Volumetric modulated arc therapy (VMAT) can be used with multiple isocenters to provide an effective treatment of the craniospinal axis. Additional efficiency can be achieved by simultaneously applying linear couch motion to generate a helical arc trajectory. This study investigated the treatment planning and delivery of helical VMAT for treatment of the craniospinal axis.VMAT plans were retrospectively created for 5 patients. The first plan consisted of multiple separate arcs. A second plan consisted of a single helical arc with a pitch of 10 cm. Three additional plans consisted of multiple helical arcs with the beam rotating alternately clockwise and counterclockwise to avoid the need for the gantry to pass through 180°. The three plans had a pitch of 5, 10, and 15 cm. For 1 of the patients, three possible plans with alternate gantry motion and a pitch of 10 cm were delivered helically, and the dose was verified.Relative to the plan with separate arcs, the continuous helical plan produced a mean objective value of 104.0% ± 14.8% (standard deviation), and the alternating helical plans produced an objective value of 118.9% ± 9.8%, 102.3% ± 13.5%, and 101.5% ± 15.8% for a pitch of 5 cm, 10 cm, and 15 cm, respectively (with lower values representing better plans). For the delivered plans, taking a mean of 17 min 51 s to deliver, a mean of 97.1% of the measurements were within 4% and 4 mm of the planned dose.A continuous helical VMAT plan provides comparable dose quality to a plan with separate VMAT arcs. Comparable quality is also produced by an alternating helical plan, provided the pitch is chosen appropriately. Alternating helical plans have been delivered and verified successfully. Alternating helical delivery offers the ultimate delivery efficiency for intensity-modulated radiotherapy for the craniospinal axis.