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Purpose: This retrospective analysis was performed to evaluate osteolytic bone lesions of breast cancer in the thoracic and lumbar spine after radiotherapy (RT) in terms of stability using a validated scoring system., Methods: The stability of 157 osteolytic metastases, treated from January 2000 to January 2012, in 115 patients with breast cancer was evaluated retrospectively using the Taneichi score. Predictive factors for stability were analyzed and survival rates were calculated., Results: Eighty-five (54%) lesions were classified as unstable prior to RT. After 3 and 6 months, 109 (70%) and 124 (79%) lesions, respectively, were classified as stable. Thirty fractures were detected prior to RT, and after RT seven cases (4.5%) with pathologic fractures were found within 6 months. None of the examined predictive factors showed significant correlation with stability 6 months after RT. After a median follow-up of 16.7 months, Kaplan-Meier estimates revealed an overall survival of 83% after 5 years., Conclusion: The majority of patients showed an improved or unchanged stability of the involved vertebral bodies after 6 months. The patients showed only minor cancer-related morbidity during follow-up and reached comparably high survival rates.

Purpose: An evaluation of dose-response relationship and an attempt to define predictive factors., Methods and Materials: A total of 137 cases of painful vertebral hemangioma irradiations (101 patients). Fraction dose (fd) varied from 2 to 15 Gy (123 fractionated and 14 radiosurgical treatments), and total dose (TD) from 8 to 30 Gy (111 cases irradiated with fd of 2 GY to TD of 24 Gy). We evaluated pain relief, changes in analgesic requirements, and reossification., Results: Means of pain relief 1, 6, 12, and 18 months after radiotherapy (defined as a decrease of primary pain level expressed in percent) were 60.5%, 65.4%, 68.3%, and 78.4%, respectively. Proportion of patients with no need for analgesics and patients using tramadol were 39%, 40%, 44%, 57%, and 20%, 17%, 22%, and 11% in these times. The proportion of patients experiencing complete/partial pain relief changed from 36/48% 1 month, to 64/22% 1.5 years after radiotherapy. No impact of radiotherapy on reossification was found. The positive impact of fd and TD increase for analgesics uptake reduction and pain relief was found. An increase of the fd by 1 Gy results in 27% chance of analgesics uptake reduction and 3.8% reduction of pain, whereas 14% analgesics uptake reduction and 2.2% of pain reduction in case of the TD. The predictive factors improving results were found: female gender, older age, better performance states (the chance of the lower analgesic treatment decreases over 2.5 times in comparison to the higher Zubrod degree), bigger Hb concentration, shorter symptoms duration and lower analgesics uptake before radiotherapy., Conclusions: The obtained data support the efficacy of radiotherapy in improving pain secondary to vertebral hemangioma, with the degree of pain amelioration being related to increasing fd and TD. The positive predictive factors were defined: female gender, older age, better performance status, increased Hb concentration, shorter symptoms duration, and lower analgesics uptake before radiotherapy., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Study Design: Case report., Objective: To report a very rare case of juvenile xanthogranuloma (JXG) of the spine in an adult., Summary of Background Data: JXG is very rare in the spine, with only five prior reports in infants and children. To the best of our knowledge, this tumor has never been reported in an adult spine., Methods: The patient is a 47-year-old woman who presented with bowel and bladder incontinence. Magnetic resonance imaging showed a very large lesion arising from the L2 vertebral body, with massive extension into the retroperitoneum with extensive intradural involvement. She had decreased rectal tone, had 4/5 strength in the right hip flexor, and had diminished sensation in her anterior right thigh and perineal region. She was otherwise neurologically intact. After preoperative embolization, a decompressive laminectomy was performed and the tumor was resected through a posterolateral transpedicular approach, followed by stabilization. Because of extensive involvement of retroperitoneum, complete resection was not possible., Results: After pathologic evaluation of the specimen, a diagnosis of JXG was made. Patient underwent postoperative radiation therapy, and her neurologic examination improved significantly over the next several months., Conclusions: To the best of our knowledge, this is the first reported case of JXG in an adult spine. Although complete resection of the tumor was not possible, decompression of the dural sac followed by postoperative radiation led to an excellent clinical outcome.

