Symptomatic adjacent segment disease after cervical total disc replacement: re-examining the clinical and radiological evidence with established criteria.

BACKGROUND CONTEXT: Although several publications in the last decade have proved equality in safety and efficacy of the total disc replacement (TDR) to the anterior fusion procedure in cervical spine, the claim that TDR may reduce the incidence of adjacent segment disease (ASD) has not been corroborated by clinical evidence. PURPOSE: We attempt to predict the true incidence of symptomatic ASD after TDR surgery in the cervical spine at one or two levels at a median follow-up period of 4 years. STUDY DESIGN: A total of 763 patients were screened to participate in four different Food and Drug Administration device exemption trials for artificial cervical disc replacement at three collaborating institutions. Two hundred seventy-one patients qualified and enrolled in the trials. One hundred seventy-three randomized to receive artificial disc replacement surgery, and 167 have completed a 4-year or longer follow-up. OUTCOME MEASURES: Patients experiencing cervical radiculopathy symptoms in the follow-up period were worked-up with clinical examinations, magnetic resonance imaging of the cervical spine, and other diagnostic studies. Once a clinical correlation was established with the imaging evidence of adjacent segment degeneration, a careful record was maintained to document the subsequent medical and/or surgical treatment received by these patients. Statistical analysis was performed to determine the true incidence of and factors affecting the ASD after cervical disc replacement in these patients. RESULTS: Twenty-six patients (15.2%) were identified to satisfy our criteria for ASD at the median follow-up of 51 months, with the annual incidence of 3.1% as calculated by life tables. The actuarial 5-year freedom from ASD rate was 71.6%±0.6%, and the mean period for freedom from ASD was 70.4±2.1 months. CONCLUSIONS: The incidence of symptomatic ASD after cervical TDR is 3.1% annually regardless of the patient's age, sex, smoking habits, and design of the TDR device. The presence of osteopenia and lumbar degenerative disease significantly increase the risk of developing ASD after anterior cervical surgery.

Factors affecting the incidence of symptomatic adjacent-level disease in cervical spine after total disc arthroplasty: 2- to 4-year follow-up of 3 prospective randomized trials.

STUDY DESIGN: Prospective randomized clinical trials. OBJECTIVE: To compare the outcome data with respect to clinical success rates and incidence of adjacent level disease (ALD) in patients after total disc arthroplasty (TDA) or anterior cervical fusion (ACDF) for 1- and 2-level cervical disc disease. SUMMARY OF BACKGROUND DATA: Previously published studies have provided evidence that ACDF procedure for cervical degenerative disc disease (DDD) may increase the stress on the nonoperated adjacent cervical segments, thus possibly increasing the risk of degeneration at these levels. The theoretical assumption that TDA may reduce the incidence of future ALD by preserving motion at the affected segments has, however, never been validated by clinical evidence. METHODS: One hundred seventy patients with established symptomatic cervical disc disease at 1 or 2 levels participated in 3 prospective randomized clinical trials at 2 institutions. Participating subjects were randomized to receive TDA (treatment; n = 113) or ACDF (control; n = 57) by 6 independent investigating surgeons. Visual analogue pain scores (0-100), Neck Disability Index, neurological examination, and cervical spine radiographs were collected at enrollment and then 6 weeks and 3, 6, 12, 24, 36, and 48 months after surgery. Patients with persistent symptoms during the follow-up period were investigated for adjacent segment disease (ASD) with computed tomography/magnetic resonance imaging of the cervical spine, neurophysiology, and subsequent active interventions. RESULTS: At the median follow-up of 42 months (range: 28-54 months), 9 (14.3%) ACDF and 19 (16.8%) TDA patients developed and were actively treated for ASD. Osteopenia dust energy x-ray absorptiometry T scores of -1.5 to -2.4) (P = 0.04; 95% confidence interval [CI]: 0.007-0.223) and concurrent lumbar degenerative disease (P = 0.02; 95% CI: 0.003-0.196) significantly increased the risk of ASD. CONCLUSION: The risk of developing adjacent segment degeneration was equivalent at median 38 months after both ACDF and TDA procedures in cervical DDD. Osteopenia and concurrent lumbar DDD significantly increase the risk of ALD.

Total disc arthroplasty and anterior cervical discectomy and fusion in cervical spine: competitive or complimentary? Review of the literature.

