Spinal Radiosurgery: Delayed Radiation-Induced Myelopathy

  • Megan E. DalyEmail author
  • Iris C. Gibbs
Part of the Tumors of the Central Nervous System book series (TCNS, volume 6)


Spinal cord dose parameters to minimize the risk of radiation myelopathy are relatively well-defined in the conventionally fractionated setting, but remain controversial for the high dose-per-fraction, partial-cord dosimetry encountered in stereotactic radiosurgery (SRS). Myelopathy has been only rarely described in the setting of SRS, and a variety of suggested dose constraints exist in the literature, ranging from a maximum cord dose (cord Dmax) of 10 to 14 Gy or a partial volume tolerance of 10 Gy (V10) to 10% of the contoured cord. Ever-improving attempts at normal tissue complication probability (NCTP) modeling permit estimation of the potential toxicity of high dose-per-fraction regimens, while animal models provide additional insights on a partial cord volume tolerance model for radiation myelopathy and suggest regional differences in radiation sensitivity across the spinal cord. The literature to date contains only ten reported cases of SRS-induced myelopathy; however, with increasing use of SRS for both benign and metastatic lesions of the spine, refining our understanding of the tolerance of the human spinal cord to hypofractionated dosimetry remains crucial.


Spinal Cord Biologically Effective Dose Normal Tissue Complication Probability Linear Quadratic Model Radiation Myelopathy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Alfonso ER, De Gregorio MA, Mateo P, Esco R, Bascon N, Morales F, Bellosta R, Lopez P, Gimeno M, Roca M, Villavieja JL (1997) Radiation myelopathy in over-irradiated patients: MR imaging findings. Eur Radiol 7:400–404PubMedCrossRefGoogle Scholar
  2. Baumann M, Budach V, Appold S (1994) Radiation tolerance of the human spinal cord. Strahlenther Onkol 170:131–139PubMedGoogle Scholar
  3. Benzil DL, Saboori M, Mogilner AY, Rocchio R, Moorthy CR (2004) Safety and efficacy of stereotactic radiosurgery for tumors of the spine. J Neurosurg 101(suppl 3):413–418PubMedGoogle Scholar
  4. Bijl HP, van Luijk P, Coppes RP, Schippers JM, Konings AW, van der Kogel AJ (2002) Dose-volume effects in the rat cervical spinal cord after proton irradiation. Int J Radiat Oncol Biol Phys 52:205–211PubMedCrossRefGoogle Scholar
  5. Bijl HP, van Luijk P, Coppes RP, Schippers JM, Konings AW, van Der Kogel AJ (2005) Regional differences in radiosensitivity across the rat cervical spinal cord. Int J Radiat Oncol Biol Phys 61:543–551PubMedCrossRefGoogle Scholar
  6. Boden G (1948) Radiation myelitis of the cervical spinal cord. Br J Radiol 21:464–469PubMedCrossRefGoogle Scholar
  7. Chang EL, Shiu AS, Mendel E, Mathews LA, Mahajan A, Allen PK, Weinberg JS, Brown BW, Wang XS, Woo SY, Cleeland C, Maor MH, Rhines LD (2007) Phase I/II study of stereotactic body radiotherapy for spinal metastasis and its pattern of failure. J Neurosurg Spine 7:151–160PubMedCrossRefGoogle Scholar
  8. Daly ME, Choi CYE, Gibbs IC, Adler JR, Chang SD, Lieberson RE, Soltys SG (2011) Tolerance of the spinal cord to stereotactic radiosurgery: insights from hemangioblastomas. Int J Radiat Oncol Biol Phys 80:213–220CrossRefGoogle Scholar
  9. Douglas BG, Fowler JF (1976) The effect of multiple small doses of x rays on skin reactions in the mouse and a basic interpretation. Radiat Res 66:401–426PubMedCrossRefGoogle Scholar
