Objective: Spinal metastases represent the most common site of bony metastases and frequently reduce quality of life. A beneficial effect of surgery and radiotherapy versus radiotherapy alone has been demonstrated in symptomatic patients. The goal of our study was to perform a cost-utility analysis of surgery for spinal metastases based on patient-level costs and health status data in a specialist spine center in Belgium. / Methods: A cost-utility analysis was performed in a prospective cohort of patients undergoing surgery for symptomatic spinal metastases in 2011–2015. EQ-5D-3L measure of health-related quality of life data were collected preoperatively and at 3, 6, 12, and 24 months. Hospital costs relating to surgical management including postoperative radiotherapy were analyzed. A retrospective cohort of patients treated with radiotherapy alone between 2011 and 2015, which matched the surgical patients for disease load and presentation, also was assessed. Quality-adjusted life years (QALYs) for nonsurgical patients were modelled against the surgical group. / Results: In total, 38 consecutive surgical patients had information for cost-utility analysis and 8 nonsurgical patients were matched. Mean total cost in the surgical group was €16,989 (SD €8148), largely comprising nonmedical staffing cost (mean €7721, 45.9%), followed by daily operational costs (€2963, 17.6%) and medical staffing costs (€2621, 15.6%). Median initial health status was 0.33 (interquartile range 0.15–0.55), and median postoperative QALYs were 0.70 (interquartile range 0.18–1.70). Mean total cost in the nonsurgical cohort was €9354. The incremental cost-effectiveness ratio for surgical management was €13,635 (range €12,726–€14,407) per QALY. / Conclusions: Surgery for symptomatic spinal metastases in a specialist hospital in Belgium is cost-effective.