Anterior cervical discectomy and arthrodesis has come to represent standard of care for patients with persistent radicular and/or myelopathic symptoms that have failed to improve with conservative treatments. One potential complication of the procedure is the accelerated degeneration of the vertebrae and the intervertebral discs adjacent to the level fused and the effects of fusion on those levels. The concern that fusion may be a contributing factor to accelerated adjacent segment degeneration led to increased interest in cervical disc replacement after anterior decompressive surgery. Several studies analyzing the short-term outcomes of the disc replacement procedure have been published since then, and the pros and cons of both procedures continue to remain a topic of debate among the scientific community. The analysis of published literature and our own experience has convinced us that the overall longer-term clinical outcomes after anterior cervical discectomy and fusion (ACDF) and total disc replacement (TDR) in the general patient population are not significantly different in terms of symptomatic improvement, neurological improvement, and restoration to better quality of life. Age of the patients and number of affected levels may impact the outcomes and hence determine the choice of optimum procedure. To definitely compare the incidence of adjacent segment disease after these procedures, multi-institutional studies with predetermined and unanimously agreed upon clinical and radiological criteria should be undertaken and the results analyzed in an unbiased fashion. Until that time, it is reasonable to assume that ACDF as well as cervical TDR are both safe and effective procedures that may have outcome benefits in specific patient subgroups based upon demographics and clinical/radiological parameters at the time of surgery.

The use of osteo-conductive stem-cells allograft in lumbar interbody fusion procedures: an alternative to recombinant human bone morphogenetic protein.

UNLABELLED: The use of autogenous bone graft in spinal fusion is progressively declining. Different allografts including the human bone morphogenetic protein have been proposed to facilitate fusion rates but are associated with various adverse effects. Osteocel belongs to a new class of allograft tissue material that is a re-absorbable biomaterial with allogenic mesenchymal stem cells. The purpose of the present retrospective study was to analyze the clinical effectiveness of mesenchymal stem cells allograft (Osteocel") to achieve radiological arthrodesis in adult patients undergoing lumbar interbody fusion surgery for different indications. Fifty-two consecutive patients received lumbar interbody fusion at one (69%) or two contiguous (31%) levels of lumbar spine for various indications. The mean age was 50 (range, 27 to 77) years; 60% were females; 43% were habitual smokers and 21% had previously failed surgery at the index level(s). OUTCOME MEASURES: Radiographic analyses of fusion by plain films and CT scans. Procedures performed were circumferential fusion (67%), ALIF (17%) and TLIF (16%). Followup radiographic data was analyzed to establish arthrodesis versus failure (pseudarthrosis), number of months until achievement of fusion, and possible factors affecting the fusion rate. Followup ranged from 8 to 27 (median, 14) months. Solid arthrodesis was achieved in 92.3% of patients at median followup time of 5 months (95% Cl; range, 3 to 11 months). Kaplan-Meier survival curves and Mantle-Cox test were conducted to assess the effect of various factors on the rate of fusion. Statistics showed that increasing age (older than 50 years) (p = 0.017) and habitual smoking (p = 0.015) delayed the fusion time and increased the risk of pseudarthrosis. The use of Osteocel allograft is safe and effective in adult patients undergoing lumbar interbody spinal fusion procedure. Increased age and habitual smoking delays fusion but gender, previous surgery at the index level, type of procedure and number of levels do not affect the fusion rates.

Cervical ganglioneuroma in an adult man: case report and literature review of a rare occurrence.

OBJECTIVE AND IMPORTANCE: Ganglioneuromas are rare benign tumors of the neural crest occurring in early childhood. They are occasionally diagnosed in young adults due to their mass-effect on adjacent structures. We report a case of ganglioneuroma incidentally diagnosed in an adult man. CLINICAL PRESENTATION: A 41-year-old man presented with left-sided cervical radiculopathy symptoms due to degenerative disc disease at the C5-6 and C6-7 levels. The diagnostic radiology work-up revealed a mass in the left side of the neck between the carotid artery and jugular vein. INTERVENTION: Surgical excision of the mass was performed and the histological diagnosis of ganglioneuroma was established. The patient developed left-sided Horner's syndrome post-operatively. CONCLUSION: The present case suggests that these tumors may have insidious presence in the adult population, and therefore, should be considered in the differential diagnosis of a lateral neck mass in asymptomatic adult patients.

