Background Palliative antalgic treatments represent an issue for clinical management and a challenge for scientific research. Radiotherapy (RT) plays a central role. Techniques such as stereotactic body radiotherapy (SBRT) were largely investigated in several phase 2 studies with good symptom response, becoming widely adopted. Still is lacking evidence from randomized, direct comparison of RT and SBRT. Methods/Design The PREST trial was designed as an interventional study without medicinal, randomized 1:1, open-label, multicentric, phase 3. Inclusion criteria: painful spinal bone metastases presenting pain level >4 (or >1 if assuming analgesic) at numeric rating scale (NRS); expected intermediate/high prognosis (superior to 6 months) according to the Mizumoto prognostic score; low spine instability neoplastic score (SINS) sores (