Impending fractures and spinal cord compression are frequent complications of bone metastasis with debilitating consequences. The issue of impending fracture of the femurs and risk of spinal cord compression was raised in an 83-year-old woman with multiple myeloma. Some type of prophylactic treatment would appear suitable, usually surgical, for this condition. While criteria for prophylactic treatment exist in the orthopedic literature, most patients present to rheumatologists, oncologists, or internists. This article reviews the various scoring systems available to evaluate the risk of these very serious complications. We also discuss the current limitations of such tools and the need for a research agenda to address this common problem.