Introduction: Heterotopic ossification (HO) is a common and serious complication after spinal cord injury, with an incidence of 5-50 %. Single-dose radiation therapy with 7 Gy is an established procedure for HO prophylaxis after total hip replacement. The aim of our study was to determine the clinical outcome after single-dose radiation therapy in the prophylaxis of HO in paraplegic patients., Patients and Methods: Between January 2006 and July 2009, 75 paraplegic patients with heterotopic ossification were treated in our hospital. On the basis of the defined inclusion and exclusion criteria, 62 patients were included in our study, whereas 55 patients participated in our follow-up examination. All patients received a bi-weekly ultrasound of the hip for an attempt at early diagnosis of the condition. In case of an ultrasound suspicion of HO, a computed tomography (CT) or magnetic resonance imaging (MRI) of the hip was performed. After confirmation of HO, a single-dose radiation therapy with 7 Gy was performed. In group A, the patients were irradiated with an electrode voltage of 15 MeV (36 patients) and in group B with 6 MeV (26 patients). All patients were assessed with a standardised questionnaire with a mean follow-up of 30.6 months (range 6-78 months)., Results: The mean interval time between the initial spinal injury and HO development was 58,2 days (range 14-125). 69,4 % of all patients revealed a Brooker grade I, 27.4 % grade II and 3.2 % a grade III. No cases of Brooker grade IV (ankylosis) occurred. No patient showed side-effects after radiation therapy. However, in group A one patient (3,2 %) and in group B three patients (12.5 %) developed HO relapse. Those patients were treated again with a single-dose radiation therapy with 7 Gy and 15 MeV and, afterwards, they were free of complaints. Deep vein thrombosis was confirmed in 11 patients (32.3 %) in group A and in 8 patients (33.3 %) in group B., Conclusions: Single-dose radiation therapy with 7 Gy in the treatment of heterotopic ossification is an effective option. A higher electrode voltage improves the effectiveness of the irradiation and the clinical outcome. Essential for the outcome is the early detection and treatment of HO with single-dose radiation therapy. Randomised, prospective studies should be undertaken in order to confirm these findings., (© Georg Thieme Verlag KG Stuttgart · New York.)

Langerhans cell histiocytosis is a non-malignant proliferative disease of unknown etiology that can affect one or more organs. This is a rare disease, 1 to 2/100,000, affecting mainly children with a male predominance. The osseous lesions are the most frequent (60 to 90%). There is however no consensus treatment for the management of these sites. We report the cases of two patients successfully treated with radiotherapy after primary chemotherapy, at doses of 15 Gy in ten sessions of 1.5 Gy for one patient and 18 Gy in ten fractions of 1.8 Gy for the other. Single or multifocal bone Langerhans cell histiocytosis without visceral involvement is a benign, self-limiting affection in most cases. Some bone lesions could be treated by radiotherapy alone. But the high variability of doses currently given in the literature does not allow determining the lowest effective dose limiting the risk of secondary neoplasia or impaired growth in children, in whom lower doses of 6 to 8 Gy are recommended. The decision of radiotherapy must be weighed against the risk of the disease. Caution should be the rule in this non-malignant tumour pathology., (Copyright © 2010 Société française de radiothérapie oncologique (SFRO). Published by Elsevier SAS. All rights reserved.)

Metastatic bone disease (MBD) is the most common cause of cancer pain and of serious skeletal-related events (SREs) reducing quality of life. Management of MBD involves a multimodal approach aimed at delaying the first SRE and reducing subsequent SREs. The objective of the study was to characterise the hospital burden of disease associated with MBD and SREs following breast, lung and prostate cancer in Spain. Patients admitted into a participating hospital, between 1 January 2003 and 31 December 2003, with one of the required cancers were identified and selected for inclusion into the study. The index admission to hospital, incidence of patients admitted and hospital length of stay were analysed. There were 28,162 patients identified with breast, lung and prostate cancer. The 3 year incidence rates of hospital admission due to MBD were 95 per 1000 for breast cancer, 156 per 1000 for lung cancer and 163 per 1000 for prostate cancer. For patients admitted following an SRE, the incidence rates were 211 per 1000 for breast cancer, 260 per 1000 for lung cancer and 150 per 1000 for prostate cancer. This study has shown that cancer patients consume progressively more hospital resources as MBD and subsequent SREs develop., (© 2009 The Authors. European Journal of Cancer Care © 2009 Blackwell Publishing Ltd.)

