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Patrick W. Hitchon, Vijay K. Goel, Thomas N. Rogge, James C. Torner, Andrew P. Dooris, John S. Drake, S. J. Yang and Koji Totoribe

Object. The goal of this study was to evaluate the comparative efficacy of three commonly used anterior thoracolumbar implants: the anterior thoracolumbar locking plate (ATLP), the smooth-rod Kaneda (SRK), and the Z-plate.

Methods. In vitro testing was performed using the T9—L3 segments of human cadaver spines. An L-1 corpectomy was performed, and stabilization was achieved using one of three anterior devices: the ATLP in nine spines, the SRK in 10, and the Z-plate in 10. Specimens were load tested with 1.5-, 3-, 4.5-, and 6-Nm in flexion and extension, right and left lateral bending, and right and left axial rotation. Angular motion was monitored using two video cameras that tracked light-emitting diodes attached to the vertebral bodies. Testing was performed in the intact state in spines stabilized with one of the three aforementioned devices after the devices had been fatigued to 5000 cycles at ± 3 Nm and after bilateral facetectomy.

There was no difference in the stability of the intact spines with use of the three devices. There were no differences between the SRK- and Z-plate—instrumented spines in any state. In extension testing, the mean angular rotation (± standard deviation) of spines instrumented with the SRK (4.7 ± 3.2°) and Z-plate devices (3.3 ± 2.3°) was more rigid than that observed in the ATLP-stabilized spines (9 ± 4.8°). In flexion testing after induction of fatigue, however, only the SRK (4.2 ± 3.2°) was stiffer than the ATLP (8.9 ± 4.9°). Also, in extension postfatigue, only the SRK (2.4 ± 3.4°) provided more rigid fixation than the ATLP (6.4 ± 2.9°). All three devices were equally unstable after bilateral facetectomy. The SRK and Z-plate anterior thoracolumbar implants were both more rigid than the ATLP, and of the former two the SRK was stiffer.

Conclusions. The authors' results suggest that in cases in which profile and ease of application are not of paramount importance, the SRK has an advantage over the other two tested implants in achieving rigid fixation immediately postoperatively.

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Amol J. Ghia, Eric L. Chang, Andrew J. Bishop, Hubert Y. Pan, Nicholas S. Boehling, Behrang Amini, Pamela K. Allen, Jing Li, Laurence D. Rhines, Nizar M. Tannir, Claudio E. Tatsui, Paul D. Brown and James N. Yang

OBJECTIVE

The objective of this study was to compare fractionation schemes and outcomes of patients with renal cell carcinoma (RCC) treated in institutional prospective spinal stereotactic radiosurgery (SSRS) trials who did not previously undergo radiation treatment at the site of the SSRS.

METHODS

Patients enrolled in 2 separate institutional prospective protocols and treated with SSRS between 2002 and 2011 were included. A secondary analysis was performed on patients with previously nonirradiated RCC spinal metastases treated with either single-fraction (SF) or multifraction (MF) SSRS.

RESULTS

SSRS was performed in 47 spinal sites on 43 patients. The median age of the patients was 62 years (range 38–75 years). The most common histological subtype was clear cell (n = 30). Fifteen sites underwent surgery prior to the SSRS, with laminectomy the most common procedure performed (n = 10). All SF SSRS was delivered to a dose of 24 Gy (n = 21) while MF regiments were either 27 Gy in 3 fractions (n = 20) or 30 Gy in 5 fractions (n = 6). The median overall survival duration for the entire cohort was 22.8 months. The median local control (LC) for the entire cohort was 80.6 months with 1-year and 2-year actuarial LC rates of 82% and 68%, respectively. Single-fraction SSRS correlated with improved 1- and 2-year actuarial LC relative to MF SSRS (95% vs 71% and 86% vs 55%, respectively; p = 0.009). On competing risk analysis, SF SSRS showed superior LC to MF SSRS (subhazard ratio [SHR] 6.57, p = 0.014). On multivariate analysis for LC with tumor volume (p = 0.272), number of treated levels (p = 0.819), gross tumor volume (GTV) coverage (p = 0.225), and GTV minimum point dose (p = 0.97) as covariates, MF SSRS remained inferior to SF SSRS (SHR 5.26, p = 0.033)

CONCLUSIONS

SSRS offers durable LC for spinal metastases from RCC. Single-fraction SSRS is associated with improved LC over MF SSRS for previously nonirradiated RCC spinal metastases.

