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Stephanie Olson
June 2, 2015
Craniospinal Irradiation Assignment
**I am using the prone position for this CSI assignment
1) If the patient were positioned prone, a board is usually placed
under the chest to build up the lower torso. What does this
accomplish?
To help create a horizontal line between the head and the body when a
patient is simulated in the prone position for CSI treatment, it may be
necessary to place a board (usually a piece of Styrofoam) under the
patients chest region. By using the board to create a horizontal line, it
is easier to standardize the source-to-skin distance to the spine.
2) How do you match the spine and head ports for a craniospinal
setup?
The inferior border of the cranial field matches with the superior border
of the spinal fields by rotating the collimator angle and couch angle for
the cranial fields. These rotations can be found using the following
equations:
To determine the collimator rotation needed for the cranial fields:
tan -1 = ( spinal field length/SAD)
To determine the couch rotation needed for the cranial fields:
tan -1 = ( cranial field length/SAD)
The collimator rotation is used to match the divergence from the PA
spine field while the couch rotation is used to account for the
divergence from the cranial fields. The picture below shows these
relationships.

For example, if the cranial field length was 20 cm and the spinal field
length was 40 cm at 100 SAD, the collimator and couch rotations
would be:
Collimator: tan -1 = ( spinal field length/SAD)
tan -1 = (20/100)
= 11 degrees
Couch:
tan -1 = ( cranial field length/SAD)
tan -1 = (10/100)
= 6 degrees
3) If you wanted to remove any divergence from the eyes in
the cranial port, how would this be accomplished? Why would
you do this?
When treating the brain using laterally opposed beams, the
contralateral eye will receive dose from the opposite beam due to
divergence. The lenses of the eyes are a critical structure and the
dose to this structure should be kept as low as possible. Optimally the
dose to the lens should be less than 10 Gy and if the dose is much
higher than this, there is a risk for cataract development. To correct for
the divergence, the degree of the gantry can be calculated by using
the following formula:
= tan -1 = ( x L)/SAD where L is the width of the field so x L is
equal to the distance from the isocenter to the canthus

Below is a picture showing how the rotation of the gantry will match
the divergence through the eyes for cranial fields.

4) In your own words describe the setup for a CSI adult patient
where 2 spine ports must be matched that extend to the
bottom of S-2.
Pretend you are telling the therapist everything that is needed
during the CT simulation.
To position a patient in the prone position for CSI treatment, the
following devices should be used: prone baseplate, thermoplastic
mask, alpha cradle or vac-loc mold and ankle sponge. The chin
position should be at a slight extension to avoid the exit dose from the
spine field from going through the mandible and oral cavity but not too
much that the extension creates a skin fold at the nape of the neck.
The spine should be as straight as possible. The patients arms should
be down at their sides with the shoulders pulled down as low as
possible. By pulling the shoulders down, this helps to ensure that the
lateral cranial fields will not go through that region and allows for the
cranial fields to be treated as low as possible into the cervical spine.
The use of the alpha cradle or vac-loc should be used under the chest,
abdomen and pelvis region to help with patient comfort and to help
build the patient up vertically on the table to create a horizontal line

from the head through the spine. The CT scan should extend from the
top of the head and extend through the thecal sac or the region of S23.
For treatment planning, approximately where will you place
the isocenter for each field for the patient above, will the
isocenters be moved? Why or why not? What are the
approximate field borders?
When simulating a CSI, typically the spine fields are simulated first and
then the brain fields are matched. The superior border of the upper
spine field is generally around the region of C7 or at the level just
above the shoulders. This level is usually a good superior border
because it avoids exit dose into the mandible and oral cavity and
allows for an adequate spot for the match edge between the cranial
and spinal fields. The upper spine field generally extends to the where
the true spinal cord ends or the bottom of the L1 vertebral body. The
field width is set to cover the spine with a margin specified by the
physician but is typically 1.5 to 2 cm lateral of the spine edge. The
picture below shows an example of the upper spine field.

To set the lower spine field, the couch height should stay the same and
a skin gap will need to be calculated using the formula:
Gap = x L1 (d/SSD1) + x L2 (d/SSD2) where L1 is the length of the
upper spine field, L2 is the length of the lower spine field, d is the
depth of the match point, SSD1 and SSD2 are the SSDs for the upper
and lower spine fields respectively.
The lower spine field lateral margin should be kept narrow towards the
top to avoid the kidneys but then widen out at the bottom to cover the
cauda equina and sacrum. The superior and inferior borders of the
lower spine field are typically L1 to S3. The picture below shows an
example of the lower spine field.

Once the spine fields have been simulated, the lateral brain fields can
then be matched to the upper spine fields using the collimator and
couch rotation equations described above. The isocenter is typically
placed near the pineal region. The inferior border of the cranial field
will match the superior border of the upper spine field while the
anterior, superior and posterior borders will need to flash the skull. An
MLC block will be drawn by the physician to block out the face but will
border at the cribriform plate. For all fields, the isocenters should be
placed in the same lateral position throughout the treatment area so
no lateral shifts will need to take place as you move from field to field.
Below are a sagittal and coronal view of the isocenter placement for
the brain, upper and lower spine fields.

Pretend that you must give the therapist a detailed description

for treatment (feathering the gaps) for the patient above.
How will the fields be feathered during treatment?
Feathering of fields is a technique used for CSI treatment to minimize
the effect of hot and cold spots which may occur at the match points
between fields. Adjusting the match points by one centimeter usually
two to three times throughout the treatment course will help to smear
out the hot and cold spots. Feathering can be done by either shifting
the fields in increments on either a daily basis or at set points
throughout the course of treatment (ie: every 3 days) or by adjusting
the jaw settings of the fields while keeping the isocenters at the same
positions throughout treatment. At our institution, we keep the
isocenter constant and adjust the jaw settings three times throughout
the course of treatment. With the isocenters constant, the superior

border of the upper spine field is adjusted one centimeter in the

superior or cranial direction while the inferior border of the brain field
is also adjusted one centimeter in the superior or cranial direction to
ensure the match is adequate. For the feathering between the upper
and lower spine fields, the inferior border of the upper spine field is
adjusted one centimeter in the inferior or caudal direction while the
superior border of the lower spine field is also adjusted one centimeter
inferiorly. Again, this is done to keep the appropriate gap needed
between the spine fields. Below is a picture showing the different
junctions used for the field feathering technique.