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OBJECTIVE To identify the rates, risks, and complications of red blood cell (RBC) transfusion in metastatic spinal tumor surgery (MSTS). METHODS The multicenter prospective American College of Surgeons National Quality Improvement Program database was queried for the years 2012 to 2016. Adult patients with disseminated cancer who underwent MSTS were identified. Transfusion was defined as having received at least one intraoperative/postoperative RBC transfusion within the first 72 hours of surgery start time. A stepwise multiple logistic regression model with backward elimination was used. RESULTS Out of 1,601 patients identified, 631 patients (38.9%) received a RBC transfusion. Independent predictors of RBC transfusion included higher ASA class (OR 1.54), preoperative anemia (OR 3.10), instrumentation (OR 1.63), and longer operative time (OR 1.52). The overall complication rate was significantly higher in transfused compared to nontransfused patients (22.3% vs. 15.0%, p<0.001). Sepsis (3.5% vs 1.9%, p=0.050), deep vein thrombosis (6.1% vs 3.3%, p=0.007), and prolonged ventilation (3.9% vs 1.3%, p=0.001) were individual complications that were more common in transfused patients. RBC transfusion (OR 1.65), hypoalbuminemia (OR 1.53), and anterior/anterolateral approaches for corpectomy (OR 2.11) were all independent risk factors for developing a postoperative complication. CONCLUSION RBC transfusion after MSTS may increase the risk of early postoperative complications. Future research into preoperative patient optimization and decreasing intraoperative blood loss is needed.