Of 167 episodes of spinal epidural neoplastic compression, 86 were treated by operation. The surgical approach was prospectively selected according to the location of the tumor in the spinal canal. Decompression was achieved by 61 vertebral body resections (VBRs) and by 25 laminectomies. The indications for operation were: (a) neurological relapse after previous radiotherapy, (b) the need to make a tissue diagnosis, (c) a radioresistant tumor, and (d) neurological deterioration during radiotherapy. Before VBR, 28% (17 of 61) were still able to walk, 51% (31 of 61) were pareparetic, and 21% (13 of 61) were paraplegic. Bowel and bladder dysfunction was present in 49% (30 of 61). After VBR, the outcome of only 57 procedures was available for evaluation because of the postoperative death of 4 patients. Eighty per cent (46 of 57) were able to walk, 18% (10 of 57) were paraparetic, and 2% (1 of 57) were paraplegic. Ninety-three per cent had normal sphincter control. Before laminectomy, 8% (2 of 25) were ambulatory, 84% (21 of 25) were paraparetic, and 8% (2 of 25) were paraplegic. Bowel and bladder dysfunction was present in 76% (19 of 25). After laminectomy, only 23 procedures were evaluated because of the postoperative death of 2 patients. Thirty-nine per cent (9 of 23) were ambulatory, 35% (8 of 23) were paraparetic, and 26% (6 of 23) were paraplegic. Fifty-seven per cent regained normal sphincter control. The operative mortality was 7% (4 of 61) in VBR and 8% (2 of 25) in laminectomy. The surgical morbidity was 11% (7 of 61) in VBR and 28% (7 of 25) in laminectomy, mainly delayed wound healing. Neurological worsening as a result of laminectomy occurred in 20% (5 of 25) and was transient after 1 VBR (2%). Dislodgement of the vertebral body replacement construct occurred in 3 patients, but has not occurred since the introduction of an improved instrumentation technique. In view of the encouraging results with anterior decompression of the spine, the role of surgical decompression as the primary treatment for ventrally located tumors should be reconsidered. The role of laminectomy in posterior compartment tumors deserves further study.