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Simple Summary: The study investigates the impact of preoperative anticoagulant and antiplatelet use on bleeding risks in patients undergoing surgery for spinal metastases, particularly focusing on the elderly population. Due to advancements in cancer treatments, more patients over 65 require such surgeries to address neurological deficits and spinal instability. Conducted retrospectively from 2010 to 2023, the study analyzed 290 patients' data, including demographics, neurological status, surgical details, anticoagulant use, and coagulation management. Among the patients, 24.1% were on anticoagulants or antiplatelets preoperatively, and the rebleeding rate within 30 days was 4.5%, which was not significantly related to anticoagulant use. A significant correlation was found between preoperative neurological deficits and rebleeding risk, and fewer surgical levels treated correlated with higher postoperative bleeding. The study concludes that surgery for spinal metastases is generally safe regardless of anticoagulation status, but it emphasizes the need for individualized preoperative planning and risk assessment to optimize patient outcomes. Introduction: The age of patients requiring surgery for spinal metastasis, primarily those over 65, has risen due to improved cancer treatments. Surgical intervention targets acute neurological deficits and instability. Anticoagulants are increasingly used, especially in the elderly, but pose challenges in managing bleeding complications. The study examines the correlation between preoperative anticoagulant/antiplatelet use and bleeding risks in spinal metastasis surgery, which is crucial for optimizing patient outcomes. Material and Methods: In a retrospective study at our department from 2010 to 2023, spinal tumor surgery patients were analyzed. Data included demographics, neurological status, surgical procedure, preoperative anticoagulant/antiplatelet use, intra-/postoperative coagulation management, and the incidence of rebleeding. Coagulation management involved blood loss assessment, coagulation factor administration, and fluid balance monitoring post-surgery. Lab parameters were documented at admission, preop, postop, and discharge. Results: A cohort of 290 patients underwent surgical treatment for spinal metastases, predominantly males (63.8%, n = 185) with a median age of 65 years. Preoperatively, 24.1% (n = 70) were on oral anticoagulants or antiplatelet therapy. Within 30 days, a rebleeding rate of 4.5% (n = 9) occurred, unrelated to preoperative anticoagulation status (p > 0.05). A correlation was found between preoperative neurologic deficits (p = 0.004) and rebleeding risk and the number of levels treated surgically, with fewer levels associated with a higher incidence of postoperative bleeding (p < 0.01). Conclusions: Surgical intervention for spinal metastatic cancer appears to be safe regardless of the patient's preoperative anticoagulation status. However, it remains imperative to customize preoperative planning and preparation for each patient, emphasizing meticulous risk–benefit analysis and optimizing perioperative care. [ABSTRACT FROM AUTHOR]