Among patients with vertebral metastases, the identification of candidates for surgical stabilization has a limited basis in evidence. We retrospectively studied patterns of tumor spread (n = 756 vertebrae) and predictors of fracture and epidural impingement (n = 113 vertebrae) in infiltrated vertebrae with varying tumor histologies using sequential magnetic resonance images. Vertebral bodies were divided into 16 cells to map lesions. Fractured vertebrae were classified based on histology, level, fracture pattern, prefracture infiltration, and epidural impingement. Lesions were most often located within upper lumbar levels and the medial vertebral body. Fracture risk was greatest for upper lumbar (RR = 1.95; 95% CI: 1.12, 3.38) and undifferentiated tumors (RR = 7.36; 95% CI: 2.69, 20.12). A fourfold increase in fracture risk was noted in vertebrae with >80% body infiltration (HR = 4.5966; 95% CI: 1.66, 12.71). Symmetric fractures with fragments had the greatest risk of epidural impingement (p = 0.002). These findings have implications for management of patients with vertebral metastases.