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Surgical decision-making for metastatic spinal tumors (MST) must extend beyond survival scoring to incorporate functional status, tumor biology, and spinal instability.

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A structured risk-stratification framework integrating SINS, Karnofsky Performance Status, and tumor histology is needed to guide patient selection for aggressive resection.

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The indications for en bloc resection versus hybrid therapy (separation surgery + sSRS) require clearer delineation, particularly in the era of modern immunotherapy and targeted agents.

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Standardized preoperative embolization protocols are critical given that technique-dependent variability directly impacts intraoperative blood loss and patient safety.

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Centralization of complex oncologic spine surgery to high-volume centers and prospective registries with standardized outcomes reporting are essential to advance the evidence base.