The incidence of metastatic spinal disease is increasing as systemic treatment options are improving and concurrently increasing the life expectancy of patients, and the interventions are becoming increasingly complex. Treatment decisions are also complicated by the increasing armamentarium of surgical treatment options. Decision-making frameworks such as NOMS (neurologic, oncologic, mechanical, and systemic) help guide practitioners in their decision making and provide a structure that would be readily adaptable to the evolving landscape of systemic, surgical, and radiation treatments. This article describes these decision-making frameworks, discusses their relative benefits and shortcomings, and details our approach to treating these complex patients.