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Peter D. Angevine, Christopher Kellner, Raqeeb M. Haque, and Paul C. McCormick

optimally achieved via a minimally invasive retropleural exposure using a tubular retraction system. Conclusions With few exceptions, intradural spinal lesions represent benign pathology for which contemporary microneurosurgical techniques can achieve long-term control or cure with preservation of neurological function. Standard posterior approaches through bilateral or unilateral laminectomy provide adequate exposure to safely remove the vast majority of these lesions, without the need for potentially destabilizing facet or pedicle resection. Most ventral

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Jack M. Fletcher, Kim Copeland, Jon A. Frederick, Susan E. Blaser, Larry A. Kramer, Hope Northrup, H. Julia Hannay, Michael E. Brandt, David J. Francis, Grace Villarreal, James M. Drake, John P. Laurent, Irene Townsend, Susan Inwood, Amy Boudousquie, and Maureen Dennis

T he purpose of this study was to evaluate the relationship of the level of a spinal lesion to the severity of anomalous brain development and neurobehavioral outcomes in children with SBM-H. Although poorer medical and cognitive outcomes have been reported in children with upper-level spinal lesions compared with the outcomes for children with lower-level spinal lesions, 1, 5, 13, 14 explanations for this observation have been limited and controversial. The level of spinal defect clearly explains variability in orthopedic and urological outcomes in SBM

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Pawel P. Jankowski, Lissa C. Baird, Sassan Keshavarzi, Mary E. Goolsby, William R. Taylor, and Andrew D. Nguyen

received whole-brain radiation. A follow-up spine MRI survey showed no recurrence or any additional spinal lesions. After 4 months of adjuvant therapy the patient elected to enter hospice care instead of continuing her chemotherapy. At that time her neurological examination remained stable; she was ambulatory and required minimal assistance. Discussion Lymphoma occurring in adults in conjunction with other tumors is rare. Eight cases have been reported in the literature, 5 of which were associated with meningiomas. 1 , 3 , 6 , 7 , 10 Of the 5 meningioma

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Ahmed Meleis, M. Benjamin Larkin, Dhiego Chaves de Almeida Bastos, Matthew T. Muir, Ganesh Rao, Laurence D. Rhines, Charles E. Cowles, and Claudio E. Tatsui

the pedicle screw construct further immobilizes the joints accelerating the absorption of cartilage and fusion of the facet surfaces. A significant improvement in the preoperative VAS score was observed regardless of the development of facet fusion ( Fig. 4 ). The pain improvement was reported within the 1-month follow-up and remained lower than baseline during the entire follow-up period. FIG. 4. Bar graph showing an improvement in the mean VAS pain score following cement-augmented percutaneous pedicle screw fixation for metastatic spinal lesions. Error

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Peter C. Gerszten, Cihat Ozhasoglu, Steven A. Burton, Shalom Kalnicki, and William C. Welch

Object

The role of stereotactic radiosurgery for the treatment of intracranial lesions is well established. Its use for the treatment of spinal lesions has been limited by the availability of effective target-immobilizing devices. In this study the authors evaluated the CyberKnife Real-Time Image-Guided Radiosurgery System for spinal lesion treatment involving a single-fraction radiosurgical technique.

Methods

This frameless image-guided radiosurgery system uses the coupling of an orthogonal pair of x-ray cameras to a dynamically manipulated robot-mounted linear accelerator possessing six degrees of freedom, which guides the therapy beam to the target without the use of frame-based fixation. Cervical lesions were located and tracked relative to osseous skull landmarks; lower spinal lesions were tracked relative to percutaneously placed gold fiducial bone markers. Fifty-six spinal lesions in 46 consecutive patients were treated using single-fraction radiosurgery (26 cervical, 15 thoracic, and 11 lumbar, and four sacral). There were 11 benign and 45 metastatic lesions.

Tumor volume ranged from 0.3 to 168 ml (mean 26.7 ml). Thirty-one lesions had previously received external-beam radiotherapy with maximum spinal cord doses. Dose plans were calculated based on computerized tomography scans acquired using 1.25-mm slices. Tumor dose was maintained at 12 to 18 Gy to the 80% isodose line; spinal cord lesions receiving greater than 8 Gy ranged from 0 to 1.3 ml (mean 0.3 ml). All patients tolerated the procedure in an outpatient setting. No acute radiation-induced toxicity or new neurological deficits occurred during the follow-up period. Axial and radicular pain improved in all patients who were symptomatic prior to treatment.

