Spinal metastases occur in nearly half of all patients with cancer and may cause instability, intractable pain, and neurologic injury secondary to epidural spinal cord compression (ESCC). A multidisciplinary approach to these patients is critical, and surgery must always be considered. Circumferential decompression and stabilization, if necessary, preserves short term function while creating borders between neural elements and metastatic tissue. After surgery, stereotactic radiotherapy can be delivered, which may achieve local control rates of nearly 80% at 2 years depending the underlying tumor etiology. In this review, we aim to elucidate the surgical decisionmaking and goals for separation surgery in patients with ESCC.