Instability of the spine caused by neoplastic disease differs from instability after spine trauma. Progress is being made in understanding characteristics of these neoplasms and their role in causing spinal instability. This progress will help surgeons decide whether or not to offer a stabilization procedure, and if so, the extent of instrumentation required based on bone quality and the lytic or blastic characteristics of the underlying tumor pathology. Advancing tumor therapies are altering the course of these tumors, and patients are living longer. This may lead to more opportunities to intervene and treat complications from neoplastic spinal instability, either by relieving pain or preventing neurologic compromise. Discussions need to be had with the patient, the oncologist and the surgeon to best determine appropriate procedures based on quality of life and estimated life expectancy. Smaller procedures, such as percutaneous stabilization, could be offered to patients with shorter life expectancies if it could allow them to mobilize and improve quality of life, while a larger procedure, such as an en bloc resection with spinal reconstruction should be reserved for patients with a longer life expectancy as the post-operative recovery may lead to a period of worsened quality of life. The spinal instability neoplastic score (SINS) is being updated to reflect further understanding of the underlying characteristics of neoplastic spinal instability. Ultimately it can be modified into a decision making support tool that a surgeon could use to help guide treatment decisions in complex patients with neoplastic spinal disease.