  10. Emami B, Lyman J, Brown A, Coia L, Goitein M, Munzenrider JE, Shank B, Solin LJ, Wesson M (1991) Tolerance of normal tissue to therapeutic irradiation. Int J Radiat Oncol Biol Phys 21:109–122PubMedGoogle Scholar
  11. Gerszten PC, Burton SA, Ozhasoglu C, Welch WC (2007) Radiosurgery for spinal metastases: clinical experience in 500 cases from a single institution. Spine 32:193–199PubMedCrossRefGoogle Scholar
  12. Gibbs IC, Patil C, Gerszten PC, Adler JR Jr, Burton SA (2009) Delayed radiation-induced myelopathy after spinal radiosurgery. Neurosurgery 64:A67–A72PubMedCrossRefGoogle Scholar
  13. Gwak HS, Yoo HJ, Youn SM, Chang U, Lee DH, Yoo SY, Chang HR (2005) Hypofractionated stereotactic radiation therapy for skull base and upper cervical chordoma and chondrosarcoma: preliminary results. Stereotact Funct Neurosurg 83:233–243PubMedCrossRefGoogle Scholar
  14. Marcus RB, Million RR (1990) The incidence of myelitis after irradiation of the cervical spinal cord. Int J Radiat Oncol Biol Phys 19:3–8PubMedCrossRefGoogle Scholar
  15. Medin PM, Foster RD, Follett K, Zhen W, van Der Kogel AJ, Solberg TD (2007) Spinal cord tolerence to radiosurgical dose distributions: a swine model. Int J Radiat Oncol Biol Phys 69:S250–S251CrossRefGoogle Scholar
  16. Pallis CA, Louis S, Morgan RL (1961) Radiation myelopathy. Brain 84:460–479PubMedCrossRefGoogle Scholar
  17. Park C, Papiez L, Zhang S, Story M, Timmerman RD (2008) Universal survival curve and single fraction equivalent dose: useful tools in understanding potency of ablative radiotherapy. Int J Radiat Oncol Biol Phys 70:847–852PubMedCrossRefGoogle Scholar
  18. Rampling R, Symonds P (1998) Radiation myelopathy. Curr Opin Neurol 11:627–632PubMedCrossRefGoogle Scholar
  19. Ryu S, Jin JY, Jin R, Rock J, Ajlouni M, Movsas B, Rosenblum M, Kim JH (2007) Partial volume tolerance of the spinal cord and complications of single-dose radiosurgery. Cancer 109:628–636PubMedCrossRefGoogle Scholar
  20. Schultheiss TE (2008) The radiation dose–response of the human spinal cord. Int J Radiat Oncol Biol Phys 71:1455–1459PubMedCrossRefGoogle Scholar
  21. Schultheiss TE, Stephens LC, Maor MH (1988) Analysis of the histopathology of radiation myelopathy. Int J Radiat Oncol Biol Phys 14:27–32PubMedCrossRefGoogle Scholar
  22. Schultheiss TE, Kun LE, Ang KK, Stephens LC (1995) Radiation response of the central nervous system. Int J Radiat Oncol Biol Phys 31:1093–1112PubMedCrossRefGoogle Scholar
  23. Uchida K, Nakajima H, Takamura T, Kobayashi S, Tsuchida T, Okazawa H, Baba H (2009) Neurological improvement associated with resolution of irradiation-induced myelopathy: serial magnetic resonance imaging and positron emission tomography findings. J Neuroimaging 19:274–276PubMedCrossRefGoogle Scholar
  24. Wang PY, Shen WC, Jan JS (1992) MR imaging in radiation myelopathy. Am J Neuroradiol 13:1049–1055PubMedGoogle Scholar
  25. Yamada Y, Bilsky MH, Lovelock DM, Venkatraman ES, Toner S, Johnson J, Zatcky J, Zelefsky MJ, Fuks Z (2008) High-dose, single-fraction image-guided intensity-modulated radiotherapy for metastatic spinal lesions. Int J Radiat Oncol Biol Phys 71:484–490PubMedCrossRefGoogle Scholar

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© Springer Science+Business Media B.V. 2012

Authors and Affiliations

  1. 1.Department of Radiation OncologyStanford University Medical CenterStanfordUSA

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