Conclusions

Spinal stereotactic radiosurgery involving a frameless image-guided system was found to be feasible and safe. The major potential benefits of radiosurgical ablation of spinal lesions are short treatment time in an outpatient setting with rapid recovery and symptomatic response. This procedure offers a successful alternative therapeutic modality for the treatment of a variety of spinal lesions not amenable to open surgical techniques; the intervention can be performed in medically untreatable patients, lesions located in previously irradiated sites, or as an adjunct to surgery.

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Hiroki Yoshida, Keisuke Takai, and Makoto Taniguchi

parameters for CT were as follows: electrical voltage 120 kV, electrical current 200 mA, and slice thickness, 4 mm. CT Myelography Assessment We determined potential leak sites and targeted the spinal levels for EBP on the basis of a comprehensive assessment of CT myelography findings as described below and the concentration gradient of contrast medium. Computed tomography myelography findings included the following 3 points: spinal lesions around the thecal sac ( Fig. 1 ), extradural collection of contrast medium, and intraforaminal contrast medium extravasations

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Timothy C. Ryken, Sanford L. Meeks, Vincent Traynelis, John Haller, Lionel G. Bouchet, Francis J. Bova, Edward C. Pennington, and John M. Buatti

Object

The relatively stationary anatomy of the intracranial compartment has allowed the development of stereotactic radiosurgery as an effective treatment option for many intracranial lesions. Difficulty in accurately tracking extracranial targets has limited its development in the treatment of these lesions. The ability to track extracranial structures in real time with ultrasound images allows a system to upgrade and interface pretreatment volumetric images for extracranial applications. In this report the authors describe this technique as applied to the treatment of localized metastatic spinal disease.

Methods

The extracranial stereotactic system consists of an optically tracked ultrasonography unit that can be registered to a linear accelerator coordinate system. Stereotactic ultrasound images are acquired following patient positioning, based on a pretreatment computerized tomography (CT) simulation. The soft-tissue shifts between the virtual CT-based treatment plan and the actual treatment are determined. The degree of patient offset is tracked and used to correct the treatment plan.

The ultrasonography-based stereotactic navigation system is accurate to within an approximate means of 1.5 mm based on testing with an absolute coordinate phantom. A radiosurgical treatment was delivered using the system for localization of a metastatic spinal lesion. Compared with the virtual CT simulation, the actual treatment plan isocenter was shifted 12.2 mm based on the stereotactic ultrasound image. The patient was treated using noncoplanar beams to a dose of 15.0 Gy to the 80% isodose shell in a single fraction.

Conclusions

A system for high-precision radiosurgical treatment of metastatic spinal tumors has been developed, tested, and applied clinically. Optical tracking of the ultrasonography probe provides real-time tracking of the patient anatomy and allows computation of the target displacement prior to treatment delivery. The results reported here suggest the feasibility and safety of the technique.

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Antonio A. F. De Salles, Alessandra G. Pedroso, Paul Medin, Nzhde Agazaryan, Timothy Solberg, Cynthia Cabatan-Awang, Dulce M. Espinosa, Judith Ford, and Michael T. Selch

the treatment of the spinal lesions reported in this study. This preliminary experience represents the validation of the system and treatment of strictly recurrent lesions exhaustively managed with standard of practice techniques. Clinical Material and Methods Patient Population Fourteen patients with 22 spinal lesions were treated at UCLA; there were six women and eight men with a mean age of 60.2 years (range 48–82 years). Eleven patients had metastasis from lung, renal cell, breast, or colon carcinoma whereas three harbored single benign tumors (two

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Leonard I. Malis

provide dangerous vessels of passage. Spinal hemangioblastomas drain into arterialized veins that are sometimes difficult to distinguish from feeding arteries. This venous shunting is responsible for the characteristic edematous enlargement of the spinal cord. Small syringomyelic cavities are occasionally present at either end of the tumor, but these are generally too small to provide assistance in tumor removal. The spinal lesion is histologically identical to the cystic hemangioblastoma of the cerebellum. Unlike its cystic counterpart, in which the tumor nodule is

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Giuseppe M. V. Barbagallo, Salvatore Lanzafame, Giovanni F. Nicoletti, Nunzio Platania, and Vincenzo Albanese

the tumor had a dural attachment, appeared to be well circumscribed, but was without connection to the spinal cord or nerve roots. Intraoperatively, it was believed to be a meningioma, as has also been described in other cases. 24, 34 In the present case the brain CT scan demonstrated no intracranial lesion, and the spinal MR images revealed a single, extramedullary enhancing lesion in the cervical spine. Because of the absence of brain CT findings, the metastatic nature of the spinal lesion was ruled out and a primary tumor was considered. The mass showed