There is an emerging consensus that spatial thinking plays a fundamental role in how people conceive, express, and perform mathematics. However, the underlying nature of this relationship remains elusive. Questions remain as to how, why, and under what conditions spatial skills and mathematics are linked. This review paper addresses this gap. Through a review and synthesis of research in psychology, neuroscience, and education, we examine plausible mechanistic accounts for the oft-reported close, and potentially causal, relations between spatial and mathematical thought. More specifically, this review targets candidate mechanisms that link spatial visualization skills and basic numerical competencies. The four explanatory accounts we describe and critique include the: (1) Spatial representation of numbers account, (2) shared neural processing account, (3) spatial modelling account, and (4) working memory account. We propose that these mechanisms do not operate in isolation from one another, but in concert with one another to give rise to spatial-numerical associations. Moving from the theoretical to the practical, we end our review by considering the extent to which spatial visualization abilities are malleable and transferrable to numerical reasoning. Ultimately, this paper aims to provide a more coherent and mechanistic account of spatial-numerical relations in the hope that this information may (1) afford new insights into the uniquely human ability to learn, perform, and invent abstract mathematics, and (2) on a more practical level, prove useful in the assessment and design of effective mathematics curricula and intervention moving forward.