Maximal feasible resection versus hybrid therapy in spinal metastases: an updated narrative review

The neurologic, oncologic, mechanical and systemic (NOMS) decision framework provides a widely recognized decision-making strategy for spinal metastases. The combination of stereotactic body radiation therapy (SBRT) and separation surgery-referred to as hybrid therapy (HT)-has emerged as a prevailing paradigm. However, with the advent of targeted therapies and immunotherapies, advances in surgical technologies, and limited global accessibility to stereotactic radiosurgery, controversies have arisen regarding the optimal roles of maximal feasible resection (MFR) and HT. In light of these evolving dynamics, a critical reassessment of current treatment strategies is warranted. This narrative review provides a comprehensive overview of the developmental trajectories of MFR and HT, elucidating their respective advantages, current clinical evidence, ongoing debates, and practical challenges related to patient selection and therapeutic prioritization. Future research is anticipated to focus on three major areas: (1) conducting high-quality clinical trials within different therapeutic modalities; (2) developing therapeutic strategies that are compatible with both MFR and HT; and (3) further exploring novel technologies and their applications. These initiatives are expected to guide future research, optimize clinical decision-making and ultimately improve patient outcomes. Given the narrative nature of this review, systematic bias may exist despite comprehensive coverage of the available evidence.