The Noms framework for decision making in metastatic cervical spine tumors

Purpose of review The question of whether to irradiate or operate may have significant consequences for successful palliation in terms of pain relief, neurologic function, and quality of life. This article reviews the relevant issues of decision making using a framework, NOMS, applied to the cervical spine. Recent findings At Memorial Sloan-Kettering Cancer Center, a decision framework is used to assess four fundamental considerations in decision making, NOMS: neurologic (N), oncologic (O), mechanical instability (M) and systemic disease and medical comorbidities (S). This framework provides a method to dissect complicated tumor issues into simple components and allows for the integration of new technologies. Currently, patients who have high-grade spinal cord compression (N) from radioresistant tumors (O) or demonstrate mechanical instability (M) are offered surgery followed by radiation. Patients with minimal or no spinal cord compression (N) and who are stable (M) are treated with radiation therapy. The evolution of surgical techniques has made decompression and instrumentation safer and more reliable. Summary The decision framework NOMS can be applied to issues relevant to decision making for the atlanto-axial and subaxial cervical spine in which they are distinct in terms of definitions of instability and indications for operation or radiation.