Megavoltage CT (MVCT) simulation on the TomoTherapy Hi·Art system is an alternative to conventional CT for treatment planning in the presence of severe metal artifact. StatRT is a new feature that was implemented on the TomoTherapy operator station for performing online MVCT scanning, treatment planning and treatment delivery in one session. The clinical feasibility of using the StatRT technique and MVCT simulation to palliative treatment for a patient with substantial spinal metallic hardware is described. A patient with metastatic non-small-cell lung cancer involving the thoracic spine underwent conventional kilovoltage CT simulation. The metal artifact due to stainless steel spine-stabilizing rods was too severe for treatment planning, despite attempts to correct using density override. The patient was then re-scanned using MVCT on a tomotherapy unit. Plans were generated using both StatRT and conventional tomotherapy planning (Tomo plan) with different settings for comparison. StatRT planning ran a total of five iterations in a short planning window (10-15 min). Two Tomo plans were generated using: (1) five iterations in the "full scatter" mode, and (2) 300 iterations in the "beamlet" mode. It was noted that the DVH of the StatRT plan was almost identical to the Tomo plan optimized by the "full scatter" mode and the same number of iterations. Dose distribution analysis reveals that these three planning methods yielded comparable doses to heart, lungs and targets. This work also demonstrated that undermodulation can result in a high degree of thread effects. The overall time for the treatment process (including 7 minutes for simulation, 15 minutes for contouring, 10 minutes for planning and 5 minutes for delivery) decreases from hours to around 40 minutes using the StatRT procedure. StatRT is a feasible treatment-planning tool for physicians to scan, contour and treat patients within one hour. This can be particularly beneficial in urgent palliative treatments.

Introduction: Langerhans cell histiocytosis of the thoracic spine is a rare condition in adults. It is a serious condition with an increased risk of spinal cord compression., Exegesis: A 55-year-old man complained of lumbar and back pain. He developed a spastic paraparesis. Magnetic resonance imaging of the spine showed a spinal cord compression due to bone and epidural tumoral lesions of the eleventh and twelfth thoracic vertebrae, located in the posterior elements of the spine. A surgical biopsy showed an infiltrate of eosinophilic cells, positive for CD1a in immunohistochemistry studies. Final diagnosis was therefore langerhans cell histiocytosis of the thoracic spine complicated by spinal cord compression. The patient received glucocorticoid therapy combined with vinblastine followed by local radiotherapy and etoposide. However, the neurological deficit persisted and the patient finally died., Conclusion: Langerhans cell histiocytosis is a rare cause of spinal cord compression.

Castleman disease is a rare lymphoproliferative disease of unknown cause. In most cases, afflicted patients present with a mediastinal mass although the disease may manifest in numerous other sites, including intracranially and rarely intraspinally. The authors report on the case of a 19-year-old woman who presented with a large paraspinal mass emanating from the T7-8 neural foramen. The morphological and signal characteristics revealed on magnetic resonance imaging were similar to those of nerve sheath tumors. The patient underwent open biopsy sampling of the lesion, and results of a pathological evaluation revealed hyaline-vascular type Castleman disease. She underwent radiotherapy and remains symptom-free with a radiographically stable lesion 1 year later. Although the disease has been reported to mimic a meningioma when encountered in intracranial locations, to the authors' knowledge, this is the first case of the disorder mimicking a nerve sheath tumor. When the diagnosis of Castleman disease is made, good results can be obtained with partial resection and radiotherapy.

