Pathological fractures occur in 0.5–1% of all patients with solid tumors and 10% of patients with spinal metastases. Burst fractures—failure of the anterior and middle columns—can lead to de novo deformity, which in the case of coronally asymmetric collapse can lead to de novo scoliosis. Burst fractures are most common in the thoracic and thoracolumbar spine and the focality, severity, and location of the burst fracture likely contribute to the severity of the associated deformity. Nonoperative treatment may be reasonable for patients too frail for surgery or who are minimally symptomatic, but in those with debilitating symptoms and reasonable prognoses, surgical intervention is merited. In this chapter, we discuss the management of de novo scoliosis following pathologic burst fracture, focusing on pathogenesis, preoperative evaluation, and instrumentation techniques.