The Neck Moves, Too

Alyssa Mellott
RadSci 3414
Reaction Paper
1. Garg M, Yaparpalvi R, Beitler J. Loss of cervical spinal curvature during radiotherapy
for head-and-neck cancers: the neck moves, too. International Journal Of Radiation
Oncology, Biology, Physics. January 2004;58(1):185.
2. AhnP,AhnA,GargM,etal.RandomPositionalVariationAmongtheSkull,
Mandible,andCervicalSpineWithTreatmentProgressionDuringHeadandNeck
Radiotherapy.InternationalJournalOfRadiationOncology,Biology,Physics.February
2009;73(2):626633.
Since Ive started studying the field of radiation therapy (RT), the most surprising
aspect has been the recent and continual changes occurring in the methods of treatment. I
thought it would be very standardized until we discussed how many differing opinions still
exist, and the large amount of protocols that have been put in place just within the last
decade. Ive already experienced this first hand, seeing small changes in treatment
regulations during my first rotation at the James Cancer Hospital. Ive also had a chance
to observe how much treatment and immobilization techniques can vary from one location
to another in my first week at Riverside Methodist Hospital. This being said, I believe it is
necessary to keep questioning the best ways to use RT in cancer treatment. The first article
listed above describes a negative consequence that head-and-neck immobilization
techniques can have on reproducibility in treating these types of cancers with RT. This
investigation was especially intriguing to me after predominantly treating head-and-neck
patients during my time at the James SBRT. The article highlights how the cervical spinal
angle (CSA) can change over the course of a head and neck treatment, even when custom
immobilization is used. This can lead to changes in the position of the neck, causing

inaccuracy in treatment. To summarize the main idea, they quoted a movie stating, The
head may control the body, but the neck controls the head. 1
When it comes to immobilization in RT, it seems that restricting a patient would create
a more precise treatment. Perhaps one of the most restrictive techniques is the custom
head-and-neck mask, but Gargs study suggests it may not be the best method for some
patients. In a study involving 50 patients with custom masks, shoulder pulls, and multiple
tattoos, their CSAs (from C2 to C6) changed significantly.1 This was especially true in
those with lower isocenters; they had an average decrease of 3.8 in their CSAs, while the
rest of the participants had an average decrease of 1.7.1 The article does not elaborate on
the effects a decrease in CSA can have on treatment outcomes, but it suggests that a more
comfortable position may be better for reproducibility than some of the unnatural positions
that are used. Though a more detailed solution is not proposed, the results of this study
are certainly significant enough to look further into the pros and cons of head and neck
immobilization techniques.
After additional research, I discovered more sources that suggest problems with the
way we secure head and neck patients. According to the Ahn researchers, There are at
lease 54% separate degrees of freedom in movement of the head and neck. 2 This is why
they compared bony anatomy to check for changes throughout head and neck treatments.
They found significant random variation in patient positioning of the skull, mandible, and
cervical spine elements.2 Theyre propositions for better patient positioning are more
detailed, and include meticulous immobilization along with daily pretreatment imaging,
and a bite block to help secure the mandible.2 Unlike the Garg article, which suggests
more comfortable and natural positions, these researchers believe that more intense

immobilization is the key. So, what is the best method? Only further investigation will
provide the answer to this question.
To conclude, I believe that the findings in the Garg article should be considered in the
practice of head and neck RT. Even when custom immobilization applied, it is shocking
how much movement is enabled, especially from C1 to C6. Though the Garg article
researchers pinpointed a significant problem, the article seems incomplete and it needs to
be expanded upon. For example, I though it was strange that they did not specify whether
or not custom head rests were used in the study. This seems to be an important aspect of
the methods section in an investigation that is assessing neck movement. Furthermore,
they didnt elaborate on how the changes in CSAs could effect the actual treatments. This
is the kind of evidence needed to convert a clinical investigation into real changes. Finally,
I think they should have included a more thorough plan to improve head and neck patient
positioning. Im sure there are future sources that will address these questions. Right now,
Id like to learn more by asking some of the therapists if theyve heard of similar findings,
and if they believe we are using the best methods to secure head and neck patients.