Total disc arthroplasty does not affect the incidence of adjacent segment degeneration in cervical spine: results of 93 patients in three prospective randomized clinical trials.

BACKGROUND CONTEXT: Advancements in the philosophy of "motion preservation" have led to the use of total disc arthroplasty (TDA) as an alternative to fusion for degenerative disc disease (DDD) in the cervical spine. A commonly proposed theory is that TDA could reduce the incidence of adjacent segment disease. All the published clinical studies for TDA discuss the "equal efficacy" results of different investigational device exemption (IDE) trials between TDA and anterior cervical discectomy and fusion (ACDF) but have not addressed the issue of adjacent segment disease. PURPOSE: To present the comparison of outcome data with respect to clinical success rates, symptom-free period, and incidence of adjacent segment disease in 93 patients with one- and two-level cervical DDD treated with TDA or ACDF in three different Food and Drug Administration (FDA) investigational trials. STUDY DESIGN: Prospective, randomized, FDA IDE trials. PATIENT SAMPLE: Ninety-three patients with established symptomatic one-or two-level cervical disc disease who failed to respond to conservative treatment were randomized to receive TDA (59) or ACDF (34) as part of clinical trials involving three different artificial discs at our institution. Subjects were blind to the assigned group until after the surgery. OUTCOME MEASURES: Visual analog pain score (VAS), Neck Disability Index, and cervical spine radiographs were collected at 6 weeks and at 3, 6, 12, 24, 36, and 48 months after surgery. METHOD: Success of the index surgery was assessed based on outcome measures at the seven data points. Success was defined as reduction by more than 30 points in both VAS and Neck Disability Index, absence of neurological deficits, and no further intervention at the index level. Adjacent segment disease was established by radiology, neurophysiology, and subsequent interventions administered to the patients. RESULTS: At median follow-up of 37 months (range, 24-49 months), 64 (25 ACDF and 39 TDA) patients satisfied the criteria for clinical success. Neck Disability Index was a better predictor of outcome than pain score (p<.05). Sixteen percent of TDA patients and 18% ACDF patients developed adjacent segment degeneration and were treated actively (p=.3). Concurrent lumbar DDD significantly increased the risk of adjacent segment degeneration (p=.01). Age, gender, smoking habits, and number of levels at index surgery had no predictive value. CONCLUSION: Total disc arthroplasty is equivalent to ACDF for providing relief from symptoms in the treatment of one- and two-level DDD of cervical spine. The risk of developing adjacent segment degeneration is equivalent after both procedures but is significantly higher in patients with concurrent DDD in lumbar spine.

Delayed hyper-reactivity to metal ions after cervical disc arthroplasty: a case report and literature review.

STUDY DESIGN: Anecdotal case report. OBJECTIVE: To report a very interesting and perplexing complication of cervical total disc arthroplasty that has not been previously reported in literature. SUMMARY OF BACKGROUND DATA: Although there has been increasing interest in the field of artificial disc replacement to treat cervical degenerative disc disease, not much has been mentioned in the literature about the potential complications of the disc itself. We encountered a delayed complication in 1 patient that has not been reported in the literature. METHOD: Thirty-nine-year-old white woman received total disc arthroplasty for herniated intervertebral disc at C5-C6 level uneventfully. She had recurrence of symptoms 9 months after the procedure and failed to respond to conservative measurements. Imaging revealed soft tissue mass posterior to the implanted disc encroaching the spinal cord. RESULTS: Surgical explantation and exploration of the disc space revealed thick layer of abnormal hyaline cartilaginous tissue with chronic inflammatory debris. The patient had complete resolution of symptoms after the revision surgery. CONCLUSION: Although there is increased enthusiasm about motion preservation technology and disc replacement surgery for intervertebral disc herniation, unexpected complications like the present case need to be shared within the scientific community to better understand the risks associated with these new and promising devices.

Implant design may influence delayed heterotopic ossification after total disk arthroplasty in lumbar spine.

