Vertebral hemangiomas are the most common benign spinal tumors with an incidence range of 10-12%. Approximately 1-2% of the cases develop clinically significant symptoms causing the necessity for treatment. Based on our own results and a review of the literature we discuss the role of radiotherapy in the management of symptomatic vertebral hemangiomas. A total dose of 30.0 Gy given in five weekly fractions of 2.0 Gy has been proven as effective for the primary treatment and postsurgical irradiation for the prevention of a recurrence. In the literature review the results are summarized of 59 reports in the period of 1929-2000 for a total of 327 cases. The analysis of 55 studies reporting results in 210 cases which underwent primary radiotherapy or combinations with other methods of treatment demonstrated that in 54% occurred a complete relief of symptoms (CR), in 32% a partial relief (PR), and 11% were non-responders (NR). The analysis of 21 reports of 63 cases which were treated with radiotherapy as the sole measure of treatment demonstrated that 57% had a complete remission of symptoms (CR), 32% a partial remission (PR), and 11% did not respond to radiotherapy (NR). We conclude that radiation therapy is very effective in the management of symptomatic vertebral hemangiomas. With regard on the delayed effects of the irradiation, cases with an acute compression of the spinal cord should be treated primarily with a surgical procedure and a postsurgical irradiation is recommended to prevent a relapse of symptoms. In order to minimise acute or late toxicity and the risk of radiation-induced neoplasms the total dose should not exceed 30 Gy.