Severe Surgical Trauma Research Articles

Neutrophil extracellular trap formation during surgical procedures: a pilot study

Neutrophils can release neutrophil extracellular traps (NETs) containing DNA fibres and antimicrobial peptides to immobilize invading pathogens. NET formation (NETosis) plays a vital role in inflammation and immune responses. In this study we investigated the impact of surgical trauma on NETosis of neutrophils. Nine patients undergoing “Transcatheter/percutaneous aortic valve implantation” (TAVI/PAVI, mild surgical trauma), and ten undergoing “Aortocoronary bypass” (ACB, severe surgical trauma) were included in our pilot study. Peripheral blood was collected before, end of, and after surgery (24 h and 48 h). Neutrophilic granulocytes were isolated and stimulated in vitro with Phorbol-12-myristate-13-acetate (PMA). NETosis rate was examined by microscopy. In addition, HLA-DR surface expression on circulating monocytes was analysed by flow-cytometry as a prognostic marker of the immune status. Both surgical procedures led to significant down regulation of monocytic HLA-DR surface expression, albeit more pronounced in ACB patients, and there was a similar trend in NETosis regulation over the surgical 24H course. Upon PMA stimulation, no significant difference in NETosis was observed over time in TAVI/PAVI group; however, a decreasing NETosis trend with a significant drop upon ACB surgery was evident. The reduced PMA-induced NETosis in ACB group suggests that the inducibility of neutrophils to form NETs following severe surgical trauma may be compromised. Moreover, the decreased monocytic HLA-DR expression suggests a post-operative immunosuppressed status in all patients, with a bigger impact by ACB, which might be attributed to the extracorporeal circulation or tissue damage occurring during surgery.

Full-Endoscopic Isolation Zone Technique for the Treatment of Lumbar Disc Herniation.

Lumbar disc herniation (LDH) is a type of serious sinus or sciatic nerve dysfunction caused by nucleus pulposus protrusion and annulus fibrosus tears. Its clinical symptoms often include severe low back pain, limited lumbar movement, sciatic nerve pain in the lower limbs, and even cauda equina syndrome. The common treatment for LDH is a conservative treatment scheme involving medicine, rest, and physical therapy. However, if the conservative treatment scheme is ineffective, a surgical treatment approach is adopted. Traditional open lumbar surgery has some disadvantages, including the potential for severe surgical trauma, severe blood loss during the operation, instability of the lumbar spine, and loss of the lumbar motor unit. Among the minimally invasive surgical schemes, full-endoscopic spine surgery (FESS) is undoubtedly the most appropriate and has the advantages of minimal trauma, high safety, quick postoperative recovery, and the retention of the stable structure and the motor unit of the lumbar spine. However, simultaneously, incomplete removal of the nucleus pulposus and residual nerve dysfunction after surgery can occur. To avoid these shortcomings, we studied a specific spinal endoscopy technique, the "isolation zone" surgical strategy, which can effectively block the pain from the nerve conduction pathway by completely relieving the nerve compression and nerve dysfunction through the orderly treatment of the protruding nucleus pulposus, the fissure of the annulus fibrosus, the sinus nerve, and the surrounding inflammatory soft tissues.

Effect of Acupoint Therapies on Postoperative Sleep Quality: A Narrative Review.

