Combination kyphoplasty and spinal radiosurgery: a new treatment paradigm for pathological fractures

Abstract

<jats:p content-type="fine-print"><jats:italic>Object.</jats:italic> Patients with symptomatic pathological compression fractures require spinal stabilization surgery for mechanical back pain control and irradiation for the underlying malignant process. The authors evaluated a treatment paradigm of closed fracture reduction and fixation involving kyphoplasty and subsequent spinal radiosurgery.</jats:p> <jats:p content-type="fine-print"><jats:italic>Methods.</jats:italic> Twenty-six patients (six men and 20 women, mean age 72 years) with pathological compression fractures (16 thoracic and 10 lumbar) were prospectively evaluated. Histological diagnoses included 11 lung, nine breast, four renal, one cholangiocarcioma, and one ocular melanoma. Seven lesions had received prior external-beam radiation therapy. All patients underwent kyphoplasty that involved the percutaneous transpedicular technique. Fiducial markers allowing for image guidance during CyberKnife treatment were placed, at time of the kyphoplasty, in the pedicles at adjacent levels. Patients underwent single-fraction radiosurgery (mean time after kyphoplasty 12 days) in an outpatient setting. The tumor dose was maintained at 16 to 20 Gy (mean 18 Gy) to the 80% isodose line. The treated tumor volume ranged from 12.7 to 37.1 cm<jats:sup>3</jats:sup>. No acute radiation-induced toxicity or new neurological deficit occurred during the follow-up period (range 11–24 months, median 16 months). Axial pain improved in 24 (92%) of 26 patients.</jats:p> <jats:p content-type="fine-print"><jats:italic>Conclusions.</jats:italic> The combined kyphoplasty and spinal radiosurgery treatment paradigm was found to be clinically effective in patients with pathological fractures; there was no significant spinal canal compromise. In this technique two minimally invasive surgical procedures are combined to avoid the morbidity associated with open surgery while providing both immediate fracture fixation and administering a single-fraction tumoricidal radiation dose.</jats:p>

CyberKnife: review of first 1,000 cases at a dedicated therapy center

“…The frameless CyberKnife radiosurgery system overcomes these problems [7][8][9][10]15]. Continuous tracking and correction for motions of the spine throughout treatment is ideal for spinal radiosurgery to ensure corrections during therapy for patient movement.…”

“…In the first reported use of image-guided robotics to perform spinal radiosurgery, Ryu and co-workers [16] demonstrated the safety and short-term efficacy for a variety of neoplastic and vascular lesions. Surgical implantation of fiducials into adjacent vertebral segments was necessary for tracking the ablated spinal lesion [7,8]. However, fiducial placement introduces some of the surgical risk associated with invasive surgery and may increase patient discomfort associated with the procedure, and a fiducial free system of image guidance was developed.…”

“…Longterm tumor control was demonstrated in 90% of lesions treated with radiosurgery as a primary treatment modality and in 88% of lesions treated for radiographic tumor progression. CyberKnife radiosurgery has been combined recently with kyphoplasty to address pathological compression fractures [8]. This is a new treatment paradigm for metastatic spinal tumors.…”

“…Body lesions are progressively increasing an overview of the indications in the first 1,000 patients treated in the CyberKnife Center Munich. Single-dose treatment was chosen because clinical studies have overwhelmingly demonstrated high efficacy and low morbidity for intracranial and spinal tumors[6][7][8][9][10].…”

Diagnosis and surgical management of breast cancer metastatic to the spine

“…Following treatment, all breast cancer patients experienced immediate pain improvement and reduction in analgesic requirement. Treatment strategies have also been proposed that combine percutaneous techniques with surgical resection as well as stereotactic radiosurgery [54] .…”