Spinal metastasis is a common occurrence in patients with metastatic cancer, causing significant morbidity of pain and neurologic dysfunction as a result of compression of spinal cord, cauda equina, or nerve roots. Palliative radiotherapy for uncomplicated spinal metastasis and surgical decompression followed by postoperative radiotherapy for patients with spinal cord compression, have been the long-standing standard of care. However, the dose of radiation that can be delivered is limited by the spinal cord tolerance, especially in patients who had prior radiotherapy in the same region. Recent technologic advances are changing the standard paradigm by allowing for highly focused delivery of an ablative radiation dose to the spine (stereotactic body radiotherapy, SBRT) while sparing the spinal cord and cauda equina. Such approach is particularly invaluable in situations where re-irradiation is needed. This panel will discuss innovations in the therapy for spinal metastases and spinal cord compression. Recent data on spinal cord tolerance pertaining to spinal SBRT (Dr. Arjun Sahgal, IJROBP), the current randomized RTOG trial evaluating SBRT (Dr. Samuel Ryu), and emerging applications of SBRT for spinal cord compression, either as primary or postoperative treatment, will be reviewed. Innovative neurosurgical techniques including minimally invasive surgery, frequently combined with SBRT, and their integration with advanced radiation techniques will be presented . The physics and technical aspects of spinal SBRT will be covered. At the conclusion of this activity, the learner will be able to do the following: 1. Identify the different innovative approaches to the management of spinal metastasis. 2. Describe the proper patient selection for those innovative approaches in different settings. 3. Recognize the potential toxicities associated with the innovative approaches.