Several studies have reported that sleep quality often decreases in patients after surgery, especially in elderly patients, which seriously affects postoperative prognosis and outcomes, inducing diseases such as postoperative delirium, long-term chronic pain, and potentially fatal cardiovascular events. With the popularization of comfortable medicine, medical workers pay more attention to the postoperative sleep quality of patients. The causes underlying the decrease in postoperative sleep quality may include postoperative pain, the severity of surgical trauma and stress, perioperative anxiety and depression, and postoperative complications. Patients with insomnia often use acupoint therapies as a safe and effective alternative to drugs. Acupoint therapies are among the oldest medical therapies of Traditional Chinese Medicine and are gradually gaining recognition among medical workers worldwide. Various types of acupoint stimulation methods such as transcutaneous electrical acupoint simulation (TEAS), acupressure, acupuncture, and electroacupuncture can change the brain's local electrical activity, inhibit the central nervous system, and achieve deep sedation through stimulating the related acupoints, which provides a novel idea and basis for improvement in factors affecting postoperative sleep quality. This review explores the mechanism of acupoint therapies from several aspects of affecting the sleep quality of patients after surgery and its clinical results. We found that acupoint therapies effectively improve sleep quality and alleviate the postoperative complications of patients, and we emphasize the importance of acupoint therapies to guide future research and clinical practice. Large-scale, multicenter studies are needed to determine the optimal duration, frequency, and timing of acupoint stimulation for improving postoperative sleep quality.

The most economical arthroscopic suture fixation for tibial intercondylar eminence avulsion fracture without any implant

BackgroundAvulsion fracture of the tibial intercondylar eminence is a rare injury, which mainly occurs in adolescents aged 8–14 years and in those with immature bones. The current commonly used surgery may result in severe surgical trauma, affecting knee joint function and accompanied by serious complications. In this study, we described an all-inside and all-epiphyseal arthroscopic suture fixation technique for a patient to treat tibial intercondylar eminence fracture.MethodsETHIBOND EXCEL-coated braided polyester sutures were used for fixation. Three ETHIBOND sutures were passed through the ACL at 2, 6 and 10 o’clock of the footprint of the ACL and made a cinch-knot loop separately. Under the guidance of ACL tibial locator, three corresponding tibial tunnels were drilled with K-wires at 2, 6 and 10 o’clock of the fracture bed, and the two ends of the suture were pulled out through the tunnel with double-folded steel wire heads. After reduction of the tibial eminence, three sutures were tightened and tied to the medial aspect of the tibial tubercle.ResultsAfter all the surgical treatments surgically performed by this method and following a standard postoperative protocol, our patient's ROM, stability, and functional structural scores all improved significantly.ConclusionThis three-point suture technique provides a suitable reduction and stable fixation and is suitable for patients with all types of avulsion fractures of the tibial intercondylar eminence.

Urinary kidney injury molecule-1 and neutrophil gelatinase-associated lipocalin are early predictors for acute kidney injury among patients admitted to the surgical ICU

ABSTRACT Objectives: Evaluation of urinary neutrophil gelatinase-associated lipocalin (UNGAL) and kidney injury molecule 1 (UKIM-1) as early predictors of development of acute kidney injury (AKI) in patients admitted to surgical ICU. Patients & Methods: 188 ICU patients were clinically evaluated and gave blood samples for estimation of at admission (T0) serum creatinine (SCr) and urine samples for estimation of urinary creatinine (UCr), UNGAL and UKIM-1 and their values were adjusted to UCr level. At 48-hr after admission SCr levels were re-estimated and AKI was diagnosed and staged according to the Acute Kidney Injury Network criteria. Study outcomes included the ability of estimated markers for prediction of possible AKI development. Results: At 48-hr after ICU admission, 73 patients (38.8%) developed AKI; 42, 21 and 10 mild, moderate and severe AKI, respectively. At T0, UNGAL and UKIM1, and their UCr ratios showed progressive increase with increased AKI grade. Calculated ∆SCr was positively correlated with clinical data and estimated levels of urinary markers. Regression analysis defined elevated BMI, TISS-28 score, UNGAL and UKIM-1 as early significant predictors for AKI. ROC curve analysis defined UNGAL and UKIM-1 and their ratios to UCr as the significant predictors for AKI development. Conclusion: Development of AKI in ICU patients was related to severity of surgical trauma. High UNGAL and UKIM-1 at time of ICU admission can predict upcoming AKI and its AUC after adjustment to UCr levels had superior predictive value for AKI. A high uKIM-1/UCr ratio can be considered the most significant early predictor for AKI.

