Spinal metastases are observed in 20–40% of cancer patients diagnosed annually in the United States, and its incidence is expected to increase, in part secondary to detection methods diagnosing cancer at earlier stages and improved therapeutic strategies. Metastatic lesions consist of cells capable of invading distant sites, either organs or bony structures. Spine involvement is frequent, with more affection for the thoracic, followed by the lumbar region. The last is unique due to its higher mechanical demands, which makes treatment more complex. Also, due to the diversity of cancer types that may affect the spine, such as prostate, lung, and breast cancers, and their different spreading patterns, including direct invasion of contiguous structures or hematogenous spread, the development of monitoring and treatment protocols is challenging. The diverse treatment modalities have developed the need for guidance tools to tailor treatment to each patient’s needs. The NOMS framework utilizes neurological, oncological, mechanical, and systemic disease factors to guide therapy. The SINS score defines mechanical instability as a loss of spinal integrity compromising the neural structures under physiologic loads. It considers clinical and anatomical parameters to guide the need for surgical stabilization. More recently, the New England Spinal Metastasis Score has been published, aiming to optimize treatment plans based on survival predictions and functionality assessments. This ongoing development of scoring systems reflects the need to improve the quality of life for patients. Current therapeutic approaches are primarily palliative and include conservative, radiotherapy, and surgical treatments. Surgical interventions, ranging from decompression, kyphoplasty/vertebroplasty, and “en bloc” spondylectomy, are usually demanding procedures with significant associated risks. Recent surgical advancements, including minimally invasive techniques and integrated radiation therapies, have presented promising avenues with the potential to enhance patient outcomes and reduce complications.