How War Has Shaped Neurosurgery

Many strides have been made in neurosurgery during times of war, helping to improve the outcomes of patients in dire circumstances. World War I introduced the concepts of early operation for trauma, forward-operating hospitals, and galeal sutures as well as techniques for careful debridement. It laid the groundwork for neurosurgery to become a specialty within medicine as well. World War II brought about the use of expedited medical evacuation, mobile neurosurgical units, improved resuscitation strategies, cranioplasty, and early laminectomy with decompression. The Korean and Vietnam Wars built on concepts from World Wars I and II, helping to establish the importance of watertight dural closure, external drainage systems after cranial trauma, multidisciplinary care, and infection prevention strategies. In the post-Vietnam period, we have seen significant technological advances allowing neurosurgeons to move farther ahead than most throughout history could have imagined. The significance of secondary brain injury, vascular injury, and the underlying pathophysiology of traumatic insults has been elucidated over the years since the Vietnam War, allowing for great advances in the care of our patients. Each major war throughout history has contributed greatly to the specialty of neurosurgery, each with its own innovations culminating in guidelines, strategies, and standards of practice that allow us to deliver the highest standard of care to our patients.

Advancements in the treatment of traumatic spinal cord injury during military conflicts

Significant advancements in the treatment of spinal cord injury (SCI) were developed in the setting of military conflicts, partly due to the large numbers of injuries sustained by service members. No effective SCI treatment options existed into the early 20th century, and soldiers who sustained these injuries were usually considered untreatable. Extensive progress was made in SCI treatment during and after World War II, as physical therapy was increasingly encouraged for patients with SCI, multidisciplinary teams oversaw care, pathophysiology was better understood, and strategies were devised to prevent wound infection and pressure sores. Recent conflicts in Iraq and Afghanistan have caused a substantial rise in the proportion of SCIs among causes of casualties and wounds, largely due to new forms of war and weapons, such as improvised explosive devices. Modern military SCIs resulting from blast mechanisms are substantively different from traumatic SCIs sustained by civilians. The treatment paradigms developed over the past 100 years have increased survival rates and outcomes of soldiers with SCI. In this paper, the authors review the role of military conflicts in the development of therapeutic interventions for SCI and discuss how these interventions have improved outcomes for soldiers and civilians alike.

Delayed return of urinary continence following the removal of neglected sacral shrapnel

Background

Globalisation of terrorism has led to an increase in the number of injuries from the explosion of improvised explosive devices, with complications resulting from the retained shrapnel. It had been found that a third of those who sustained penetrating spinal cord injuries are from explosions. Retained foreign body in the sacral canal segment is rare, especially shrapnel presenting with urinary incontinence. Moreover, the one who had a dramatic recovery of urinary continence following removal of neglected sacral canal shrapnel. We report a case of a delayed improvement (recovery) in urinary continence following removal of neglected sacral canal shrapnel remotely aided by a pelvic floor exercise.

Case presentation

Our patient was a 14-year-old male who presented with a 3-year history of trauma to the lower back from an Improvised Explosive Device. He was initially associated with difficulty in walking that improved over eight months. However, the urinary incontinence persisted. He was found to be preserved with no neurological deficit in the lower limb. There was a lower back, midline wound, discharging pus. Lumbosacral imaging revealed a sacral (S2) canal Shrapnel. As a case of urinary incontinence from sacral shrapnel, he had the removal of the shrapnel, did well postoperatively, commenced on pelvic floor exercise. He became continence of urine over time.

Conclusions

Retained foreign bodies in the spinal canal are associated with complications that include neurological deficit. Neglected (long-standing) sacral shrapnel with urinary incontinence is rare; moreover, the recovery of the continence with the removal of the shrapnel is aided by the commencement of pelvic floor exercise.

Epidemiology of War-Related Spinal Cord Injury Among Combatants: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

War-related spinal cord injuries (SCIs) are commonly more severe and complex than traumatic SCIs among civilians. This systematic review, for the first time, synthesized and critically appraised the literature on the epidemiology of war-related SCIs. This review aimed to identify distinct features from the civilian SCIs that can have an impact on the management of military and civilian SCIs.

METHODS

Medline, EMBASE, and PsycINFO databases were searched for articles on epidemiology of war-related SCI among combatants, published from 1946 to December 20, 2017. This review included only original publications on epidemiological aspects of SCIs that occur during an act of war. The STROBE statement was used to examine the quality of the publications.