Surgical trauma-induced immunosuppression in cancer: Recent advances and the potential therapies.

Surgical resection remains the mainstay treatment for solid cancers, especially for localized disease. However, the postoperative immunosuppression provides a window for cancer cell proliferation and awakening dormant cancer cells, leading to rapid recurrences or metastases. This immunosuppressive status after surgery is associated with the severity of surgical trauma since immunosuppression induced by minimally invasive surgery is less than that of an extensive open surgery. The systemic response to tissue damages caused by surgical operations and the subsequent wound healing induced a cascade alteration in cellular immunity. After surgery, patients have a high level of circulating damage‐associated molecular patterns (DAMPs), triggering a local and systemic inflammation. The inflammatory metrics in the immediate postoperative period was associated with the prognosis of cancer patients. Neutrophils provide the first response to surgical trauma, and the production of neutrophil extracellular traps (NETs) promotes cancer progression. Activated macrophage during wound healing presents a tumor‐associated phenotype that cancers can exploit for their survival advantage. In addition, the amplification and activation of myeloid‐derived suppressor cells (MDSCs), regulatory T cells (Tregs) or the elevated programmed death ligand‐1 and vascular endothelial growth factor expression under surgical trauma, exacerbate the immunosuppression and favor of the formation of the premetastatic niche. Therapeutic strategies to reduce the cellular immunity impairment after surgery include anti‐DAMPs, anti‐postoperative inflammation or inflammatory/pyroptosis signal, combined immunotherapy with surgery, antiangiogenesis and targeted therapies for neutrophils, macrophages, MDSCs, and Tregs. Further, the application of enhanced recovery after surgery also has a feasible outcome for postoperative immunity restoration. Overall, current therapies to improve the cellular immunity under the special condition after surgery are relatively lacking. Further understanding the underlying mechanisms of surgical trauma‐related immunity dysfunction, phenotyping the immunosuppressive cells, and developing the related therapeutic intervention should be explored.

Postoperative sleep disorders and their potential impacts on surgical outcomes.

Postoperative sleep disturbance is a common occurrence with significant adverse effects on patients including delayed recovery, impairment of cognitive function, pain sensitivity and cardiovascular events. The development of postoperative sleep disturbance is multifactorial and involves the surgical inflammatory response, the severity of surgical trauma, pain, anxiety, the use of anesthetics and environmental factors such as nocturnal noise and light levels. Many of these factors can be managed perioperatively to minimize the deleterious impact on sleep. Pharmacological and non-pharmacological treatment strategies for postoperative sleep disturbance include dexmedetomidine, zolpidem, melatonin, enhanced recovery after surgery (ERAS) protocol and controlling of environmental noise and light levels. It is likely that a combination of pharmacological and non-pharmacological therapies will have the greatest impact; however, further research is required before their use can be routinely recommended.

A Prospective Randomized Controlled Trial of Single-Port and Three-Port Laparoscopic Appendectomy in Children.

Background: This study aimed to evaluate single-port laparoscopic appendectomy (SPLA) in comparison with three-port laparoscopic appendectomy (3PLA) in children about the extent of surgical trauma after SPLA and 3PLA measured by serum interleukin-6 (IL-6) and C-reactive protein (CRP) concentrations. Materials and Methods: A total of 50 patients with a median age of 11.5 were randomized to two groups. Experts in both methods performed the surgeries. The decision on the type of planned surgery was randomly determined. Serum IL-6 and CRP levels were measured using an enzyme-linked immunosorbent assay before, and at 12 and 36 hours after surgery. Furthermore, we compared operating time, hospital stay, postoperative pain, and complication rates. Results: The operative time in the 3PLA group was shorter than that in the SPLA group (P < .05). Preoperative IL-6 levels were not different between the two groups, but the rise (pre- versus postoperative) of IL-6 in the SPLA group was remarkably higher when compared with the 3PLA group (P < .05). Similar results were obtained for CRP; basal serum CRP levels were not different between the two groups, but the rise of CRP in the 3PLA group was significantly lower compared with that in the SPLA group. During the first 12 hours postoperative, the SPLA patients reported more severe postoperative pain and longer inpatient opiate usage was noted that after 3-PLA. Only one SPLA case was converted to 3PLA. There were no conversions to open surgery. The length of hospital stay and complication rate were not different between the two groups. Conclusions: SPLA in children is associated with longer operative times, increased pain level, and more severe surgical trauma as measured by postoperative CRP and IL-6 levels in comparison with a 3PLA. The two approaches were comparable regarding the length of hospital stay and complication rate.

