Abstract: Sinopodophyllum hexandrum is a rare and endangered Tibetan medicinal plant of the Qinghai–Tibet Plateau and the Himalayas. Its roots and rhizomes are rich in lignans, particularly podophyllotoxin, whereas destructive harvesting, slow population recruitment, and an insufficient supply of cultivated seedlings constrain sustainable utilization. This review integrates evidence along four linked themes: germplasm conservation, artificial propagation, cultivation regulation, and quality formation. Current studies indicate that population decline results from the combined effects of habitat change, harvesting pressure, and complex seed dormancy. Cold stratification, embryo culture, and tissue culture can improve propagation efficiency, but acclimatization and stable field establishment remain bottlenecks. Reported parameters, including a sowing depth of 3-4 cm and 30%-50% shading, are useful regional references rather than universal standards. Quality is jointly shaped by germplasm, environment, management, organ, and harvest time; therefore, evaluation should move from a single podophyllotoxin index toward multi-component and yield–quality–ecological assessments. Future work should establish core germplasm collections and multi-site trials, resolve germplasm × environment × management interactions, optimize understory cultivation, develop non-destructive utilization pathways, and functionally validate endophytic microorganisms.