In addition, cross-links to improve stability of the implanted system are not available for minimal-invasive implantation. Therefore a conventional open approach should be performed to allow for an uncompromised reduction of the spinal injury, especially in regard to eventual secondary anterior column surgery (see Figure 4). On the other hand, if sufficient reduction during posture and following traction or cautious manipulation of the patient is achieved, one should keep in mind percutaneous fixation in those rare cases [24]. Figure 4 Conventional open reduction and instrumentation

with secondary anterior surgery in a polytraumatized NVP-HSP990 patient with compression fracture of T12 and complete burst fracture of L1. This case features a 39 year old male patient following a fall from height (ISS = 41). The patient was unconscious at the site of the injury and transferred after tracheal intubation to the trauma centre. Following primary survey and whole-body CT-Scan, severe Selleckchem NU7026 traumatic brain injury with epidural hematoma, retroperitoneal bleeding with bilateral lung contusions and instable spine injuries from a complete burst fracture of L1 with substantial spinal canal

compromise (type A3.3) and adjacent compression fracture of T12 (type A1.2) were revealed (images VX-661 mouse A-D). The patient was positioned prone and simultaneous surgery was performed for evacuation of epidural hematoma and stabilization of the spine. Posterior fusion using a conventional approach was performed to achieve optimized reduction of the posterior wall fragment and strongest stabilization using a cross-link and bone graft (image E). Following uneventful recovery from intracranial injuries, the patient was operated anterior using an expandable cage on day 10 post trauma (images F-G). Removal

of the internal fixator after 14 months released cranial motion segment T11-T12 and showed sufficient bisegmental oxyclozanide anterior fusion (images H-I). (Adopted from Heyde CE, Stahel PF, Ertel W. “”Was gibt es Neues in der Unfallchirurgie”" in: Meßmer, Jähne, Neuhaus: Was gibt es Neues in der Chirurgie? Ecomed Medizin 2005). What to do with neurologic deficit in the first operative phase? Considering spinal cord injury, a vast array of research efforts have been undertaken for we kindly refer the reader to the current literature and reviews. The consensus has been established, that a mechanical impact to the spinal cord initiates and entertains secondary injury events, that exacerbate the spinal cord injury [43, 97], as it is also evident for traumatic brain injury [41, 42]. As a consequence, spinal cord decompression has to be performed even in the polytraumatized patient [30] and this as quick as possible, since decompression between 24 h and 72 h is shown to be too late to prevent substantial neurologic deficits [98–102].