Future studies should specifically address the question on where the damage control concept in spinal trauma is necessary to limit surgery related additional injury and where early total care can be performed safely. Secondary surgery after restoration of immunologic homoeostasis Following initial operative stabilization of e.g. femoral fractures using external fixators and instable spine fractures using internal fixators, additional anterior surgery can be performed safely at day 7 to 10 post trauma in the uneventful recovery [2, 23, 30]. Conditio sine qua non is that no secondary insults e.g. infection or ARDS occurred as mentioned in the

antecendent paragraphs that would prolong the hyperinflammatory status via SIRS to MODS or MOF. For instance burst fractures (Type A3) with substantial kyphotic deformation and flexion-distraction injuries (Type B) with discoligamentous injury, can be treated learn more by e.g.

anterior lateral thoracic or retroperitoneal approach without the risk of further aggravating the immunologic disturbances by the surgery-related release of pro-inflammatory mediators. This phase is generally assigned the invulnerable phase following the initial phase of hyperinflammation and secondary phase of immune paralysis. Various reports show that secondary hit from Vismodegib in vitro surgical approaches is best tolerated in this period around day 7 to 10 post trauma [30, 124, 125]. Patients suffering from prolonged SIRS or CARS are rendered Glutamate dehydrogenase for individual secondary

surgery. In particular patients suffering from type C fractures of the thoracolumbar spine present with seriously elevated Injury Severity Scores (ISS) due to e.g. associated intraabdominal lacerations or lung injuries with high risk for secondary abdominal infections or ARDS, respectively. These associated injuries and complications together with the cardiopulmonary state predict the timing of secondary spine surgery in these severely injured patients. Coming from the fact that certain inflammatory mediators account for beneficial or adverse outcome in polytraumatized patients, it is without doubt, that investigators highlight immunologic monitoring as a new parameter which could be of prime importance for future planning of surgical interventions [126–128]. Conclusion Spinal injury in association with a polytraumatized patient is a challenge regarding diagnosis and therapeutic decision making. Precise guidelines for diagnostic workup including plane x-ray, CT-Scan and MRI do not exist, neither do therapeutic algorithms on exact timing and type of procedure, since the broad spectrum of injury patterns does not allow proposal of a structured approach or algorithm to these patients. Nevertheless, basic recommendations for the spine trauma patient can be given.