Vertebral pathological fracture and metastatic epidural spinal cord compression (MESCC) due to metastatic cancer inevitably cause pain, neurological deficit, impaired function, and decreased quality of life and are indications for surgery. In such cases, earlier surgical intervention has the potential to prevent permanent neurological deficit and disability and to maintain function and quality of life. Therefore, the aim of this study was to identify and evaluate risk factors for pathological fracture and MESCC in patients with spinal metastases. Retrospective assessment of clinical and radiological parameters was undertaken in patients with spinal metastases. Seventy-two patients with spinal metastases underwent decompressive and/or stabilization surgery for pathological fracture and/or MESCC or nerve root compression. The following items were assessed for association with pathological fracture or MESCC: tumor size, location, type, and morphology; disease burden; pain; and function. Pain, tumor size within the vertebral body, vertebral endplate and 3-column involvement, primary tumor growth rate, and multiple vertebral metastases were associated with increased risk for pathological fracture. Vertebral posterior element and costovertebral joint involvement by tumor, primary tumor growth rate, and the presence of visceral metastases were associated with MESCC or nerve root compression. These factors should be considered in the decision-making process for surgery for spinal metastases. Patients with osteolytic spinal metastatic lesions causing pain, greater than 25% occupancy of the vertebral body, and involvement of the vertebral endplate or all 3 columns should be considered for prophylactic or therapeutic decompressive and stabilization surgery. [Orthopedics. 2018; 41(1):e38-e45.].
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