Improve postoperative sleep: what can we do?

Purpose of reviewWe reviewed evidences regarding occurrence, risk factors, harmful effects, prevention, and management of sleep disturbances in patients after surgery.Recent findingsNormal sleep is important to maintain physical and mental health. Sleep disturbances frequently occur in patients after surgery. Factors associated with the development of postoperative sleep disturbances include old age, preoperative comorbidity, type of anesthesia, severity of surgical trauma, postoperative pain, environment stress, as well as other factors leading to discomfort of patients. Development of sleep disturbances produces harmful effects on postoperative patients, that is, leading to higher risk of delirium, increased sensitivity to pain, more cardiovascular events, and poorer recovery. Both nonpharmacological and pharmacological measures (such as zolpidem, melatonin, and dexmedetomidine) can be used to improve postoperative sleep. Recent evidences show that sleep promotion may improve patients’ outcome, but requires further evidences.SummarySleep disturbances are common in patients after surgery and produce harmful effects on postoperative recovery. Sleep-promotion therapy may be helpful to improve postoperative recovery, but long-term effects deserve further study.

Impact of different analgesic depths and abdominal trauma of different severities on stress and recovery of rats undergoing total intravenous anesthesia.

A number of animal models have been developed to examine the pathophysiological consequences of surgical procedures, but anesthetic methods, monitoring, and management measures in these models are very different from those used in humans. This study was designed to create a rat model of abdominal surgery using anesthetic methods and perioperative treatment similar to those used in the clinic and to investigate the effects of different injury severities and depths of anesthesia and analgesia on surgical stress and postoperative recovery. Abdominal skin/muscle incision was compared with exploratory laparotomy in rats under propofol intravenous anesthesia, accompanied by perioperative measures such as oxygen inhalation, fluid infusion, warmth, blood gas analysis, and infection prevention. Stress indices (mean arterial pressure, heart rate, blood glucose, and plasma corticosterone) were monitored during anesthesia and surgery, and recovery indicators (body weight, food consumption, and pain) were measured after surgery. In addition, animals undergoing laparotomy were subjected to low and high dosages of propofol and sufentanil, in order to examine the relationship between anesthetic and analgesic depth and stress on recovery. Exploratory laparotomy induced a greater stress response and caused slower postoperative recovery as measured than somatic injury. High-dose sufentanil downregulated plasma corticosterone and improved postoperative recovery more effectively than high-dose propofol (P<0.05). Taken together, a rat model of abdominal surgery using anesthetic methods and perioperative treatment similar to those used in the clinic was successfully developed. It showed a positive correlation between severity of surgical trauma and stress response and postoperative recovery and a significant role of adequate analgesia in reducing surgical stress and improving postoperative recovery.

