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Technology Insight: image-guided robotic radiosurgery—a new approach for noninvasive ablation of spinal lesions

Nature Clinical Practice Oncology volume 5, pages 405–414 (2008)Cite this article

Abstract

The need for an effective noninvasive tool to ablate spinal lesions reflects the limitations of traditional surgical and radiotherapeutic approaches. Open surgery is invasive and carries a risk of neurological injury and vertebral column dysfunction. Conventional radiotherapy often has poor clinical efficacy and a risk of neurologic complications. Spinal radiosurgery has been developed to overcome these limitations. This technique consists of precise delivery of high-dose radiation to a spinal target. To spare the delicate and radiation-sensitive spinal cord and to avoid potentially devastating neurological complications, it is essential that the radiation dose decreases rapidly outside of the target. This is accomplished by use of advanced, image-guidance technology, treatment planning software, and robotics. Preliminary data indicate that this approach can achieve high rates of tumor control of spinal and paraspinal lesions and durable reduction of associated vertebral pain without neurological complications. Although spinal radiosurgery is not yet widely practiced, the benefits of this new therapeutic approach are likely to encourage its widespread adoption in coming years.

Key Points

  • The accurate, tightly focused delivery of radiation to spinal lesions is possible by frameless robotic radiosurgical technologies such as CyberKnife® and Novalis® Shaped Beam

  • Image guidance is the key to spinal radiosurgery; X-ray images are registered to images derived from preoperative CTs, and the computations required to align the images provide the coordinates for lesion targeting

  • A range of pathologies have been treated with spinal radiosurgery, including metastatic lesions, primary malignant and benign lesions, and arteriovenous malformations

  • Spinal radiosurgery provides durable pain relief and local tumor control while maintaining physical and mental quality of life

  • Spinal radiosurgery is associated with a low rate of complications; no neurological complications were observed in the largest series to date (500 lesions)

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Figure 1: The CyberKnife® system.
Figure 2: Treatment planning (coronal view) and 3-dimensional view showing the planned penetration trajectories for CyberKnife® treatment of a thoracic metastatic lesion (T2–T4).
Figure 3: Novalis® Shaped Beam Surgery system for extracranial treatments.
Figure 4: On-screen images seen during an Xsight® fiducial-free spine tracking treatment with the CyberKnife®.

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Acknowledgements

The authors wish to thank Professor G Cantore for his unwavering support and Dr D Schaal for his invaluable editorial assistance.

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Authors and Affiliations

  1. P Romanelli is Chief of Functional Neurosurgery in the Department of Neurosurgery, IRCCS Neuromed, Pozzilli, Italy,

    Pantaleo Romanelli

  2. JR Adler Jr is Dorothy and Thye King Chan Professor in Neurosurgery in the Department of Neurosurgery at Stanford University, Stanford, CA, USA.,

    John R Adler Jr

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Correspondence to Pantaleo Romanelli.

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Competing interests

P Romanelli has worked occasionally as a consultant for Accuray Incorporated during the past 3 years. JR Adler Jr is a shareholder and is on the Board of Directors of Accuray Incorporated.

Supplementary information

Supplementary Table 1

Studies of high-dose stereotactic radiosurgery for spinal lesions. (DOC 100 kb)

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Romanelli, P., Adler, J. Technology Insight: image-guided robotic radiosurgery—a new approach for noninvasive ablation of spinal lesions. Nat Rev Clin Oncol 5, 405–414 (2008). https://doi.org/10.1038/ncponc1131

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