## 4 Discussion
Additionally, the growing utilization of CT scans and MRI surveillance for spinal evaluation has led to an increase in the number of patients presenting both asymptomatic and symptomatic spinal metastases. The crucial focus now is on identifying patients with painful spinal metastases who would derive the greatest benefit from this essential therapeutic option [33]. In carefully selected cases, SBRT is an effective treatment to achieve adequate disease control, either as a single treatment or in combination with surgery. Thus, SBRT is currently the treatment of choice when local ablation of a metastatic lesion is indicated. Thus, there has been a paradigm shift in the treatment of patients with metastatic disease, which is even more evident in patients who are oligometastatic, i.e., those patients with fewer than 5 foci of metastases, where data suggest adequate disease control at 2-5 years in approximately 20% of patients when all foci have been eliminated [20]. Vertebral metastases require a multidisciplinary approach, involving radiation oncologists, spine surgeons, medical oncologists, and radiologists, for their evaluation and appropriate treatment. In the context of this treatment, decision making becomes intricate, involving multiple considerations. These include the following: (1) patient-dependentfactors (such as neurological function, pain presence and severity, age, comorbidities, functional status, estimated life expectancy, and patient preferences); (2) oncologic factors (such as tumor histology, molecular characteristics, tumor burden, and systemic treatment options), and (3) treatment-specific factors (such as location, spinal level, epidural disease presence and degree, radiographic appearance, previous surgical or radiotherapy treatment, and spinal instability). Before the advent of spinal SBRT and minimally invasive surgical techniques, the Tomita scoring system and the Tokuhashi scoring system were developed for the prognostic/pre-operative assessment of spinal metastases. More recently, the neurologic, oncologic, mechanical instability, and systemic disease (NOMS) framework and the spinal instability neoplastic score (SINS) have been developed [20]. In this regard, the SINS scoring system is a tool developed to assist the different medical specialties involved in the treatment of the spine to categorize and assess spinal instability, and to facilitate communication and referrals between medical specialists. In addition, SINS serves to identify and select patients who may benefit most from RT and may even be useful in predicting survival in patients with metastatic spinal disease [34]. Physicians face challenges in identifying patients with spinal metastatic disease who exhibit mechanical instability of the spine. For effective stabilization, it is crucial to involve a spine surgeon, as stereotactic body radiotherapy (SBRT) does not specifically target this issue. Recently, [PERSON] and colleagues introduced the SINS to evaluate the extent of spinal instability in these patients [20]. Over the recent 15 years, the multidisciplinary spine team at the Memorial Sloan Kettering Center has devised a framework called NOMS. This framework integrates four essential assessments for making decisions regarding metastatic spine tumors: neurological status, oncologic tumor behavior, mechanical stability, and systemic disease burden/medical co-morbidities. NOMS facilitates decision making and patient care by incorporating advances in interventional radiology, radiation therapy, systemic treatments, and surgical techniques to optimize outcomes and provides a common language to develop individualized treatment plans and encourage interstitial analysis of outcomes. Radiation therapy has become the treatment of choice to achieve a durable tumor outcome, and the goals of surgery have shifted from attempting to resect the maximum amount of tumor to attempting to separate the tumor from the spinal cord to optimize the radiation dose [35].