The skeleton is a frequent site of metastatic spread, leading to skeletal-related events (SREs) such as pathological fractures, spinal cord compression, and refractory pain that profoundly impact patient survival and quality of life. Traditionally managed by a triad of radiotherapy, surgery, and systemic treatments, the landscape of bone metastasis care has undergone a major paradigm shift. Interventional radiology (IR) has emerged as the “fourth pillar” of oncology, evolving from a palliative last-resort tool into a proactive specialty integrated into precision medicine and multidisciplinary decision-making. Through high-resolution image guidance, IR provides critical diagnostic tissue sampling for molecular profiling, immediate mechanical reinforcement via hybrid stabilization — combining percutaneous osteosynthesis and cementoplasty — and local tumor control through thermal ablation and cryoablation. Beyond its mechanical and local effects, an emerging body of research highlights the immunomodulatory potential of cryoablation and thermablation technics. IR-induced tumor necrosis may act as a potent “in situ” vaccine, releasing tumor-associated antigens and damage-associated molecular patterns that could trigger a systemic abscopal effect, especially when synergistic with immune checkpoint inhibitors. This review details the state-of-the-art IR techniques, from devascularization via embolization to advanced cryoablation, emphasizing their strategic integration into modern care pathways. It highlights the transition from simple symptom management to aggressive, curative-intent strategies in the era of personalized oncology, where IR serves as a bridge between conservative medical therapy and invasive surgical intervention.