Vertebral compression fractures commonly occur as sequelae to osteoporosis, malignancy, infection, or trauma. Although all compression fractures have an underlying pathology, the term pathologic vertebral compression fracture (pVCF) is traditionally reserved for fractures that result from primary or metastatic spine tumors. Discriminating a pVCF from osteoporotic vertebral compression fractures is important because the subsequent diagnostic workup and therapeutic plan differ substantially between the two etiologies. A carefully obtained history inquiring about high-risk symptomatology and a thorough review of the radiographic data are the cornerstone of making the correct diagnosis. If history and imaging increase the suspicion for pVCF, the subsequent workup is dependent on whether the pathologic spine fracture represents a newly discovered malignancy with spinal metastasis, known malignancy without previous metastasis, or progression of known metastatic disease. Management strategies for pVCF hinge on the neurologic and biomechanical stability of the patient along with the patient's pain and functional mobility. Surgeons should be familiar with the diagnosis and treatment of pathologic vertebral compression fractures caused by metastatic disease.