Devoted to diagnostic and interventional spine imaging and therapeutics


Imaging-guided percutaneous fiducial seed placement for Cyberknife stereotactic radiosurgery of the thoracic spine 2007

Interventional Spine

Jonathan S Luchs, MD
Orlando Ortiz, MD, MBA, ASSR Member
Alan J Katz, MD, Non ASSR Member
Matthew R Witten, PhD, Non ASSR Member
Nancy E. Epstein, MD, Non ASSR Member

Scientific Paper


To report our preliminary experience with fluoroscopy guided placement of gold seed fiducials in three outpatients with thoracic spine pathology (two with vertebral body metastases, one with an intraspinal intradural extra medullary mass).

Methods & Materials

The fiducials are placed bilaterally into two non-contiguous , alternating vertebral bodies using coaxial technique, strict aseptic technique, local lidocaine anesthesia at the puncture sites, and intravenous sedation and analgesia. A posterior bilateral transpedicular approach is used with the patient in the prone position. A 10 gauge Kyphx bone needle (Kyphon Co., Sunnyvale, CA) is advanced into the posterior pedicle. A twist drill is then used to create a working channel with a trajectory that is direct towards the lateral aspect of the vertebral body. When indicated, a biopsy specimen can be obtained using a biopsy cannula that can be inserted through the bone needle cannula. A 20 cm length 17G needle which contains a 1.2 mm gold fiducial, is then advanced into the working channel. The gold seed is then deployed into the vertebra under direct fluoroscopic visualization. This procedure is repeated on the opposite side of the vertebra such that two fiducials are placed per vertebra. Confirmatory radiographs are obtained in the frontal, lateral, and both 45 degree oblique projections. The puncture sites are secured with steri-strip bandaids. The patient is then recovered for 1 hour and discharged home.


The procedure was efficiently and safely performed in all 3 patients. Successful fiducial placement was observed. Furthermore, stable fiducial locations were confirmed at one week stereotactic localizing CT�s of the thoracic spine. The procedure provided effective localization for subsequent radiosurgery using the Cyberknife.


Fluoroscopy guided gold seed fiducial placement can be performed effectively and without complication using coaxial technique.


1. CyberKnife frameless single-fraction stereotactic radiosurgery for benign tumors of the spine. Gerszten PC, Ozhasoglu C, Burton SA, Vogel WJ, Atkins BA, Kalnicki S, Welch WC. Neurosurg Focus. 2003 May 15;14(5):e16.
2. CyberKnife frameless stereotactic radiosurgery for spinal lesions: clinical experience in 125 cases. Gerszten PC, Ozhasoglu C, Burton SA, Vogel WJ, Atkins BA, Kalnicki S, Welch WC. Neurosurgery. 2004 Jul;55(1):89-98; discussion 98-9.
3. Image-guided hypo-fractionated stereotactic radiosurgery to spinal lesions. Ryu SI, Chang SD, Kim DH, Murphy MJ, Le QT, Martin DP, Adler JR Jr.Neurosurgery. 2001 Oct;49(4):838-46.

Ortiz- Kyphon
Luchs- Kyphon