Spinal metastasis may be the initial presentation in 10% of patients with systemic cancer. About 2% of symptomatic patients have no identifiable systemic disease. Approximately 90% of patients with spinal metastasis present with bone and/or back pain, followed by radicular pain. Bone pain at night in a patient with systemic cancer is always an ominous symptom. In fact, it is the most ominous symptom in patients with metastatic disease to the spine. Not all spinal metastasis result in neurological deficit, only 50% of these patients have sensory and motor dysfunction, and 50% have bowel and bladder dysfunction. A small group of (5–10%) of patients with cancer present with cord compression as their initial symptom. Among those who present with cord compression, 50% are nonambulatory at diagnosis, and 15% are paraplegic. Cord compression is commonly seen as a preterminal event in cancer patients.