Taste disturbance after stapes surgery: an evaluation of frequency, severity, duration, and quality-of-life

Conclusion: The incidence of taste disturbance after stapes surgery is high (61.9%), whereas the majority (94.8%) recovers within 1 year. More severe surgical nerve trauma caused more disturbance, implying that the nerve should be handled carefully during surgery.Objectives: Patients operated on for otosclerosis seem more often to complain about post-operative taste disturbance than those operated on for chronic otitis media, although the chorda tympani nerve more seldom becomes maltreated in stapedotomy. These observations seem paradoxical. It is unclear to what extent a post-operative taste disturbance affects the quality-of-life. This study aims to shed light on the occurrence of post-operative taste disturbances, on possible prognostic factors, and to what extent post-operative taste disturbance impairs the quality-of-life.Methods: One hundred and thirty-four adults undergoing primary stapedotomy were included. Questionnaires on taste disturbance and quality-of-life (SF-36) were answered before and after surgery, until 1 year post-operatively.Results: Eighty-three (61.9%) study persons reported post-operative taste disturbance. Seven (5.2%) reported persisting disturbance at 1 year. Surgically more traumatized chorda tympani nerves correlated with more severe taste disturbance post-operatively than less traumatized. Taste disturbance at 1 year post-operatively correlate with a decrease of the physical function domain in the SF-36.

Effects of parenteral nutrition in different administration methods on the treatment of CRRT

Objectives To explore the effect of different parenteral nutrition (TPN) dosing time on critical surgical patients of continuous renal replacement therapy (CRRT) influence the nutritional status of patients. Methods 80 cases of renal failure induced by severe surgical trauma or sepsis were collected from January 2014 to January 2015 in our SICU.All patients with APACH II type >10 were performed CRRT, and , randomly divided into early and late group. According to plasma specimens after renal replacement therapy, the amino acid filtration rate and creatinine clearance rate were compared between two groups. Results There was no difference in creatinine clearance rate between the two groups(P>0.05). The amino acid filtration rate in group of patients with early filtration rate was significantly higher than the control group(P<0.05). Conclusions Although the nutrients in CRRT by combination of TPN therapy for AKI patients was filtered out, the rest of nutrients in plasma of patients was still high. CRRT by combination of TPN therapy for AKI patients can be used in nutrition support. So we think using early PN to CRRT patients is the preferred way of filtration. Key words: Kidney Failure; Renal Replacement Therapy; Parenteral Nutrition

English

Abstract This study aimed to compare three different surgery approaches for pituitary adenoma excision. A total of 162 patients underwent pituitary adenoma excision through the sphenoid sinus approach. Among patients, five underwent the sublabio-septo-sphenoidal approach (abbreviated as approach), seven underwent the sphenoid sinus approach and 150 underwent the nasal septum approach. The operative cases that underwent the sublabio approach showed severe surgical trauma because of the complicated operation procedure. The sphenoid sinus approach was relatively easy to operate, but the procedure may confuse an inexperienced operator, which occurred in two out of seven cases in our study. The anatomical landmark was clearer under the nasal septum approach than the other approaches. Thus, operators were less likely to make mistakes during the nasal septum operation. In our study, a success rate of 100% was obtained for the 68 patients who underwent nasal septum operation. The nasal septum approach was suitable for most patients with pituitary adenoma. The hierarchy of the anatomy was distinctive and easily controlled. Thus, the entire nasal septum operation was relatively safe, effective and minimally invasive and can be completed by an operator with sufficient anatomical knowledge and operation skill.

Surgical trauma induces postoperative T-cell dysfunction in lung cancer patients through the programmed death-1 pathway.

The programmed death-1 (PD-1) and programmed death ligand-1 (PD-L1) pathway have been shown to be involved in tumor-induced and sepsis-induced immunosuppression. However, whether this pathway is involved in the surgery-induced dysfunction of T lymphocytes is not known. Here, we analyzed expression of PD-1 and PD-L1 on human peripheral mononuclear cells during the perioperative period. We found that surgery increased PD-1/PD-L1 expression on immune cells, which was correlated with the severity of surgical trauma. The count of T lymphocytes and natural killer cells reduced after surgery, probably due to the increased activity of caspase-3. Caspase-3 level was positively correlated with PD-1 expression. Profile of perioperative cytokines and hormones in plasma showed a significantly increased level of interferon-α, as well as various inflammatory cytokines and stress hormones. In ex vivo experiments, administration of anti-PD-1 antibody significantly ameliorated T-cell proliferation and partially reversed the T-cell apoptosis induced by surgical trauma. We provide evidences that surgical trauma can induce immunosuppression through the PD-1/PD-L1 pathway. This pathway could be a target for preventing postoperative cellular immunosuppression.