Study Design: Retrospective case study., Objectives: Report a rare case of cervical myelopathy induced by calcium pyrophosphate dehydrate (CPPD) deposition in multiple cervical levels., Setting: An area teaching hospital in Taiwan., Method: A patient with cervical myelopathy was evaluated by computerized tomography (CT) scan and magnetic resonance (MR) image. CPPD deposition known as pseudogout was diagnosed and approved by a polarized microscope., Result: A prominent hypertrophy of ligmentum flavum and a retro-odontoid bulging mass induced cord compression were found in CT scan and MR image. CPPD deposition was confirmed by the histological examinations in the ligamentum flavum at the spinal levels of C3-C6. After decompression surgery of spine and comprehensive rehabilitation, the patient's neurological symptoms subsided and her neurological functions improved leading to a good prognosis., Conclusion: CPPD deposition in cervical spine occurring at multiple levels is rare. Image studies with CT scan and MR are complementary in the diagnosis of CPPD-induced myelopathy. Surgical decompression is always required and expected to have a good outcome.

Object: Posterior lumbar interbody fusion (PLIF) has been shown to be effective in the treatment of axial low-back pain. Minimally invasive spine surgery for arthrodesis has several advantages, including quicker patient recovery, less postoperative pain, and less destruction of adjacent tissue. The purpose of this paper is to evaluate the clinical outcomes after PLIF procedures in which unilateral pedicle screw fixation was used., Methods: Prospective data were collected in 34 patients undergoing a one-level minimally invasive transforaminal lumbar interbody fusion (TLIF) in 2003. Conservative therapy, including physical therapy and aggressive multimodality pain management, had failed in all patients. Selection was based on magnetic resonance imaging studies demonstrating degenerative disc disease. All patients underwent a unilateral TLIF procedure in conjunction with posterior unilateral pedicle screw fixation. Twenty patients in whom the follow-up duration was longer than 6 months were included in this study. The follow-up duration in all patients ranged from 6 to 12 months. Seventeen (85%) of 20 patients had a good result, which was defined as a greater than 20-point reduction in the Oswestry Disability Index (ODI) score. The other three patients had no improvement. The mean preoperative ODI score of 57 improved to 25 after surgery (p < 0.005). In the 17 patients who demonstrated improvement, the mean ODI score improved from 57 to 18. The patients' visual analog scale pain scores improved from 8.3 to 1.4 (p < 0.005) after surgery. In patients who received Workers' Compensation, three (75%) of four improved. Follow-up computerized tomography scans were obtained in all 20 patients at 6 months. At that time, 13 of the patients demonstrated some degree of fusion, and no symptomatic pseudarthrosis was noted., Conclusions: Minimally invasive TLIF in conjunction with unilateral pedicle screw instrumentation is an effective treatment for axial low-back pain in appropriately selected patients.

Study Design: Simulation of lumbar spine fluoroscopy used during surgical treatments of spinal disorders on a humanoid phantom and monitoring of the scattered radiation levels., Objectives: To assess the potential of adverse effects to progeny due to the preconceptual and embryo/fetal exposure to ionizing radiation resulting from the parental occupational exposure to scattered radiation from lumbar fluoroscopy., Summary of Background Data: There are no available data on embryo/fetal doses resulting from maternal occupational exposure in the orthopedic theater. Besides, studies on staff gonadal doses from fluoroscopically assisted spine surgery are scarce and their results are not generally applicable., Methods: Lumbar spine anterior-posterior and lateral fluoroscopy were performed on an anthropomorphic phantom. Scattered radiation within the orthopedic theater was recorded at the staff genitals and waist level. Gonadal, abdominal surface, and embryo/fetal doses normalized to the dose-area-product specific to each projection were calculated., Results: If the annual dose limits of occupational exposure are continuously exhausted for 10 years, the resulting radiogenic risk of congenital malformation in infants born to the orthopedic theater staff will be at least two orders of magnitude lower than the corresponding spontaneous probability. The occupational exposure of the pregnant mother bears a negligible contribution to the risk of hereditary effect on the newborn's progeny compared with the natural incidence rate., Conclusions: Radiogenic genetic and embryo/fetal risks resulting from occupational exposure due to fluoroscopically assisted surgical treatments of spinal disorders are well within tolerance levels provided that rigorous confinement to all pertinent occupational dose constraints is established.

