Background: Spinal tumours represent a diverse group of lesions with variable biological behaviour and clinical outcomes. Categorizing these tumours into “good,” “bad,” and “ugly” subgroups facilitates understanding of their natural history, diagnostic challenges, and therapeutic strategies. Aim: To categorize spinal tumours based on biological behaviour and to analyze their clinical features, diagnostic approaches, therapeutic strategies, and treatment outcomes. Materials and Methods: This retrospective observational study was conducted at a tertiary care neurosurgical centre between 2011 and 2024. A total of 251 patients with histologically or radiologically confirmed spinal tumours were included. Tumours were categorized into benign (good), malignant/aggressive (bad), and rare/complex (ugly) groups. Clinical profiles, diagnostic modalities, surgical outcomes, use of adjuvant therapies, and recurrence rates were analyzed. Statistical analyses included descriptive measures, Chi-square tests, ANOVA, and Kaplan-Meier survival where applicable, with a p-value <0.05 considered significant. Results: Benign tumours constituted the majority (72.1%), with schwannomas (43.8%) and meningiomas (25.1%) most common. Malignant/aggressive lesions comprised 8.0% of cases, while rare/complex tumours such as ependymomas formed 19.9%. Patients with malignant tumours were significantly older (mean 57.9 years, p<0.001) and presented with shorter symptom duration compared to benign or rare groups. Gross-total resection was highest in benign tumours (88.4%), intermediate in rare/complex (62.0%), and lowest in malignant cases (35.0%) (p<0.001). Two-year recurrence was lowest in benign (5%) but markedly higher in malignant (40%) and rare/complex (22%) tumours (p<0.001). Use of adjuvant radiotherapy was significantly greater in malignant (75%) and rare/complex tumours (38%) compared to benign lesions (6.6%). Advanced imaging modalities and intraoperative adjuncts were more frequently utilized in the malignant and rare/complex groups. Conclusion: Spinal tumours display distinct clinical, diagnostic, and therapeutic patterns depending on their biological behaviour. Benign tumours have favourable outcomes with surgery, whereas malignant and rare/complex lesions require multimodal management and advanced adjuncts, with higher recurrence and adjuvant therapy needs. A classification into “good,” “bad,” and “ugly” categories offers a practical framework for clinical decision-making and highlights the importance of individualized, multidisciplinary care in spinal oncology.

Spinal tumours. Gross-total resection. Multimodal management.