In case of risk of fracture, or in case of spinal cord compression, patients enrolled in group II of Tokuhashi (intermediate survival) decompression and/or stabilization could be a good solution.

In 2012, Crnalic et al. [13] identified a new specific score for patient with cord compression from prostate cancer; the items include hormone status of prostate cancer, Karnofsky performance status, evidence of visceral metastasis, and preoperative serum prostate-specific antigen (PSA). They identified three specific prognostic groups corresponding to different score:

Patients with a score higher than 2 are more suitable to undergo surgery in case of spinal cord compression.

Stabilization alone is rare, considering the high frequency of osteoblastic lesions; nevertheless it can be fundamental in case of spinal cord compression; indeed, the following decompression can cause an iatrogenic instability.

Decompression can be performed both from anterior and posterior approach basing on the metastasis-specific localization, the spine level, and the surgeon expertise. In the thoracic spine, decompression should be performed from an anterior approach because the presence of the spinal cord could make difficult and effective decompression from a midline posterior access; nevertheless, cutting roots could be useful to have access to the vertebral body from behind.

At lumbar levels the presence of cauda equina allows an easier access to the anterior metastatic bodies.

Posterior stabilization is the most commune; it is performed by posterior midline incision or also by minimally invasive approach consisting in little incisions corresponding to the pedicles necessary for the screw insertion through the pedicle [14].

Several instrumentations are commercially available, but nowadays carbon fiber-reinforced rods should be preferred [15]. Indeed, they should allow a more effective adjuvant radiotherapy because it is characterized by a lower level of artifacts.

The artifacts at CT scan blind some areas in the surrounding tissue, introducing diffraction and refraction phenomena, so the actual dose administered to the tissues becomes unpredictable.

Anterior stabilization can be done with a body cage alone or with anterior plating and screws; also in those cases, carbon fiber cages should be preferred [16, 17].

Cement plasty (Kyphoplasty, vertebroplasty, vesselplasty): these techniques are very commune in osteoporotic fractures; nevertheless they can have indication also in metastatic lesion.

In case of metastatic spinal fracture, they can be able to stabilize it in a minimally invasive way, even if attention has to be paid for possible posterior cement or tumor migration.

Indeed, spine metastasis from prostate cancer difficultly causes body fracture, but they can cause important not responsive pain that can be effectively treated with these techniques [18, 19].

The procedure can be performed by monoportal or biportal transpedicular approach basing on the specific necessity of stabilization; the integrity of the posterior body wall is essential for safety performing the procedure (Fig. 13.2).

Proximal femur is the most commune site of metastasis, after the spine [20].

Even if the treatment of these lesions should not modify directly the survival from a biological/oncological point of view, the patient constricted to bed because of risk of fracture is exposed to complications that could interfere with medical therapies decreasing survival [21, 22].

Otherwise survival estimation is important as in the other sites for the best therapeutic strategy, but in case of metastases located in the limbs and moreover in the proximal femur, an important problem is to value the fracture risk [23].

Several systems are available, but the most used is the Mirel’s classification [24]; it identifies four items: location of the metastasis, its nature and radiographic appearance, its size related to the diameter of the entire segment, and the presence of pain.

Each item is scaled from 1 to 3.

When the total score is 7 or less, observation and radiation therapy is advisable; when it is 9 or more, prophylactic fixation is suggested; if the score is 8, the indication is uncertain, and it should be valued basing on clinical conditions as well.

The metastasis of prostate cancer is usually osteoblastic so surgical indication is usually less frequent than metastases from other primitive tumors.