We studied 100 patients in whom symptomatic pseudarthrosis had been established at more than 9 months after lumbar spine fusion. All patients were treated with a pulsed electromagnetic field device worn consistently 2 hours a day for at least 90 days. Solid fusion was achieved in 67% of patients. Effectiveness was not statistically significantly different for patients with risk factors such as smoking, use of allograft, absence of fixation, or multilevel fusions. Treatment was equally effective for posterolateral fusions (66%) as with interbody fusions (69%). For patients with symptomatic pseudarthrosis after lumbar spine fusion, pulsed electromagnetic field stimulation is an effective nonoperative salvage approach to achieving fusion.

Objective and Importance: Epidermoid cysts are benign lesions that account for 0.7% of all intraspinal tumors. Standard treatment is complete resection. The recurrence rate after surgery cannot be estimated from the scarce literature, but it has been acknowledged that, in some patients, curative surgery may be impossible and temporary relief of symptoms is the only aim., Clinical Presentation: In 1996, a 59-year-old woman presented with a 30-year history of a spinal epidermoid cyst, for which she had previously undergone eight operations. Spastic paraplegia of the lower limbs had been present from initial diagnosis, and the neurological level had moved upward to C6. At the time of presentation, paresthesia in her arms and hands had developed. A magnetic resonance imaging scan revealed typical sequelae of previous surgery and a fibrotic region starting at the level of C5-C6 with formation of a cyst that extended to the conus terminalis. The spinal cord could not be visualized caudally at C7., Intervention: Because both patient and surgeons did not want further surgical interventions that might comprise upper limb function, radiotherapy was performed. A dose of 46 Gy was delivered to the cervicothoracic spine (C4-T1) by opposing anteroposterior high-energy photon beams. The treatment was well tolerated, and after treatment, the patient's clinical symptoms improved slightly, without evolution on magnetic resonance imaging., Conclusion: Irradiation was effective in stabilizing the patient's disease. Although radiotherapy is not established in the treatment of epidermoid cysts, it should be considered as an alternative to palliative surgery and in patients who cannot undergo operations.

Sacral tumors represent a small subset of spinal lesions and typically include chordomas, metastases, other primary bone tumors, and benign schwannomas. Resection is the standard treatment for many sacral tumors, but many types of sacral lesions have the potential for recurrence after excision. In these cases, adjuvant radiotherapy is often beneficial. Although conventional radiotherapy plays an important role in the management of spinal lesions, the radiation doses required for adequate local control of many sacral lesions generally exceed the tolerance doses of normal tissues, thus limiting its definitive role in the management of sacral tumors. Recent advances in the field of stereotactic radiosurgery have allowed precise targeting of the sacrum. In this report the authors review the use of these two forms of radiation treatment and their role in managing sacral tumors.

Objective: To determine whether or not exposure to ionizing radiation as an adult increases the risk of developing parathyroid adenomas., Design and Patients: A cohort of 27 415 patients had received X-ray treatment to palliate pain originating from arthrosis and spondylosis from 1950 to 1964. In a subcohort of 8144 patients the cervical spine was the target, or one of the targets for the treatment. With the technique used it could be assumed that, as a rule, the parathyroid glands had been included in the treated volume. Patients with parathyroid adenomas were obtained from the Swedish Cancer Register from 1958 to 1995. The standardized incidence ratio (SIR) was calculated., Results: The number of person-years at risk was 180 492 in the cohort exposed at the cervical spine, and 412 994 in the control cohort irradiated only at other sites. The calculated dose in the parathyroid region in the study cohort was about 1 Gy. The observed number of parathyroid adenomas in the study cohort was 22, and 24 in the control cohort. Expected numbers based on population data were 12.0 and 24.7, respectively, giving an SIR of 1.83 (95% CI 1.14-2.76) and 0.97 (CI 0.62-1.45), respectively. Mean age at exposure was 48.9 years (SD 10.2) and at diagnosis 71.5 years (SD 8.3). The time from exposure to diagnosis varied from 2 to 34 years (median 26 years). The excess relative risk was about 0.8 per Gy., Conclusion: Exposure to ionizing radiation to the cervical spine in adult age seems to be associated with an increased risk of developing parathyroid adenomas.

