BACKGROUND CONTEXT Pedicle screw fixation can be a major challenge in patients with spinal metastases. The osteopenic nature of the vertebrae along with factors like previous radiation, immunosuppression, and marrow replacement by cancer affect the bone quality for fixation. Complications related to cement augmentation are known. We share our initial experience with the fenestrated screws. PURPOSE To demonstrate the efficacy and safety of this new screw technology in challenged fixation environements, specifically vertebral column metastases. STUDY DESIGN/SETTING Retropsective analysis from a prospective spine oncology database at a major cancer center. PATIENT SAMPLE We identified 38 consecutive patients who underwent posterior thoracic, lumbar, or sacral decompression and stabilization for pathologic fracture or cord compression (T1-sacrum) related to metastatic cancer over a 1 year period. OUTCOME MEASURES Preoperative SINS (spine instability neoplastic score), ASIA grade, cancer histology, radiation history, ECOG, and patient demographics were recorded and analyzed in a multivariable regression analysis. Postoperative CT was performed in all cases. CT was reviewed and cement extravasation was recorded at each level of pedicle screw placement in (1) the epidural space, (2) neural foramen, (3) paravertebral space, (4) lung, and (5) nearby vasculature including the segmental vessels and aorta. Complications and instrumentation or implant failure were recorded. Patient reported outcomes measures were recorded prospectively including EQ-5D, PROMIS-pain, PROMIS-disability, PROMIS-depression, Spine Oncology Study Group Questionnaire. METHODS IRB approval was obtained and a retrospective analysis was performed on a prospective spine oncology outcomes database. Fenestrated screws became available at our institution in November 2016. We identified 38 consecutive patients who underwent posterior thoracic, lumbar, or sacral decompression and stabilization for pathologic fracture or cord compression (T1-sacrum). In each case, postoperative CT imaging was performed within 24 hours of surgery. The investigators independently reviewed the studies evaluating for the extent of cement fill and extravasation. Chart review was performed for analysis of implant or construct failure and complications. RESULTS Thirty eight patients were identified and a total of 292 fenestrated screws were placed with an mean 7.21 screws implanted percase. The most common construct was two levels above and two levels below the site of worst vertebral fracture or cord compression. Cement extravasated into the (1) epidural space at six levels (2.97%), (2) neural foramen at three levels (1.49%), (3) paravertebral space at 37 levels (18.3%), (4) lung – 0, (5) nearby vasculature at 15 levels (7.42%). There was no cement spread to the aorta or vena cava. No patients developed a symptomatic radiculopathy from foraminal extent. No patient required reexploration, cement removal, or hardware revision. Follow-up ranged from 1 month to 15 months with no significant change invertebral body height at the instrumented levels by CT and x-ray. CONCLUSIONS Fenestrated screws with cement provide a safe and effective method for stabilization in the cancer patient.