Purpose: We performed a retrospective analysis of all cases of lumbo-sacral or sacral metastases presenting with compression of the cauda equina who underwent urgent surgery at our institution. Our objective was to report our experience on the clinical presentation, management and finally the surgical outcome of this cohort of patients. Methods: We reviewed medical notes and images of all patients with compression of the cauda equina as a result of lumbo-sacral or sacral metastases during the study period (2004-2011). The collected clinical data consisted of time of onset of symptoms, neurology (Frankel grade), ambulatory status and continence. Operative data analysed were details of surgical procedure and complications. Postoperatively, we reviewed neurological outcome, ambulation, continence, destination of discharge and survival. Results: During the 8-year study period, 20 patients [11 males, 9 females; mean age 61.8 years (29-87)] had received urgent surgery for metastatic spinal cauda compression caused by lumbo-sacral or sacral metastases. The majority of patients presented with symptoms of pain and neurological deterioration (n = 14) with onset of pain considerably longer than neurology symptoms [197 days (3-1,825) vs. 46 days (1-540)]; all patients were Frankel C (n = 2, both non-ambulatory), D (n = 13) or E (n = 5) at presentation and three patients were incontinent of urine. Operative procedures performed were posterior decompression with (out) fusion (n = 12), posterior decompression with sacroplasty (n = 1), decompression with lumbo-pelvic stabilisation with (out) kyphoplasty/sacroplasty (n = 7) and posterior decompression/reconstruction with anterior corpectomy/ stabilisation (n = 2). Post-operatively, 5/20 (20 %) patients improved one Frankel grade, 1/20 (5 %) improved two grades, 13/20 (65 %) remained stable (8 D, 5 E) and 1/20 (5 %) deteriorated. All patients were ambulatory and 19/20 were continent on discharge. The mean length of stay was 7 days (4-22). There were 6/20 (30 %) complications: three major (PE, deep wound infection, implant failure) and three minor (superficial wound infection, incidental durotomy, chest infection). All patients returned back to their own home (n = 14/20, 70 %) or a nursing home (n = 6/20, 35 %). Thirteen patients are deceased (mean survival 367 days (120-603) and seven are still alive [mean survival 719 days (160-1,719)]. Conclusion: Surgical intervention for MSCC involving the lumbo-sacral junction or sacral spine has a high but acceptable complication rate (6/20, 30 %), and can be important in restoring/preserving neurological function, assisting with ambulatory function and allowing patients to return to their previous residence. © Springer-Verlag Berlin Heidelberg 2012.