While there is very good epidemiological evidence for induction of thyroid cancer by radiation exposure in children, the risk for adults after exposure is still uncertain, especially when concerning relatively small radiation doses. A cohort of 27,415 persons which in 1950 through 1964 had received x-ray treatment for various benign disorders in the locomotor system (such as painful arthrosis and spondylosis) was selected from three hospitals in Northern Sweden. A proportion of this cohort, consisting of 8 ,44 persons (4,075 men and 4,069 women), had received treatment to the cervical spine and thereby received an estimated average dose in the thyroid gland of about 1 Gy. Standard incidence rates (SIR) were calculated by using the Swedish Cancer Register. In the cervical spine cohort, 22 thyroid cancers were found versus 13.77 expected (SIR 1.60, CI 1.00-2.42). The corresponding figures for women were 16 observed cases versus 9.60 expected cases (SIR 1.67: Cl 0.75-2.71). Most thyroid cancers (15 out of 22) were diagnosed > 15 years after the exposure. In the remaining part of the total cohort, i.e. those without cervical spine exposure, no increased risk of thyroid cancer was found (SIR 0.98, CI 0.64-1.38). The study strongly suggests that external radiation exposure of adults at relatively small doses increases the risk of thyroid cancer but also that this increase is very much lower than that reported after exposure in children.

We report the nonoperative treatment of a recurrent, multilevel spinal aneurysmal bone cyst by injection of 32P chromic phosphate colloid into the cyst. The patient was then followed up with serial CT examinations, which showed stabilization and progressive ossification within the lesion. The rationale, alternatives, and possible contraindications to radionuclide ablation of spinal aneurysmal bone cysts are discussed.

Objective and Importance: Considered benign and malformative in nature, enterogenous cysts are predominantly spinal lesions. Although recurrences have been reported, especially in the rare intracranial examples, craniospinal dissemination has never been described., Clinical Presentation: We report a 63-year-old woman who presented 16 years previously with a histologically typical enterogenous cyst of the cerebellum. Fourteen years after its incomplete excision, numerous supratentorial, infratentorial, and spinal subarachnoid cysts were detected. A histological examination revealed multiple enterogenous cysts without evidence of malignancy. Ki-67 (MIB-1) proliferative indices were less than 1% in all except one specimen, wherein it was 4%; immunohistochemistry demonstrated rare p53 protein overexpression., Intervention: During the last 2 years, four subtotal resections of spinal enterogenous cysts have been performed for progressive paraplegia, pain, paresthesia, and bladder dysfunction. Considering the multiple recurrences and progressive neurological deficits, craniospinal radiation therapy was given., Conclusion: To our knowledge, this is the first report of widespread craniospinal dissemination associated with the incomplete resection of an enterogenous cyst. Although a rare complication, it emphasizes the advantages of early, aggressive surgery.

Two female patients with Gorham-Stout syndrome (GSS) of the spine are described. One 25 year old patient developed progressive osteolysis of the upper cervical spine over a period of several years but despite gross extent of the disease had no neurological complications. Some bone implanted in order to stabilise the spine was absorbed after only a few weeks. A six year old girl with progressive osteolysis of the thoracic spine developed a reversible trans-section syndrome on several occasions. During an active episode, the spine was stabilised by a titanium implant. In both patients the condition arrested spontaneously. A review of the world literature (175 cases) has indicated that, including our two patients, there were only 15 patients with primary involvement of the spine and 27 patients with secondary involvement. The relatively good prognosis of the condition (mortality 13.3%), which often shows spontaneous arrest, becomes much worse if there is involvement of the spine or thorax because of neurological complications or a chylothorax. Involvement of the spine increases mortality to 33.3%, and to 52% if the thorax is involved. Early diagnosis and the institution of appropriate treatment is therefore essential. For involvement of the spine, a combination of radiotherapy and surgical stabilisation with a titanium implant should be performed since in nearly all patients bone transplants are reabsorbed. For this treatment the patient should be transferred to a neuro-orthopaedic centre.

