Primary bone lymphoma is an infrequently encountered tumor of the spine that has a better prognosis than other primary spinal malignancies. The understanding of this entity and its differences from other secondary bone lymphomas have evolved over time. The thoracic spine is the commonly reported site of the lesions. However, it is seldom considered as a first diagnosis when the patient presents to the neurosurgeon. A case of this uncommon tumor in a 68-year-old woman at an extremely rare location-the lateral mass of C1-is used to illustrate the detailed evaluation, nuances in treatment, and outcomes of primary bone lymphomas.