RESULTS

The literature search identified 1594 publications, of which 25 articles fulfilled the inclusion and exclusion criteria. The studies were classified into the following topics: 17 articles reported demographics, level and severity of SCI, mechanism of injury and/or associated bodily injuries; 5 articles reported the incidence of war-related SCI; and 6 articles reported the frequency of SCI among other war-related bodily injuries. Overall, military personnel with war-related SCI were typically young, white men, with predominantly thoracic or lumbar level, complete (American Spinal Injury Association [ASIA] Impairment Scale A) SCI due to gunshot or explosion and often associated with other bodily injuries. Marines appear to be at a greater risk of war-related SCI than the military personal in the Army, Navy, and Air Force.

CONCLUSIONS

The war-related SCIs among soldiers are distinct from the traumatic SCI in the general population. The majority of the current literature is based on the American experiences in most recent wars.

Surgical management of penetrating spinal cord injury primarily due to shrapnel and its effect on neurological outcome: a literature review and meta-analysis

OBJECTIVE

This study was performed to determine whether decompression of penetrating spinal cord injury (SCI) due to explosive shrapnel leads to greater neurological recovery than conservative management.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive literature search using PubMed/MEDLINE, Web of Science, Google Scholar, and the Defense Technical Information Center public site was conducted on May 2, 2016. Studies that described penetrating SCI with shrapnel as an etiology, included surgical and/or conservative management, and demonstrated admission and follow-up neurological status were eligible for inclusion in this study. Odds ratios were calculated for the overall effect of surgical treatment on neurological recovery. Funnel plots were used to evaluate publication bias.

RESULTS

Five case series (Level IV evidence) met the study criteria, and 2 of them had estimable odds ratios for use in the Forest plot analysis. Among the patients from all 5 studies, 65% were injured by shrapnel, 25% by high-velocity bullet, 8% by low-velocity bullet, and 2% by an unknown cause. A total of 288 patients were included in the overall odds ratio calculations. Patients were stratified by complete and incomplete SCI. The meta-analysis showed no significant difference in outcomes between surgical and conservative management in the complete SCI cohort or the incomplete SCI cohort. Overall rates of improvement for complete SCI were 25% with surgery and 27% with conservative treatment (OR 1.07, 95% CI 0.44–2.61, p = 0.88); for incomplete SCI, 70% with surgery and 81% with conservative treatment (OR 1.67, 95% CI 0.68–4.05, p = 0.26).

CONCLUSIONS

This study demonstrates no clear benefit to surgical decompression of penetrating SCI due predominantly to shrapnel. There is a considerable need for nonrandomized prospective cohort studies examining decompression and stabilization surgery for secondary and tertiary blast injuries.

Defining the essential anatomical coverage provided by military body armour against high energy projectiles

INTRODUCTION

Body armour is a type of equipment worn by military personnel that aims to prevent or reduce the damage caused by ballistic projectiles to structures within the thorax and abdomen. Such injuries remain the leading cause of potentially survivable deaths on the modern battlefield. Recent developments in computer modelling in conjunction with a programme to procure the next generation of UK military body armour has provided the impetus to re-evaluate the optimal anatomical coverage provided by military body armour against high energy projectiles.

METHODS

A systematic review of the literature was undertaken to identify those anatomical structures within the thorax and abdomen that if damaged were highly likely to result in death or significant long-term morbidity. These structures were superimposed upon two designs of ceramic plate used within representative body armour systems using a computerised representation of human anatomy.

RESULTS AND CONCLUSIONS

Those structures requiring essential medical coverage by a plate were demonstrated to be the heart, great vessels, liver and spleen. For the 50th centile male anthropometric model used in this study, the front and rear plates from the Enhanced Combat Body Armour system only provide limited coverage, but do fulfil their original requirement. The plates from the current Mark 4a OSPREY system cover all of the structures identified in this study as requiring coverage except for the abdominal sections of the aorta and inferior vena cava. Further work on sizing of plates is recommended due to its potential to optimise essential medical coverage.

Characterization of combat-related spinal injuries sustained by a US Army Brigade Combat Team during Operation Iraqi Freedom

BACKGROUND CONTEXT

The United States is presently engaged in the largest scale armed conflict since Vietnam. Despite recent investigations into the scope of injuries sustained by soldiers in Iraq and Afghanistan, little information is available regarding the incidence and epidemiology of spine trauma in this population.

