[Prognosis scores for spinal metastases]. / Prognostische Scores bei Wirbelsäulenmetastasen.

Advances in early detection and therapy of spinal metastasis have improved life expectancy of patients with various tumor entities. However, this and the demographic development have led to an increased risk for developing spinal metastases. Numerous prognostic factors have been determined to allow an assessment of outcome and survival time of patients with metastatic spinal tumors. The implementation of these factors into different scoring systems has been encouraging in the decision making process of spinal surgery. This overview highlights some of the most important prognostic factors and scores which may facilitate surgical considerations.

Multiple revisions of a L2 burst fracture in a suicide jumper: a retrospective analysis of what went wrong.

A 35-year-old female patient sustained three contiguous vertebral fractures at the thoracolumbar junction while jumping off the third floor in a suicide attempt. Initial fracture treatment occurred in the setting of a multiple injury scenario. While the Th12 and the L1 vertebral fractures were considered stable, the L2 fracture exhibited a complete burst configuration with 80% canal compromise due to a posterior wall fragment causing paraplegia. A posterior pedicle screw stabilisation with indirect fracture reduction was carried out initially from T12 to L3. At 1 year follow-up the patient presented to us for new onset radiculopathy L2, and loss of correction. A circumferential revision surgery with an expandable cage was carried out to restore the anterior and posterior columns. Unfortunately again loss of reduction with kyphosis occurred, this time at the upper instrumented vertebra, which made another revision necessary. In this situation a longer construct was chosen using a combined approach and a Mesh cage. This later procedure was complicated by a postoperative paraparesis believed to be vascular in origin. Six months later a further complication involving MSSA deep wound infection required a series of irrigation debridement for healing. At the 2.5 years follow up the spine was stable and the patient had a neurologic recovery allowing her to ambulate with crutches. This Grand Round Case raises the question on the initial management of multiply injured patients with spine fracture, the classification of these fractures, the optimal initial internal fixation, the need for complementary anterior column reconstruction and the strategy when all these fails.

Impaired erythropoiesis after haemorrhagic shock in mice is associated with erythroid progenitor apoptosis in vivo.

OBJECTIVE: Multiply traumatised patients often suffer from blood loss and from subsequent therapy-resistant anaemia, possibly mediated by apoptosis, necrosis, or humoral factors. Therefore, the underlying mechanisms were investigated in bone marrow (BM) and peripheral blood in a murine resuscitated haemorrhagic shock (HS) model. METHODS: In healthy male mice, pressure-controlled HS was induced for 60 min. The BM was analysed for Annexin-V, 7-amino-actinomycin D, apoptotic enzymes (caspases-3/7, -8, and -9), expression of death receptors (CD120a, CD95), mitochondrial proteins (Bax, Bcl-2, Bcl-x), as well as erythropoietin (EPO) receptor (EPO-R). Blood cell count, peripheral EPO, and tumour necrosis factor-alpha response were additionally monitored. RESULTS: Twenty-four and 72 h after HS, EPO and EPO-R were strongly up-regulated in peripheral blood and BM, respectively. Decreasing numbers of erythroid progenitors in BM after HS correlated with significant apoptotic changes confirmed by increased caspases-3/7, -8, -9 activity in total BM, death receptor CD95 and CD120a expression on erythroid progenitors, and down-regulated mitochondrial Bcl-2 expression in total BM. Erythroid progenitors in peripheral blood were found to be increased after 72 h. CONCLUSION: Despite the massive EPO response and up-regulation of EPO-R, BM erythroblasts (EBs) decreased. This could be due to deficient maturation of erythroid progenitors. Furthermore, the increased intrinsic and extrinsic apoptosis activation suggests programmed death of erythroid progenitors. We propose that both apoptosis and negatively regulated erythropoiesis contribute to BM dysfunction, while erythroid progenitor egress plays an additional role.

[Treatment options for problematic thoracic and lumbar osteoporotic fractures]. / Behandlungsmöglichkeiten bei thorakalen und lumbalen osteoporotischen Problemfrakturen.

Most osteoporotic sintering fractures are treated conservatively. However, persistent pain and consecutive spinal deformity may require certain cement-augmenting interventions. These procedures have proven their intermediate-term efficacy in pain reduction, prevention of progressive sintering and improvement of the overall quality of life in the majority of patients. In fractures with relevant spinal stenosis, persisting instability, gross deformity and trauma-associated osteoporotic fractures with or without neurological deficits, the therapeutic options may call for more extensive surgical procedures. In this regard, poor bone quality, age and respective comorbidities of the individual patient must be considered during preoperative planning and management. This article provides an overview of the diverse problem-solving strategies discussed in today's literature. It is generally acknowledged that any decision to perform surgery on an osteoporotic fracture is strongly case-dependent. Treating physicians must therefore master the complete therapeutic spectrum in order to meet this complex orthopedic challenge appropriately.

[Gene therapy for treatment of acute inflammatory immune response]. / Gentherapie zur Behandlung der akuten inflammatorischen Immunantwort.

Acute inflammation and the innate immune response to severe tissue trauma continue to pose a critical pathophysiological challenge in the intensive care regimen. Advances in the development of improved gene therapeutics and their application in diverse animal models of acute inflammation have shown promising results in reducing both morbidity and mortality. The introduction of inflammatory antagonists, by either viral or non-viral vectors, has thereby proven to play a significant role in determining the overall outcome. Recent findings of utilizing the functional characteristics of immunocompetent cells (e.g. dendritic cells) in combination with the gene therapy-induced overexpression of anti-inflammatory target proteins have significantly expanded this gene therapeutic spectrum. The results from diverse experiments in our own murine model of sepsis, in connection with findings from various other analogous international studies, have demonstrated great potential to revolutionize the clinical treatment concept and prevention of acute inflammatory diseases.

[Role of gene therapy in trauma and orthopedic surgery]. / Stellenwert der Gentherapie in Unfallchirurgie und Orthopädie.

Modern molecular and genetic technologies enable the modification of a cellular genome through transfer of specific genes. The various procedures alter specific cell functions, which allow the transfected cell to produce any encoded transgene information. The transfected cell then synthesizes proteins that are normally not produced or only in very small amounts. Numerous animal studies have demonstrated that gene therapy may support and accelerate the healing and regeneration of specific tissues such as skin, tendons, cartilage, and bones. Currently, further animal studies are evaluating new vectors with reduced immunogenicity in the continuous effort to improve the efficacy and safety of gene transfer. In the forthcoming decade we expect gene therapy to have an important influence on the treatment of fractures, cartilage lesions, and infection.