Outpatient clinics are often visited by family members of patients with metastatic spine cancer who often ask, “Should we have chemotherapy, radiation therapy, or surgery?” Overall, it is said that the treatment of tumor in any period should be comprehensive. When the tumor metastasizes to the spine, it means that the tumor has developed to an advanced stage, and it is very difficult to achieve the purpose of curing the tumor at this time. The treatment at this time is mainly aimed at improving the patient’s quality of life, avoiding fracture and paralysis of the spine, and prolonging the patient’s survival time to some extent. The principle of treatment is still comprehensive. Chemotherapy and the immunotherapy methods developed in recent years are systemic treatment options that can not only control the local tumor, but also reduce or control the occurrence and development of metastases, and sometimes even cure the tumor. However, when the tumor has spread to the spine and entered the advanced stage of the disease, most patients are in very poor physical condition, and high dose chemotherapy is already afraid to be difficult for the patient’s body to accept. Therefore, only palliative chemotherapy drugs or immunotherapy drugs can be used to prevent further spread of tumor cells. Radiotherapy is a kind of local treatment. With the development of radiotherapy technology in recent years, it has been able to locate the tumor cells more precisely, and increase the dose of radiotherapy to kill the tumor cells as much as possible while reducing the damage to the spinal cord and nerves. Therefore, it can achieve the purpose of controlling local tumor cell growth and reducing local pain, which is basically suitable for all patients with metastatic spinal cancer. However, in the following two cases, only radiotherapy is not enough and even risky. The first is when the spine has been or is about to be fractured. I often make the analogy of termites eating the column. Radiation therapy is like insecticide, which can kill the termites inside the pillar, but if the termites have hollowed out the pillar and the house is about to collapse, it is not enough just to kill the termites, but also to strengthen the pillar so that the whole house does not collapse. Therefore, when a fracture of the spinal column is about to occur or has already occurred, it should be combined with surgery to strengthen the “house” and then combined with “insecticide” (radiotherapy). The second is when the tumor has compressed the spinal cord causing neurological problems. I compare the modern radiotherapy technology to a missile, which can kill the enemy within a certain range and with accurate positioning. But on the battlefield when the enemy and our troops are in physical combat they are afraid to use missiles, right? Because even if it is precisely guided, it will burn all the stones at this time. When the tumor has already compressed the spinal cord and nerves, the relationship between the tumor and the spinal cord is just like the troops in a physical fight, so it is difficult to kill the tumor without injuring the spinal cord; if the dose is lowered to reduce the damage to the spinal cord, it will not be able to kill the tumor. In addition, at the early stage of radiotherapy to kill tumor, the tumor tissue will have edema reaction, which will aggravate the compression of spinal cord within a certain period of time. Therefore, at this time, it is necessary to combine with surgical treatment. From the above description, we can see the role and timing of surgery. First, when tumor destruction causes spinal fracture, surgery is needed to keep the spinal column from breaking and compressing the spinal cord. Surgery restores stability of the spine, relieves pain, and treats or prevents fractures through techniques such as internal fixation and bone cement. Second, surgery is considered when a tumor is compressing the spinal cord and nerves causing neurological impairment. Surgery can remove the tumor compressing the spinal cord to achieve immediate decompression, thus saving the nerve function in time. Since the metastasis in the spine may be only one part of the metastasis in the whole body, surgery at this time does not aim to completely remove the tumor, but to remove the tumor around the spinal cord so that the remaining tumor has a safe space with the spinal cord, and the remaining tumor is left to the postoperative radiotherapy to solve. This makes the surgery safe and effective, while minimizing the injury and risk of the surgery. Therefore, tumors, even at an advanced stage, can still be treated in a comprehensive way, allowing patients to live their last days in comfort and dignity. Let’s work together for this!