Orthopaedic and spinal surgery can provide significant palliation to patients with symptoms arising for bony metastatic involvement in addition to patients that are at risk for skeletally related events (SREs). This chapter will review the role of surgery in the management of bone metastases and discuss factors that need to be considered prior to surgery. The treatment of pathologic fractures and the evaluation of pre-critical bony lesions will be presented. An overview of assessing the need for potential surgical intervention(s) by different criteria and reported scoring systems will be reviewed as well as a synopsis of the surgical treatment and management for appendicular, pelvic, and vertebral metastasis. Novel approaches to more accurately guide fracture risk prediction radiologically will be presented and the role of emergent surgery discussed.