Background/Objectives: Malnutrition is common in patients with metastatic spine tumors (MSTs) and may adversely affect surgical outcomes. The Prognostic Nutritional Index (PNI) reflects both nutritional and immune status, but its role in palliative MST surgery is not well defined. The aim of this study was to investigate the association between preoperative the PNI and postoperative outcomes, including functional recovery and survival, in patients undergoing palliative surgery for MSTs. Methods: A brief description of the main methods or treatments applied. This can include any relevant preregistration or specimen information. Results: Patients with a higher PNI (≥42.8) demonstrated significantly better postoperative ambulation and longer overall survival compared to those with a lower PNI (<42.8). The higher PNI group showed earlier ambulation (p = 0.017) and longer median survival (30.7 vs. 7.0 months; p = 0.002). Multivariate analysis confirmed that a PNI ≥ 42.8 was an independent predictor of early ambulation (HR = 1.516; 95% CI: 1.010–2.277; p = 0.045) and prolonged survival (HR = 0.955; 95% CI: 0.927–0.985; p = 0.003). No significant association was found between the PNI and postoperative infections. Conclusions: The PNI is a simple and effective predictor of postoperative functional recovery and survival in patients undergoing palliative surgery for MSTs. Its routine preoperative assessment may help stratify surgical risk, guide nutritional interventions, and optimize clinical outcomes in this vulnerable population.

Background/Objectives: Surgery is generally recommended for higher Bilsky grade metastatic epidural spinal cord compression (MESCC); however, Bilsky grades 2–3 are often grouped together, leaving limited evidence for managing patients with Bilsky grade 3 MESCC who have not developed neurological deficits. This study aimed to evaluate whether, and when, surgery should be performed in Bilsky grade 3 MESCC. Methods: This retrospective cohort study included patients diagnosed with Bilsky grade 3 MESCC from January 2021 to January 2025. A total of 138 patients were assigned to a radiotherapy (RT) group (n = 54) or a surgery group (n = 65) based on initial treatment. Demographics, clinical data, treatment outcomes, and treatment modalities were analyzed. Logistic regression identified risk factors for local progression, motor recovery, and ambulatory outcomes. Results: Ninety-five patients (70.3%) initially presented with weakness. Among 30 patients diagnosed before neurological deficits, interval from diagnosis to onset was 17.2 ± 14 days. Local progression and survival rates did not significantly differ between the groups. Surgery was associated with a higher likelihood of motor recovery (odds ratio [OR] = 10.05, p < 0.001) and better ambulatory function (OR = 0.433, p = 0.003). Higher initial motor grade and lower Eastern Cooperative Oncology Group Performance Status scores were also linked to favorable ambulatory outcomes. Conclusions: In Bilsky grade 3 MESCC, the mean interval from diagnosis to weakness onset was 17.2 days. Local progression and survival did not differ between RT and surgery; however, surgery provided superior motor recovery and ambulatory outcomes. Early surgery may offer improved functional outcomes in Bilsky grade 3 MESCC.