Background: Prognosis of hepatocellular carcinoma (HCC) has improved with recent treatment protocols. Egypt ranks the third in Africa and is the 15th most populous country worldwide with respect to incidence of HCC. Spinal metastases has poor prognosis and occurs in 6%–20% of patients with HCC. The goal of treatment for spinal metastasis is improving the quality of the remaining life, preserving ambulatory function, and reducing pain. We studied surgical treatment to prove its efficacy in improving patients’ survival and functional outcomes. Methods: In this study, we included 21 patients (17 males and 4 females) who were diagnosed with HCC-derived spinal metastases and had undergone surgical treatment between April 2014 and October 2019. We analyzed the clinical and radiological data and studied the surgical outcomes and prognostic factors of surgical treatment. Results: The most common site of spinal metastases was the dorsal region (12 patients), followed by the lumbosacral region (six patients), and three patients presented with cervical spine metastases. Regarding back pain, the mean visual analog scale score was significantly improved from 78.57 preoperatively to 7.14 at last follow up (p < 0.001). Regarding improvement of activities of daily living there was a statistically significant increase in the Barthel index. The mean post-treatment survival period was 9.52 ± 4.38 months (range 1–19 months). Conclusion: Surgical treatment of HCC-derived spinal metastases in patients with severe pain and neurological deficits had better outcomes with respect to overall survival, pain control, neurological recovery, and functional state. However, the risk of excessive hemorrhage was high.