The standard treatment of metastatic epidural spinal cord compression (MESCC) in a symptomatic patient with good performance status, histology that is not exquisitely radiosensitive (lymphoma, small cell, myeloma and germinoma), and a single level of compression, is surgical decompression followed by external beam radiotherapy (EBRT). This treatment approach is supported over EBRT alone in these well-selected patients by level I evidence . The landmark Patchell study showed that the addition of surgery improved the likelihood of patients being able to walk, and was associated with a survival benefit (although this study was not powered for survival). Unfortunately, some patients are unable to undergo decompressive surgery and, as a result, EBRT alone is the treatment of choice despite inferior functional outcomes . In patients who have been exposed to prior EBRT to the same spinal segments with MESCC, and who are not surgical candidates, repeat EBRT is feasible, but the radiation dose that can be delivered is limited. Ultimately, to respect spinal cord tolerance, we have to under-dose the tumor and, therefore, the expectation is short-term gains and not necessarily long-term tumor control.