BACKGROUND: As total disk arthroplasty (TDA) gains increasing acceptance as an alternative to fusion for degenerative disk disease of the lumbar spine, new complications are encountered by the physicians during and after the procedure. We hereby report a complication after TDA in the lumbar spine that is in variance from previously proposed theories and suggests the possibility of implant design as one of the etiologic factors. The purpose of the present submission is to report a case of delayed heterotopic ossification (HO) after TDA that suggests that the keel-based design of the implant might have contributed to the etiology. CASE DESCRIPTION: The patient underwent TDA for L3-4 degenerative disk disease and had fusion surgery for L5-S1 disease about 6 months later. During follow-up, development of significant HO was noticed at the L3 and L4 level. Radiologic studies revealed the origin of HO to be the keel cut made in the body of L3 to accommodate the keel-based artificial disk. CONCLUSION: The exact etiology of HO after TDA is not clear. The presented anecdote points toward vertebral body trauma due to the design of the implant as a possible factor that needs to be studied more elaborately.

Choice of plate may affect outcomes for single versus multilevel ACDF: results of a prospective randomized single-blind trial.

BACKGROUND CONTEXT: Conflicting views exist according to the individual philosophy about various plate designs that can be used in anterior cervical discectomy and fusion (ACDF) to achieve clinical and radiological improvement within shortest time period. No prospective randomized study has ever been conducted to clarify the relationship between clinical outcomes, fusion rates, and the choice of plate (static vs. dynamic design). PURPOSE: To compare the clinical and radiological outcomes of patients treated with one-level or multiple levels ACDF using cervical plates of dynamic (slotted-holes) versus static (fixed-holes) design. STUDY DESIGN: Single masked, prospective, randomized study. PATIENT SAMPLE: Over a 4-year period, 66 patients (M:F=37:29) had ACDF using either dynamic (n=33) or static (n=33) plates for intractable radiculopathy as the result of degenerative cervical spine disease. Overall, 28 patients had single-level fusion and 38 had two or three levels fused. OUTCOME MEASURES: Visual Analogue Pain scores (VASs), Neck Disability Index (NDI), and radiological criteria of established fusion. METHODS: The qualifying subjects were randomized to receive ACDF using either fixed-holes (static) or the slotted-holes (dynamic) anterior cervical plates. Clinical and radiographic data were collected and analyzed. Paired-sample t test was used to correlate clinical and radiological outcomes and General Linear Model Analysis of Variance (GLM ANOVA) with repeated measures was used to detect outcome differences between the two groups for single and multiple fusions. RESULTS: At a mean follow-up of 16 months (range, 12-24), 49 patients (73.7%) had clinical success and 56 (85%) showed radiological fusion. Although clinical success was a predictor of fusion (p=.043), the reverse was not true (p=.61). In single-level fusion, no statistical difference of outcome was observed between the two groups but multilevel fusions with dynamic plate showed significantly lower VAS and NDI than those with static plates (p=.050). CONCLUSIONS: Although clinical improvement is a good predictor of successful ACDF, radiological evidence of fusion alone is not reliable as a parameter of success. The design of plate does not affect the outcomes in single-level fusions but statistics indicate that multiple-level fusions may have better clinical outcome when a dynamic plate design is used.

Intradiscal electrothermal therapy (IDET): a viable alternative to surgery for low back pain in workers' compensation patients?

OBJECTIVE: This prospective study was conducted to evaluate improvements in pain and disability in a series of 53 consecutive worker's compensation patients with discogenic low back pain following treatment with the intradiscal electrothermal therapy (IDET) procedure. MATERIAL AND METHODS: Between 2002 and 2004, a total of 53 consecutive patients, who were claimants of worker's compensation, were treated using IDET for their discogenic low back pain. The outcomes of these patients were analyzed statistically for the current study by physical exam and self-assessment questionnaires of pain and disability at baseline and at 24-months post-procedure. Pain and disability outcomes were assessed by visual analog pain score (VAS) on a 0-100 mm scale and Oswestry Disability Index respectively. RESULTS: The mean patient age was 41.83 years (range 20 to 61 years). Caucasians (53 %), African-Americans (30%), and Hispanics (17%) formed the majority of population. Forty-nine percent were using narcotic pain medications at the time of initial assessment. The first definitive end point was considered at 24 months after the procedure. Median follow-up period was 56 months (range 29-72 months). A mean reduction (p < 0.001) of 63% in the VAS score and 70% in the Oswestry scores was noted after IDET. The patient's initial VAS and Oswestry scores (p < 0.05) significantly affected the final outcomes. Forty-seven percent of the patients returned to some degree of economic productivity and only seven (initial 26) consumed narcotic analgesics. CONCLUSION: IDET procedure can be a useful, safe and cost-effective option in the management of carefully selected workers' compensation claimants with chronic low back pain of discogenic etiology.

