An algorithmic approach to the treatment of Paget's disease of the spine is based on the authors' collective experience in managing 70 patients and a review of the literature. For patients with active disease, even if asymptomatic, cyclical treatment with etidronate is recommended until normalization of biochemical parameters is achieved. For patients with back pain and/or neurologic dysfunction, cyclical etidronate treatment in the blastic and mixed phase is advocated. Those who fail to respond to calcitonin in the lytic phase should be given the new generation of bisphosphonates and gallium nitrate. No antipagetic drug therapy is indicated for the sclerotic phase. Surgery for complications of Paget's disease should be preceded by intravenous therapy to minimize intraoperative bleeding. For cases of spinal stenosis with impending paraplegia, the new bisphosphonates, mithramycin (plicamycin), or gallium nitrate should be used. If conservative treatment fails, surgery should not be delayed.