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Approximately 70% of cancer patients have metastatic disease at death. The spine is involved in up to 40% of those patients. Spinal cord compression may develop in 5% to 10% of cancer patients and up to 40% of patients with preexisting nonspinal bone metastasis (>25,000 cases/y). Given the increasing survival times of patients with cancer, greater numbers of patients are likely to develop this complication. The role of surgery in the management of metastatic spinal cord compression is expanding. The management of metastatic spine disease can consist of a combination of surgery, radiation treatment, and chemotherapy. Treatment modalities are not mutually exclusive and must be individualized for patients evaluated in a multidisciplinary setting.

Cancer-related fractures of the spine are different from osteoporotic ones, not only in pathogenesis but also in natural history and treatment. Higher class evidence now supports offering balloon kyphoplasty to a patient with cancer, provided that the pain is significant in intensity, has a positional character, and correlates to the area of the fractured vertebrae. Absence of clinical spinal cord compression and overt instability are paramount. Because of the frequent disruption of the posterior vertebral body cortex in these patients, the procedure should be performed by experienced operators who could also quickly perform an open decompression if cement extravasation occurs. Patients will benefit from vertebral augmentation, even in chronic malignant fractures. A biopsy should be routinely performed and a combination with radiation treatment would be beneficial in most cases.