neurologic outcome compared to radiation alone and will likely become the standard of care in the future. Newer modalities, such as transarterial embolization and extracranial stereotactic radiosurgery, are emerging and may be considered in appropriate cases if available.