Object Spinal cord vascular malformations are rare, fascinating lesions. In this paper, the authors' goal was to demonstrate how these lesions, more specifically spinal cord arteriovenous malformations and dural arteriovenous fistulas, are assessed, classified, and managed at their institution. They also highlight some aspects of classification and management that may be different from the views of others. Methods The authors reviewed the 20-year experience at the senior author's institution regarding the management of spinal cord vascular malformations. They discuss the management, surgical and endovascular treatment results, and the classification that resulted from the combined experience of 3 major reference centers. Results The accumulated knowledge on embryological and pathophysiological aspects in such a rare disease resulted in a more global, patient-oriented (and not radiologically oriented) approach to spinal cord shunts. Conclusions The multiple classifications proposed for spinal cord vascular malformations reflect the continuous advancement of the authors' understanding. They adopt a classification based on new physiological and genetic data that treats these lesions as expressions of more complex disease processes and not simply a morphological target, with direct impact on therapeutic options.