The objectives of this study were to define clinical problems and treatment strategies in vertebral metastases of prostate cancer. The clinical files of 634 patients with prostate cancer seen in a comprehensive cancer center during a 4-year period were retrospectively reviewed. One hundred nineteen patients (18.8%) had 212 significant episodes of osseous spinal metastases. Pain was nearly universal (93%), and motor and bladder impairment occurred in 25% and 3.1% of patients, respectively. Bone scan and magnetic resonance imaging (MRI) were performed in 197 and 64 episodes, respectively. Fifteen episodes of spinal cord compression were treated surgically. Other treatments included hormonal therapy (163 episodes), chemotherapy (70 episodes), and radiation therapy (103 episodes). Osteolytic lesions were observed alone and in combination with osteoblastic pattern in 18% and 26% of episodes, respectively. Bone scan was the most effective screening procedure of vertebral involvement, and MRI effectively showed epidural involvement. Overall treatment led to improvements in pain and motor impairment in 77% and 50% of patients, respectively. However, clinical episodes were recurrent (1.78 episodes per patient; range, 1-8). Median survival after vertebral metastasis episode was 14 months compared with only 4 months after surgery for spinal cord compression. Vertebral metastases strongly alter quality of life in patients with prostate cancer. Pain and neurologic complications are the major problems. Careful early screening with bone scan and MRI may help to define better treatment strategy. However, further prospective studies of clinical management are needed to determine the optimal timing of radiation therapy, medical treatments, and surgery.