An estimated 18,000 new cases of spinal metastases are diagnosed annually in North America. Spinal metastases signify an advanced stage of cancer and represent an exceptionally debilitating and life-altering event with high healthcare costs, stemming from the required treatments for the disease itself and to ensure a good quality of life for the affected patient. The present chapter provides a comprehensive review of the current knowledge in the field. The chapter aims to offer an up-to-date summary to guide clinicians and surgeons in optimal patient management. Numerous attempts were made to identify the most effective algorithm for managing patients with spinal metastasis. Although various scores exist to indicate prognosis, the need for surgical intervention, and the necessity of radio and chemotherapy, none represent a definitive system, all remaining subject to improvement. The chapter delves into the description of leading radiotherapeutic approaches, which have become fundamental, and in some cases exclusive, in managing patients with spinal metastasis. Surgical approaches are also detailed, each illustrated with a significant clinical case. Diagnostic and therapeutic algorithms, with the NOMS (neurologic, oncologic, mechanical stability, systemic disease) decision framework at the forefront, are critically examined. In conclusion, efficient management of spinal metastases demands a collaborative, multidisciplinary approach. The NOMS framework emerges as a structured platform seamlessly integrating medical innovations, streamlining decision-making processes, and enhancing overall patient care.