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Jack Phan, Courtney Pollard III, Paul D. Brown, Nandita Guha-Thakurta, Adam S. Garden, David I. Rosenthal, Clifton D. Fuller, Steven J. Frank, G. Brandon Gunn, William H. Morrison, Jennifer C. Ho, Jing Li, Amol J. Ghia, James N. Yang, Dershan Luo, He C. Wang, Shirley Y. Su, Shaan M. Raza, Paul W. Gidley, Ehab Y. Hanna and Franco DeMonte

OBJECTIVE

The objective of this study was to assess outcomes after Gamma Knife radiosurgery (GKRS) re-irradiation for palliation of patients with trigeminal pain secondary to recurrent malignant skull base tumors.

METHODS

From 2009 to 2016, 26 patients who had previously undergone radiation treatment to the head and neck received GKRS for palliation of trigeminal neuropathic pain secondary to recurrence of malignant skull base tumors. Twenty-two patients received single-fraction GKRS to a median dose of 17 Gy (range 15–20 Gy) prescribed to the 50% isodose line (range 43%–55%). Four patients received fractionated Gamma Knife Extend therapy to a median dose of 24 Gy in 3 fractions (range 21–27 Gy) prescribed to the 50% isodose line (range 45%–50%). Those with at least a 3-month follow-up were assessed for symptom palliation. Self-reported pain was evaluated by the numeric rating scale (NRS) and MD Anderson Symptom Inventory–Head and Neck (MDASI-HN) pain score. Frequency of as-needed (PRN) analgesic use and opioid requirement were also assessed. Baseline opioid dose was reported as a fentanyl-equivalent dose (FED) and PRN for breakthrough pain use as oral morphine-equivalent dose (OMED). The chi-square and Student t-tests were used to determine differences before and after GKRS.

RESULTS

Seven patients (29%) were excluded due to local disease progression. Two experienced progression at the first follow-up, and 5 had local recurrence from disease outside the GKRS volume. Nineteen patients were assessed for symptom palliation with a median follow-up duration of 10.4 months (range 3.0–34.4 months). At 3 months after GKRS, the NRS scores (n = 19) decreased from 4.65 ± 3.45 to 1.47 ± 2.11 (p < 0.001); MDASI-HN pain scores (n = 13) decreased from 5.02 ± 1.68 to 2.02 ± 1.54 (p < 0.01); scheduled FED (n = 19) decreased from 62.4 ± 102.1 to 27.9 ± 45.5 mcg/hr (p < 0.01); PRN OMED (n = 19) decreased from 43.9 ± 77.5 to 10.9 ± 20.8 mg/day (p = 0.02); and frequency of any PRN analgesic use (n = 19) decreased from 0.49 ± 0.55 to 1.33 ± 0.90 per day (p = 0.08). At 6 months after GKRS, 9 (56%) of 16 patients reported being pain free (NRS score 0), with 6 (67%) of the 9 being both pain free and not requiring analgesic medications. One patient treated early in our experience developed a temporary increase in trigeminal pain 3–4 days after GKRS requiring hospitalization. All subsequently treated patients were given a single dose of intravenous steroids immediately after GKRS followed by a 2–3-week oral steroid taper. No further cases of increased or new pain after treatment were observed after this intervention.

CONCLUSIONS

GKRS for palliation of trigeminal pain secondary to recurrent malignant skull base tumors demonstrated a significant decrease in patient-reported pain and opioid requirement. Additional patients and a longer follow-up duration are needed to assess durability of symptom relief and local control.

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Oral Presentations

2010 AANS Annual Meeting Philadelphia, Pennsylvania May 1–5, 2010