A 9-year-old girl with a solid variant of an aneurysmal bone cyst in the 3rd lumbar vertebra showed a good response to low-dose radiation as the only treatment. The solid variant of aneurysmal bone cyst is thought to be a reactive response to intraosseous hemorrhage and is also called giant cell reparative granuloma or giant cell reaction. These lesions in the jaw and the short tubular bones of the hands and feet frequently recur after surgery. Aneurysmal bone cysts of the spine also show a fairly high recurrence rate after incomplete resection or radiation therapy. However, 7 previous cases of the solid variant of aneurysmal bone cyst in the spine and this case did not show recurrence after a mean follow-up period of 45 months. This difference in behaviour suggests that the solid variant should be recognized before surgery as being distinct from conventional aneurysmal bone cysts, especially in the spine.

A phase II trial was planned to investigate the feasibility of radiotherapy (RT) without steroids in 20 consecutive patients with metastatic spinal cord compression (MSCC), no neurologic deficits, or only radiculopathy, and no massive invasion of the spine at magnetic resonance imaging (MRI) or computed tomography (CT). Aiming at an early diagnosis, MRI or CT was prescribed for all cancer patients with back pain and osteolysis, even when there were no signs of neurologic spinal compression. All patients were given 30 Gy in 10 fractions over 2 weeks with no steroids. Back pain and motor capacity were the parameters adopted to verify response to RT. Sixteen of 20 patients (80%) were able to walk without support, and 14 (70%) had no radiculopathy. Seventeen of 20 cases (85%) achieved relief from back pain. Regarding motor function, all patients (100%) responded to RT because the 16 patients able to walk without support at diagnosis did not deteriorate and the other 4, who needed support, became ambulatory without motor impairment. Median survival time was 14 months. Eight of 20 (40%) treated patients are still alive (14 to 36 months after end of RT), fully ambulatory, and free from relapse in the treated spine. Acute side effects were documented in only 2 patients (10%) and were managed without steroids. The results of this study suggest that RT without steroids is a feasible regimen for MSCC patients with good motor function. Elimination of steroids from the standard treatment for MSCC avoids cortisone side effects above all in those patients with diabetes, hypertension, peptic ulcer, and other steroid-sensitive medical problems.

A study was performed on 13 patients with 16 primary aneurysmal bone cysts (ABC) to assess long-term results and functional outcome. The average age at diagnosis was 19.8 years. The anatomical sites were femur (4), tibia (5), humerus (2), fibula (2) and other (3). Four ABC's required no treatment. One patient underwent radiotherapy for an ABC of the spine. Eleven ABC's were treated surgically, mostly by intracapsular resection and bone grafting. Three patients had a total of 6 recurrences, which needed further treatment. At the time of follow-up (average period: 102 months), the average functional evaluation rate of 13 patients was 96%. These functional results were graded as excellent in 9 patients and good in 4.

Study Design: This is a case report of Gorham disease of the spine with review of the literature., Objective: To review the diagnosis, therapy, clinical course, and prognosis of Gorham disease of the spine., Summary of Background Data: This is the 17th reported case of spinal involvement by this rare type of idiopathic osteolysis., Methods: The patient was studied with radiographs, nuclear bone scans, computed tomography scans, magnetic resonance scans, and biopsies. His spine was stabilized by posterior and anterior rods, corpectomies, and bone grafts., Results: The patient's spine had remained stable for 22 months after surgery, but intractable chylothoraces and spreading bone destruction were present., Conclusions: Spinal Gorham disease has high morbidity and mortality, but the course in an individual patient is difficult to predict. Early spinal stabilization should be considered before irreversible neurologic complications occur.

A 25-year-old man developed multiple eosinophilic granuloma of bone including vertebral and sacral localization. Radiotherapy was initially administered. One year later, a relapse occurred in another vertebrae which was previously irradiated. Percutaneous vertebroplasty was, for the first time to our knowledge performed, in this indication, with a good clinical result with follow-up now for one year. We emphasize that such treatment is permissible only in symptomatic, progressive lesions, with threatened decompensation of spinal stability. This technique should be used only on an adult.

