The temporal effect of Category II fetal monitoring on neonatal outcomes.

OBJECTIVE: To correlate the duration of Category II cardiotocograms (CTG) with adverse neonatal outcomes associated with perinatal asphyxia and determine the duration before fetal compromise. STUDY DESIGN: This retrospective, observational study used electronic medical record data from a cohort of 271 patients, delivered by C-section due to non-reassuring fetal heart rate, at a tertiary medical center, from 2015 through 2017. Duration of Category II CTG, variability, tachycardia and deceleration frequency were analyzed and correlated to immediate postnatal outcomes. including cord pH ≤ 7, cord base excess >12, 1- and 5-min Apgar scores ≤7, need for ventilation, need for chest compressions, NICU admission, hypoglycemia and convulsions. Intrapartum fever and meconium stained amniotic fluid were correlated to the same outcomes. Categorical and continuous variables were analyzed using chi-square and t-tests, respectively. P < 0.05 was considered significant. RESULTS: The mean duration of Category II CTG was 146 min (range 17-553). Longer duration did not result in increased rates of adverse neonatal outcomes. In contrast, reduced fetal heart rate (FHR) variability, fetal tachycardia and intrapartum fever did show increased rates of adverse neonatal outcomes, as follows: patients exhibiting reduced vs. normal (FHR) variability had 12.9% vs. 1.4% cord pH ≤ 7, P = 0.006 and 12.5% vs. 1.3% cord BE > 12, P = 0.004: patients with fetal tachycardia vs. normal baseline FHR exhibited 48% vs. 17.9% 1-minute Apgar score ≤7, P = 0.0004; 8% vs. 0.8% 5-minute Apgar score ≤7, P = 0.04; and 48% vs. 18.7% ventilation support, P < 0.001; patients with intrapartum fever vs. normal temperature, cord BE > 12 was seen in 9.7% vs. 1.7%, P = 0.035; 1-minute Apgar score was ≤7 in 35.5% vs. 18.7%, P = 0.03; 5-minute Apgar score ≤7 in 9.7% vs. 0.4%, P = 0.005; need for ventilation in 35.5% vs. 19.6%, P = 0.042; need for chest compressions in 6.45% vs. none, P = 0.013; and NICU admission in 12.9% vs. 2.5%, P = 0.018. CONCLUSIONS: Our results suggest that the duration of Category II CTG alone does not appear to predict perinatal asphyxia. Parameters associated with perinatal asphyxia are reduced FHR variability, fetal tachycardia and intrapartum fever. Therefore, when contemplating intervention during labor to avoid fetal asphyxia, these parameters should be strongly considered.

Postoperative radiosurgery for malignant spinal tumors.

OBJECTIVE: Although, as a primary therapy, radiosurgery for spinal tumors is becoming more common in clinical practice and is associated with encouraging clinical results, we wanted to evaluate outcomes after radiosurgery in a series of postoperative patients. METHODS: We examined the medical records of 18 postoperative patients who received radiosurgical treatment to their residual spinal tumors: metastatic carcinoma (10), sarcoma (3), multiple myeloma/plasmacytoma (4), and giant cell tumor (1). Marginal radiosurgical doses ranged from 6 to 16 Gy (mean, 11.4 Gy) prescribed to the 90% isodose line. All regions of the spine received treatment: 2 cervical, 15 thoracic, and 1 lumbosacral. The volume of irradiated spinal elements receiving 30, 50, and 80% of the total dose ranged from 0.51 to 11.05, 0.19 to 6.34, and 0.06 to 1.73 cm, respectively. Treatment sessions (i.e., patient in to patient out of the room) varied between 20 and 40 minutes. Follow-up ranged from 4 to 36 months (median, 7 mo). RESULTS: Even though significant doses of radiation were delivered to all regions of the spinal cord and nerve roots coincidentally involved in the treatments, only one patient in this series developed progressive symptoms possibly attributable to a toxic effect of the radiosurgery. Of those patients initially presenting with neurological deficits, 92% either remained neurologically stable or improved. CONCLUSION: Our observations suggest that radiosurgery as prescribed in this series of postoperative patients with residual spinal tumor is well-tolerated and associated with little to no significant morbidity.

The evolving role of stereotactic radiosurgery and stereotactic radiation therapy for patients with spine tumors.

Traditional management strategies for patients with spinal tumors have undergone considerable changes during the last 15 years. Significant improvements in digital imaging, computer processing, and treatment planning have provided the basis for the application of stereotactic techniques, now the standard of care for intracranial pathology, to spinal pathology. In addition, certain of these improvements have also allowed us to progress from frame-based to frameless systems which now act to accurately assure the delivery of high doses of radiation to a precisely defined target volume while sparing injury to adjacent normal tissues. In this article we will describe the evolution from yesterday's standards for radiation therapy to the current state of the art for the treatment of patients with spinal tumors. This presentation will include a discussion of radiation dosing and toxicity, the overall process of extracranial radiation delivery, and the current state of the art regarding Cyberknife, Novalis, and tomotherapy. Additional discussion relating current research protocols and future directions for the management of benign tumors of the spine will also be presented.