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          Spine          Radiosurgery

Spine Radiosurgery is a relatively new tool utilizing advanced imaging systems, planning software, image-guided localization, and intensity-modulated dose delivery. Radiosurgery of spine tumors yields high rates of pain control and local control, and offer both the patients and the treating physicians an effective non-invasive alternative. This review covers the indications for SRS, the current techniques used and the outcome of SRS.

Radiosurgery is the delivery of high-intensity radiation energy to a target while sparing the surrounding organs. Cranial radiosurgery is a routine treatment for intracranial tumors, however, the transition to extracranial radiosurgery required technological advances such as patient immobilization, radiation targeting and precision delivery. These technologies made spinal radiosurgery a viable tool for the treatment of spinal tumors in recent years. The treatment is planned according to a CT scan and MRI done with special high-resolution protocols and immobilization devices, targets and organs at risk are contoured, treatment is planned and quality assurance (Q/A) protocols are followed. Following Q/A procedures the patient undergoes the treatment with the same immobilization device in an outpatient setting.

Indication for SRS treatment includes solitary spine metastases, Radioresistant spine tumors (tumors with poor response to conventional radiation), Progression after prior conventional radiation, Residual/ progression after surgery, Difficult surgical approaches and Significant medical co-morbidities.

Dr. Harel has done a spine radiosurgery fellowship in Cleveland Clinic after which he started the first spine radiosurgery in Israel in 2011. Since he has treated hundreds of patients with very high success rates. Dr. Harel published few instrumental papers regarding spine radiosurgery, some could be found in the list below.

1: Harel R, Pfeffer R, Levin D, Shekel E, Epstein D, Tsvang L, Ben Ayun M, Alezra
D, Zach L. Spine radiosurgery: lessons learned from the first 100 treatment
sessions. Neurosurg Focus. 2017 Jan;42(1):E3. 

2: Hadelsberg UP, Harel R. Hazards of Ionizing Radiation and its Impact on Spine 
Surgery. World Neurosurg. 2016 Aug;92:353-359. 

3: Zach L, Tsvang L, Alezra D, Ben Ayun M, Harel R. Volumetric Modulated Arc
Therapy for Spine Radiosurgery: Superior Treatment Planning and Delivery Compared
to Static Beam Intensity Modulated Radiotherapy. Biomed Res Int.

4: Harel R, Emch T, Chao S, Elson P, Krishnaney A, Djemil T, Suh J, Angelov L.
Quantitative Evaluation of Local Control and Wound Healing Following Surgery and 
Stereotactic Spine Radiosurgery for Spine Tumors. World Neurosurg. 2016

5: Harel R, Zach L. Spine radiosurgery for spinal metastases: indications,
technique and outcome. Neurol Res. 2014 Jun;36(6):550-6. 

6: Harel R, Spiegelmann R. Spinal radiosurgery using the synergy-S system. Isr
Med Assoc J. 2013 Nov;15(11):712-3. PubMed PMID: 24511655.

7: Harel R, Chao S, Krishnaney A, Emch T, Benzel EC, Angelov L. Spine
instrumentation failure after spine tumor resection and radiation: comparing
conventional radiotherapy with stereotactic radiosurgery outcomes. World
Neurosurg. 2010 Oct-Nov;74(4-5):517-22. 

8: Harel R, Angelov L. Spine metastases: current treatments and future
directions. Eur J Cancer. 2010 Oct;46(15):2696-707. 

9. Harel R, Kaisman-Elbaz T, Emch T, Elson P, Chao ST, Suh JH, Angelov L. A
quantitative and comparative evaluation of stereotactic spine radiosurgery local
control: proposing a consistent measurement methodology. Neurosurg Focus. 2022

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