Comparison of pressure effects on adjacent disk levels after 2-level lumbar constructs: fusion, hybrid, and total disk replacement.

BACKGROUND: With increasing advocacy for the use of TDR procedure as a surgical alternative to fusion in the management of lumbar DDD, intradiskal pressures at the adjacent levels of spine have generated considerable interest. The common belief is that adjacent-level disk pressures will be lower after a TDR as opposed to conventional fusion. The aim of this study is to present the effect of different constructs on adjacent-level disk pressures in lumbar spine. We hypothesized that the adjacent-segment disk pressures after 1- and 2-level TDR and/or a fusion-TDR hybrid procedure will show significant variance within physiological range of motion. METHODS: Six adult spine segments T12-S1 with intact ligaments were harvested from cadavers and held firmly in a specially designed fixture. Intradiskal pressures, in motions of flexion, extension, and lateral bending, at L2-L3 and L3-L4 were measured using needle transducers after 2-level TDR L4 through S1, hybrid procedure, and 2-level fusion L4-S1 with femoral ring allograft and pedicle screws. RESULTS: The pressures with lateral bending were not significantly lower than those with flexion and extension at both levels (P = .18). Although TDR and hybrid specimens recorded slightly lower pressures specifically during lateral bending, no statistical difference in pressures could be detected when movements were combined with various procedures. CONCLUSION: Contrary to the assumed hypothesis, the pressures at the adjacent-level disks (L3-4 and L2-3) did not depend upon the stabilization procedure (2-level disk replacement, hybrid, or 2-level fusion) performed after 2-level diskectomy in the lumbosacral spine.

Intradiscal electrothermal therapy (IDET) for low back pain in worker's compensation patients: can it provide a potential answer? Long-term results.

OBJECTIVE: This prospective study was conducted to evaluate improvements in pain and disability in a series of 53 consecutive worker's compensation patients with low back pain (LBP) after treatment with the intradiscal electrothermal therapy (IDET) procedure. MATERIALS AND METHODS: All patients seen in the out-patient clinic of the Spine Institute of Louisiana for LBP of discogenic origin were screened for eligibility to receive IDET procedure. A total of 134 patients were treated using IDET for their discogenic LBP during the study period. Fifty-three patients presented to us via the worker's compensation claim program. The outcomes of these 53 patients were analyzed statistically for the current study by physical examination and self-assessment questionnaires of pain and disability at baseline and at 12-months postprocedure. Pain and disability outcomes were assessed by visual analog scale (VAS) pain score and Oswestry disability index, respectively. RESULTS: The mean patient age was 41.83 years (range 20 to 61 y). Whites (52.8%), African-Americans (30.2%), and Hispanics (17%) formed the majority of population. Forty-nine percent were using narcotics. The first definitive end point was considered at 12 months after the procedure. Median follow-up period was 56 months (range 29 to 72 mo). A mean reduction (P<0.001) of 62.6% in the VAS score and 69.3% in the Oswestry scores was noted after IDET. The patient's initial VAS and Oswestry scores (P<0.05) significantly affected the final outcomes. About 47.2% of the patients had some degree of economic productivity and only 7 (initial 26) consumed narcotic analgesics. CONCLUSIONS: IDET procedure can be a useful, safe, and cost-effective option in the management of carefully selected workers compensation claimants with chronic LBP of discogenic etiology.

Intraspinal meningioma in a 101-year old: should age determine the aggressiveness of intervention?

BACKGROUND: Intraspinal meningiomas are less frequent in occurrence as compared with their intracranial counterparts. Typical presentation is onset of new spinal pain followed by other deficits in the sixth decade of life. Although total surgical removal is the optimum treatment, various tumor- and patient-related factors can determine the aggressiveness of the surgical endeavor. We present our experience of diagnosis and management of cervical intraspinal meningioma in the oldest reported patient (101 years) with an atypical clinical presentation and remarkable dissociation between clinical and radiologic findings. METHOD: The patient, a 101-year-old woman, experienced progressive weakness in her legs. Motor examination revealed no definite weakness. There was stocking type sensory loss to just below the knees bilaterally. The MRI of the cervical spine showed an enhancing mass anterolateral to the cord at the region C7 through T1. It markedly compressed the cord. RESULT: The tumor was removed in total, and the dural attachment was thoroughly coagulated. CONCLUSION: The presented experience supports the belief that, in spinal meningiomas, a good clinical outcome can be expected even in patients who may be less than perfect candidates for an aggressive surgical approach.