Prophylactic lithium alleviates splenectomy-induced cognitive dysfunction possibly by inhibiting hippocampal TLR4 activation in aged rats.

Though the pathogenesis of postoperative cognitive dysfunction (POCD) remains unclear, evidence is accumulating for a pivotal role of neuroinflammation in the disease process. Advanced age and severe surgical trauma are two main risk factors for POCD. Lithium, a neuroprotective agent, can alleviate peripheral surgery-induced memory impairment in aged rats. The results of in vivo and in vitro experiments also showed that toll like receptor 4 (TLR4) was associated with the occurrence and development of neuroinflammation and POCD. So we hypothesized that inhibition of TLR4 signaling in the hippocampus maybe involved in the protective effects of prophylactic lithium on the occurrence of inflammation and POCD. In the present study, we incubated BV-2 microglia with 1μg/ml lipopolysaccharide (LPS) to mimic neuroinflammation in vitro. We found that pretreatment with 10mM of lithium or 100nM of TLR4 siRNA could inhibit the tumor necrosis factor (TNF)-α and TLR4 mRNA expression induced by LPS in BV-2 microglia. Furthermore, combination of prophylactic lithium and TLR4 siRNA even decreased their mRNA expression to the baseline levels, which showed that TLR4 signaling may be vital in protective effects of prophylactic lithium on neuroinflammation. So we further undergone the in vivo experiment. Then, we firstly demonstrated that prophylactic 2mM/kg of lithium alleviated splenectomy-induced cognitive impairments, decreased splenectomy-associated systemic, central, and hippocampal TNF-α and interleukin (IL)-1β expression and reduced the increase of CD11b(+) area in hippocampal CA1 region caused by the surgery. Then, we also found that splenectomy merely increased hippocampal TLR2 and TLR4 mRNA levels in aged rats. At last, we confirmed that prophylactic lithium reduced the increased levels of hippocampal TLR4/NF-κB induced by splenectomy. Taken together, these results demonstrate that TLR4 signaling inactivation may contribute to the protective effects of prophylactic lithium on the occurrence of POCD by inhibiting systemic inflammation and especially neuroinflammation.

Safety and efficacy of a new procedure for treating traumatic iliopsoas hematoma: a retroperitoneoscopic approach

Surgical treatment is often recommended for traumatic iliopsoas hematoma. Open surgeries lead to severe surgical trauma, and minimally invasive surgeries cannot completely remove the hematoma. A new treatment protocol for traumatic iliopsoas hematoma by retroperitoneoscopic approach has been introduced. The goal of this study was to determine the safety and efficacy of retroperitoneoscopic approach used to remove iliopsoas hematoma. Between January 2009 and July 2012, 13 patients were diagnosed of traumatic iliopsoas hematoma. Retroperitoneoscopic surgeries were performed on all patients to remove the hematomas after admission. The size of hematoma, VASA score and neurologic status were dynamic evaluated before and after surgery. Soft tissue damage and complications caused by retroperitoneoscopic approach also were recorded and evaluated. We performed retroperitoneoscopic surgery to remove traumatic iliopsoas hematoma successfully on 13 patients without complications. The mean procedure time was 52.5 ± 13.4 min, and mean blood loss was 30.7 ± 9.2 ml. Hematoma was completely removed confirmed by ultrasound after surgery. Pain in the affected lower abdominal and thigh immediately was relieved totally for ten patients and partly for three patients after surgery. Quadriceps strength was restored to grade 5 and pain completely disappeared 2 months postoperatively on all patients. Numbness along the femoral nerve distribution disappeared for 11 patients and improved for 2 patients until the last follow-up. None of 13 patients suffered from infection or a new hematoma during follow-up. Retroperitoneoscopic approach is a safe and effective procedure alternative to conventional surgical approach for treating traumatic iliopsoas hematoma in terms of complete removal of hematoma, minimal invasiveness, absence of radiation, and rapid recovery.

