In addition to the standard functional monitoring during surgery of the lumbosacral spine, operative interventions for tumors in this region add several special considerations, particularly regarding intraoperative neuromonitoring (IONM). Positioning may be prone, lateral, or supine, with the extent of the bony exposure dictated by the tumor itself. Intradural extramedullary pathologies may involve or compress the cauda equina, necessitating comprehensive monitoring of lower extremity, bowel, and bladder function. Commonly, metastatic disease invades vertebral bodies and can cause ventral compression of the thecal sac. Multimodal intraoperative neuromonitoring during metastatic tumor decompression has been shown to be both sensitive and specific in detecting neural injury. Modalities such as motor evoked potentials (MEPs) and somatosensory evoked potentials (SSEPs) must be combined with sacral reflex monitoring to provide comprehensive neuromonitoring in the lumbosacral spine. Understanding the interplay between surgical approaches, patient positioning, and neuromonitoring is crucial for optimizing patient outcomes.