Primary osteoblastic osteosarcoma in an elderly female: a case report of perplexing presentation.

With advances in imaging technology and increased alertness by clinicians, the reported incidence of primary vertebral osteosarcoma (PVOS) has increased in recent times and, therefore, the importance of its correct diagnosis has repeatedly been emphasized. One such case of PVOS is reported, that presented with insidious clinical, radiological and pathological findings, resulting in a slightly delayed final diagnosis and treatment.

Exposure of brain to high-dose, focused gamma rays irradiation produces increase in leukocytes-adhesion and pavementing in small intracerebral blood vessels.

OBJECTIVE: Radiosurgery is used to destroy a predetermined target within the brain, with minimal radiation injury to the surrounding tissue. We hereby present our in vivo model to study the effects of single-session, high-dose radiation on the cerebral vessels that are targeted with radiosurgery using the Leksell Gamma Knife. METHODS: The study was conducted in 29 adult male WT C57BL/6J mice weighing 21 to 28 g (6-8 wk old). The animals were exposed to 100 Gy single-session focused gamma ray irradiation using the Leksell Gamma Knife, and subsequently underwent intravital microscopy at different time intervals to study leukocytes and platelets adhesion patterns to the endothelium of the irradiated cerebral micro-vessels. RESULTS: The leukocyte adhesion response showed a bell-shaped curve upon quantitative analysis with a steady increase in the number of adherent cells during the first four hours and a subsequent plateau response that was maintained during the next 24 hours. The platelet adhesion response did not demonstrate any particular pattern similar to the leukocyte response. CONCLUSION: The experiment was able to establish in vivo increased leukocyte adhesion to the cerebral vascular endothelial cells in response to radiation injury and elaborate the time frame within which the leukocyte adhesion response increases, reaches a peak and then starts decreasing.

Primary central nervous system lymphoma of the brain stem responding favorably to radiosurgery: a case report and literature review.

OBJECTIVE: To explore various therapeutic alternatives and evaluate the clinical results of patients with primary central nervous system lymphoma (PCNSL). We report a case of PCNSL with involvement of the brain stem managed with radiosurgery using the Leksell gamma knife as the treatment modality. CASE DESCRIPTION: A 55-year-old white woman presented with complaints of weakness on the left side of her body and double vision associated with a frontal headache. Nervous system examination revealed right-sided oculomotor palsy and left-sided motor paresis, grade 2/5, in both upper and lower limbs. Her Karnofsky performance score was 50. A contrast-enhanced magnetic resonance imaging scan of the brain revealed an irregular space-occupying lesion in the pons that enhanced uniformly with gadolinium. A frame-based stereotactic biopsy was performed revealing a B-cell malignant lymphoma. Subsequently, stereotactic radiosurgery using the Leksell gamma knife was performed. A dose of 11 Gy was delivered to the tumor margin. A follow-up magnetic resonance imaging scan after 2 months revealed a 50% reduction in the size of the enhancing lesion. CONCLUSION: Our own results and limited evidence from the literature suggest stereotactic radiosurgery as a potentially safe and effective treatment option in patients with PCNSL.

Role of stereotactic radiosurgery as a primary treatment option in the management of newly diagnosed multiple (3-6) intracranial metastases.

OBJECTIVE: The objective of this study was to assess the role of stereotactic radiosurgery in the management of newly diagnosed multiple intracranial metastases from known primary cancer locations. METHODS: Fifty (29 women and 21 men) patients received radiosurgery for newly diagnosed 3 or more metastatic brain tumors. Their mean age was 53 years. Lung cancer was the most common primary cancer (66%). RESULTS: Arrest in the growth of irradiated tumors was achieved in 41 (82%) patients. Eight patients (16%) required further intervention for tumors in other brain locations. Mean survival after diagnosis of brain disease was 12 months and the brain disease-controlled period was 19 months. The period of brain disease control prolonged (P=.03) with decreasing tumor volumes (<10 mL). Control of treated tumors positively affected survival after diagnosis of brain disease (P=.0001). CONCLUSION: Radiosurgery as an adjuvant improves survival in patients with cancer who have newly diagnosed multiple intracranial metastases by arresting the growth of tumors.