Metastatic spine disease is increasingly common, with an estimated 20% of cancer patients impacted. The treatment of these lesions has changed significantly over the course of the past three decades. Surgical decompression became an established treatment paradigm after the landmark 2005 Patchell et al. study showed the benefits of surgery combined with adjuvant conventional external beam radiation therapy for the management of metastatic epidural spinal cord compression. This resulted in the surgical pendulum swinging toward aggressive surgical techniques for maximal tumor resection to attempt to improve local tumor control, and it was not until the development of spine stereotactic radiosurgery (sSRS) that the goals of surgery again shifted. The advent of sSRS brought with it improved local control due to more conformal and ablative doses of radiation being able to be delivered, and this resulted in the surgical goal shifting from maximal tumor resection to that of thecal sac decompression for the creation of a safe radiation target, a technique known as separation surgery. Herein, we will describe this evolution, the durable local control achieved with separation surgery followed by adjuvant sSRS, and current surgical trends toward a more minimal footprint in treating patients with metastatic epidural spinal cord compression.