The records of twenty-three patients with a primary benign or malignant osseous neoplasm of the cervical spine were reviewed in an attempt to clarify the most appropriate diagnostic and treatment methods for such tumors. Thirteen patients had a benign tumor and ten patients had a malignant tumor. Nineteen patients had been followed for two to eighteen years (average, six years), and four had died from the malignant disease between one and five months after its discovery. In addition to surgery, medical treatment in the ten patients with a malignant tumor included radiation therapy in seven and chemotherapy in two. Surgical treatment consisted of an anterior and posterior partial resection combined with an arthrodesis in four patients; an anterior partial resection in three, two with an arthrodesis; a posterior partial resection and an arthrodesis in two; and a biopsy but no further treatment in one patient. The duration of survival ranged from one to five months for four patients and from two to three years for four, and was eight and sixteen years in two patients. Two of the thirteen patients with a benign tumor received radiation therapy. Surgical treatment included both an anterior and a posterior resection with arthrodesis in four, an anterior resection in three (with arthrodesis in two), a posterior resection in four (with arthrodesis in three), and a biopsy without surgical resection in two. At follow-up, twelve patients were pain-free and had a solid arthrodesis, although one had required a repeat excision posteriorly. One patient with Gorham's disease (diffuse hemangiomatosis) died. During the period of thirty years (1953 to 1983) when these patients were seen, both the diagnostic methods available and the surgical approaches used have changed. Our present opinion is that all primary osseous lesions of the cervical spine should be carefully defined by arteriography, tomography, bone-scanning, computed tomographic scanning, and myelography in order to properly plan the surgical approach. Total excision of suspect malignant lesions is not attempted, but a major intralesional excision should be carried out to decompress neural and vascular structures and to obtain a biopsy specimen, followed by an arthrodesis to stabilize the spine. For both malignant and benign tumors, an anterior resection should be performed if the tumor is located anteriorly, and a posterior approach should be used if the tumor is predominantly in the posterior vertebral elements. Both of these procedures should be combined with an arthrodesis.(ABSTRACT TRUNCATED AT 400 WORDS)