Although there have been a few large case series of giant cell tumor (GCT) in the spine and sacrum, the treatment of these lesions remains controversial. We are reporting 23 additional cases of giant cell tumor in the spine and sacrum gathered from our institution and the personal consultation files of the senior author. Ten lesions occurred in the sacrum with an average age of 31 years (range of 13-49) and 13 occurred in the mobile spine with an average age of 39.1 years (range of 13-64). Most patients presented with pain or neurologic deficit at the site of tumor involvement, and symptoms were usually present for many months prior to diagnosis. Six of the sacral GCT patients were treated with pre-operative arterial embolization and intralesional surgical resection, and two developed a recurrence. Two of the sacral GCT patients had an en bloc resection and neither developed a recurrence. One sacral GCT patient was treated only with serial arterial embolization with good disease control. One sacral GCT patient did not receive any treatment. Eleven spinal GCT patients were treated with en bloc surgical resection and two developed a recurrence, the other two spinal GCT patients were treated with intralesional surgical resection and both developed a recurrence. Giant cell tumors of the spine and sacrum should be managed with en bloc resections whenever possible as this provides the greatest chance for cure. When the risk of post-operative neurologic deficit after en bloc excision is high, as in most of our sacral lesions, conservative therapy involving arterial embolization and intralesional resection offers the best results.