Study Design: Retrospective study. Objective: To evaluate the clinical outcome of palliative surgery using posterior decompression and fixation combined with intraoperative vertebroplasty (PDFIV) for the treatment of spinal metastases, and analyze the indications for PDFIV using a neurological, oncologic, mechanical, and systemic framework. Summary of Background Data: Palliative surgery is widely used to spinal metastatic patients with poor condition for enough postoperative recovery. PDFIV which is a new palliative surgery is rarely reported its efficacies and indications. Methods: A retrospective analysis of 26 consecutive patients with spinal metastases treated by PDFIV was performed. The group includes 18 men and 8 women with an average age of 55.7 years (range, 47-79 y). All patients presented with local pain, 18 patients had compressive myelopathy, and 9 had radiculopathy. The total segments involved were 32. Postoperative imaging was used to evaluate cement leakage, the status of fixation, and recurrence. The visual analogue score and Frankel grade were used to identify neurological function. Results: There were no intraoperative neurological or vascular injuries. The mean operative time was 173 minutes (range, 125-245min), the mean blood loss was 659mL (range, 350-2500mL), and the average amount of cement used in the vertebrae was 4.1mL (range, 2.0-5.5mL). All patients were followed for an average of 25 months (range, 6-56mo). The visual analogue score decreased from 8.1 preoperatively to 2.1 postoperatively. Fifteen of 18 patients with compressive myelopathies had improved Frankel grades. Postoperative computed tomography scans showed cement leakage in 3 patients (11.5%); however, all of the leakages were clinically asymptomatic. There were local tumor recurrences requiring reoperation in 2 patients. Conclusions: Palliative surgery using PDFIV can improve neurological function and alleviate pain effectively, and allow low cement leakage and timely disposal of leakage combined with intraoperative visual vertebroplasty.