Spinal cord astrocytoma (SCA) is the most common type of spinal glioma in children and the second most common in adults. The standard treatment involves surgical resection, with adjuvant radiotherapy and chemotherapy being considered depending on the degree of malignancy. However, for malignant SCA, especially diffuse midline gliomas (DMG) with H3 K27M alterations, the relationship between resection extent and patient prognosis remains a topic of debate. The primary goal of surgery is to maximize tumor removal while minimizing damage to spinal cord function. Due to the complexity of spinal structures and the diffuse nature of these tumors, complete resection is often challenging. The choice of surgical strategy significantly impacts long-term survival and quality of life, highlighting the importance of in-depth studies on surgical approaches and tumor biology. This review provides an overview of recent advancements in understanding the role of surgical resection extent in malignant SCA, with a focus on the underlying biological factors, aiming to guide clinicians in practice. Additionally, we emphasize the importance of comprehensive treatment, including postoperative radiotherapy, chemotherapy, and novel therapies, to improve survival rates and overall clinical outcomes.© 2025. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.