Multimodal analgesia - a standard of care in severe surgical thoracic trauma patients?

Pavelescu, D.; Mirea, L.; Luca, Vasiliu I.; Grintescu, I.; Pavelescu, C.; Dumitrascu, M.Author Information

Immunoenhancing therapy with interleukin-18 against bacterial infection in immunocompromised hosts after severe surgical stress

IL-18 has a potential to up-regulate the Th1 and Th2 immune responses. It is known that IL-18, in synergy with IL-12, augments the Th1 response to bacterial infections, but it also augments the Th2 response to allergic disorders in the absence of IL-12. Although the Th1 and Th2 immune responses cross-regulate each other, our recent murine studies have demonstrated that multiple, alternate-day IL-18 injections (but not a single injection) could augment not only the Th1 immune response but also the Th2 immune response, including IgM production against bacterial infection in mice. In addition, critically ill patients who suffer from severe surgical stresses, e.g., trauma injury, burn injury, and major surgery, are known to be highly susceptible to bacterial infections/sepsis, and their outcomes become extremely poor as a result of infectious complications. Their host defense systems against infections, such as Th1-mediated cellular immunity, Th2-mediated humoral immunity, and neutrophil-mediated immunity, are impaired severely and multifactorially. Although simultaneous enhancement of these immune responses may be ideal for such immunocompromised patients, its achievement appears to be difficult because of the cross-regulating effect of the Th1 and Th2 responses. However, multiple IL-18 injections into mice can effectively restore these impaired immune responses in the immunocompromised mice receiving severe burn injury or splenectomy, thus improving their survival after bacterial infections. Therefore, IL-18 treatment may be an attractive and useful therapeutic tool against bacterial complications in immunocompromised hosts after severe surgical stress.

The Interspinous Spacer: A Clinicoanatomical Investigation Using Plastination

Purpose. The relatively new and less-invasive therapeutic alternative “interspinous process decompression device (IPD)” is expected to result in improved symptoms of neurogenic intermittent claudication (NIC) caused by lumbar spinal stenosis. The aim of the study was to analyze IPD position particularly regarding damage originating from surgical implantation. Methods. Anatomic assessments were performed on a fresh human cadaver. For the anatomic examination, the lumbar spine was plastinated after implantation of the IPDs. After radiographic control, serial 4 mm thick sections of the block plastinate were cut in the sagittal (L1–L3) and horizontal (L3–L5) planes. The macroanatomical positioning of the implants was then analyzed. The insertion procedure caused only little injury to osteoligamentous or muscular structures. The supraspinous ligament was completely intact, and the interspinous ligaments were not torn as was initially presupposed. No osseous changes at the spinal processes were apparent. Contact of the IPD with the spinous processes was visible, so that sufficient biomechanical limitation of the spinal extension seems likely. Conclusions. Minimally invasive IPD implantation with accurate positioning in the anterior portion of the interspinous place is possible without severe surgical trauma.

Perioperative Period: Immunological Modifications

Surgical stress induces complex modifications in the hemodynamic, metabolic, neuro-hormonal and immune response of the individual. The magnitude of these alterations depends on preoperative events leading to surgery, the severity of surgical trauma, and also on post-operative/post-traumatic complications (multiple hit hypothesis). As in other conditions of tissue damage, surgery trauma is followed by an immune-inflammatory response, initiated at the site of injury by the innate immune system, followed by a compensatory anti-inflammatory (or immunosuppressive) response (CARS), involving mainly cells of the adaptive immune system, which predispose the host to septic complications. The up-regulated inflammatory response, together with a profound impairment of macrophage and cell-mediated immunity, appear to be the cause for patients&#x0027; increased susceptibility in developing subsequent sepsis after major surgery.