Recent trends in the management of bone metastases include the use of prophylactic bisphosphonates and low dose single fraction radiotherapy in favour of high dose fractionated radiotherapy. A recent animal model [1] suggests that cord compression is often associated with predominant soft tissue epidural disease, with bone collapse as a late event. In the present study, potential implications were investigated by retrospective evaluation of the pattern of disease on MRI scans of patients with spinal cord compression. The dominant component of spinal cord compression was determined in 62 patients. Two main patterns were identified, 45 (73%) had predominant soft tissue epidural disease and 15 (24%) had bone collapse. There were two with intrathecal deposits. The patterns were correlated with response to radiotherapy. Positive response was observed in 64% of those with soft tissue epidural disease and 27% of those with bone collapse. These data support the animal model, suggesting soft tissue epidural disease rather than collapse as the predominant cause of cord compression. This implies that prophylactic bisphosphonates alone would be unlikely to reduce the incidence of spinal cord compression. It also introduces concern about the long term safety of low dose single fraction radiotherapy for bone metastases in patients with a medium term life expectancy (e.g. > 2 years). These patients may benefit from more than a single fraction of radiotherapy to produce longer growth delay for sub-clinical epidural disease.

Low dose laser therapy (LDLT) has been available for the treatment of various diseases for almost two decades. The aim of therapy is usually to reduce pain. The literature offers a plethora of reports, some negative and some positive. This review discusses the relatively few placebo-controlled, double-blind trials on the subject, in an attempt to provide an evaluation of the clinical effectiveness of LDLT. The majority of these studies suggest that LDLT is not clinically effective. There is no particular disease or symptom which seems to respond to LDLT. The same can be said of the type of laser light or its intensity. Based on this collective data, LDLT does not seem to be a scientifically proven therapy.

An emergency in radiotherapy is a case calling for such urgent treatment that the usual stages of planning are abbreviated and radiation is started within a few hours. After a short summary of the biological effects of radiotherapy, we will discuss the emergency situations one has to deal with. Most frequent are those in the course of malignant disease. Yet, in the context of increasingly practised transfusion- and transplantation-techniques, the number of other emergencies is rising.

The cases of twenty-two patients with an aneurysmal bone cyst of the spine above the sacrum were analyzed with regard to sex, age, site, symptoms, and radiographic findings. Four patients had extension of the lesion to the adjacent vertebra or rib, and twelve patients had neurological deficits. The primary treatment was either radiotherapy or surgery alone, or surgery and radiotherapy combined. No recurrences were found in patients who were treated with surgery alone or with surgery and radiotherapy, while three of the six patients who were treated with radiotherapy had a local recurrence, two of which were fatal. The patients with neurological deficits recovered after healing of the cyst.

A rare case of histiocytosis-X of the spine is presented. The clinical and histological features of histiocytosis-X are reviewed. Complete neurological recovery was exhibited by the patient after surgical treatment and radiotherapy. The literature dealing with the eight cases previously reported is reviewed.

Three children presenting with aneurysmal bone cysts are described. The first patient was 10 months old with a cyst of the scapula. The second was more typical but his cyst was treated initially as a malignant tumour. In the third child the second cervical vertebra was affected which posed considerable problems of management; it was treated by radiotherapy. Despite the problems all 3 children have made a good recovery.

Painful changes of the vertebral column frequently can be treated by radiation therapy, although fundamental differences have to be made between benign or primary and secondary malignant diseases. As efficacy is totally different for benign and malignant diseases, the dosage radiation is many times lower or higher respectively. For both ranges of application but especially for the treatment of benign diseases a critical profit-risk analysis with careful consideration of alternative therapy should find out the distinct indication.

Aneurysmal bone cyst is a pseudoneoplastic skeletal disorder. The material of the Tumor Center at the Rizzoli Orthopaedic Institute refers to 198 cases, 25 (12.6%) with spinal localization. The X-ray pattern of aneurysmal bone cyst is represented by an osteolytic area more or less evidently involving the vertebra, with frequent extension to the surrounding soft tissues. Its maturing evolution is typical, and occurs both spontaneously and after surgical and/or radiation therapy.

Patients with neurological syndromes of lumbar osteochondrosis were subjected to clinico-electromyographic examination to study whether it is possible to regulate the function of spinal alpha-motoneurons by decimetric waves (DMW). The effect of DMW on the excitability of alpha-motoneurons was found to depend on their initial function. The neurophysiological mechanisms underlying the therapeutic action of DMW in this pathology are analyzed.