The bony spine is one of the most frequent sites for metastatic disease. Significant advancements have been made in radiation therapy, including the development of focused modalities such as stereotactic body radiation therapy (SBRT), which can provide durable palliative therapy with fewer off-target toxicities than conventional external beam radiation therapy (EBRT). The higher doses delivered by SBRT, however, may be accompanied by an increased risk of vertebral column fractures (VCF). A subset of patients suffering from VCF is symptomatic and may experience associated functional decline. Studies have attempted to elucidate various risk factors for VCF with pre-existing VCF and lytic lesion quality being two commonly cited factors. Prevention may include anti-resorptive therapies such as bisphosphonates or denosumab. Treatment of symptomatic VCF can include vertebral augmentation, for which balloon kyphoplasty has shown superior palliation relative to vertebroplasty. The Spine Instability Neoplastic Score can aid with assessing spinal instability in the setting of a spinal tumor, and patients with a suspected unstable spine may benefit from surgical stabilization.