PURPOSE

Characterize the incidence and epidemiology of spinal injuries sustained during combat by soldiers of a US Army Brigade Combat Team (BCT) that participated in Operation Iraqi Freedom.

STUDY DESIGN

Descriptive epidemiologic study.

PATIENT SAMPLE

A total of 4,122 soldiers who served in Iraq with an Army BCT during "The Surge" operation.

OUTCOME MEASURES

Spine injury epidemiology was calculated for the BCT, including the spine combat casualty rate, and percent medically evacuated (MEDEVAC).

METHODS

Unit rosters were obtained, and a comprehensive database identifying all combat-related spine injuries was created by querying each soldiers' electronic medical record and the unit's casualty rosters. Demographic information was recorded including age, sex, rank, injury mechanism, presence of polytrauma, and injury outcome. Injury outcomes were classified as killed in action, died of wounds, MEDEVAC, or returned to duty. The incidence of spine injuries was determined, and epidemiology was characterized using calculations of the spine combat casualty rate and percent MEDEVAC. Comparisons were made to published reports from previous conflicts.

RESULTS

A total of 29 soldiers sustained 31 combat-related spine injuries. These accounted for 7.4% (29 out of 390) of all casualties sustained during combat. Blunt trauma to the spine, often resulting from an explosive mechanism, was encountered in 65% of cases. Closed fractures of the spine occurred in 21% of casualties and open injuries occurred in 7%. The spine combat casualty rate was 5.6 out of 1,000 soldier combat-years, and the percent MEDEVAC was 19%.

CONCLUSIONS

This investigation is the first of its kind, documenting the nature of spine trauma in a major American conflict. The incidence of spine injuries in this study is the highest ever documented and is indicative of the tactics used by the enemy in the current war. Given this fact, it is likely that the prevalence of combat-related spine trauma will increase in the future. Larger, more extensive, studies of this kind must be conducted in the future.

Complications associated with military spine injuries

BACKGROUND CONTEXT

To assess the presence of complications associated with spine injuries in the Global War on Terror.

PURPOSE

To characterize the effect of complications in and around the battlefield during Operation Enduring Freedom and Operation Iraqi Freedom from 2001 to 2009.

STUDY DESIGN/SETTING

Retrospective study.

PATIENT SAMPLE

American servicemembers sustaining spine injury during combat.

METHODS

Extracted medical records of warriors identified by the Joint Theater Trauma Registry from October 2001 to December 2009. Complications were defined as unplanned medical events that required further intervention. Complications were classified as major or minor and further subdivided among groups, including surgical and nonsurgical management, mounted (in an armored vehicle) or dismounted at the time of injury, and blunt or penetrating trauma.

RESULTS

Major complications were encountered in 55 servicemembers (9%), and 38 (6%) sustained minor complications. Forty-four percent (n=24) of those with major complications had more than one complication. Eleven servicemembers sustained three or more complications. There were five intraoperative complications, and 50 occurred in the perioperative period. Intraoperative complications included gastrointestinal injury, dural tear, and instrument malposition. Among patients who sustained complications, precipitating spinal injuries occurred primarily in combat (n=43 [78%]) and resulted from blunt (18) or penetrating (25) mechanisms. Complications occurred in 10 (3%) of those treated nonoperatively and 45 (25%) of those receiving surgery. Complications were higher in the dismounted group (80%) as compared with those who were mounted in vehicles at the time of injury (20%). Thirty-five percent (n=24) of surgically treated, dismounted, and penetrating injured servicemembers had complications. Seventeen percent (n=8) of surgically treated and blunt injured mounted servicemembers and 20% (n=13) of dismounted servicemembers had complications. Among the dismounted and nonspinal cord-injured servicemembers, both blunt (p=.002) and penetrating injured (p<.0005) treated with surgery were correlated with complications. Only the dismounted servicemembers with spinal cord injuries because of a penetrating mechanism were also at an increased risk for complications (p<.0005).

CONCLUSIONS

Patients treated with surgery appear to be at increased complication risk regardless of the mechanism of injury. Uparmored vehicles may safeguard servicemembers from spine injuries and complications associated with their treatment. This may be reflective of the fact that less severe spinal and concomitant injuries are sustained in the precipitating trauma because of the protection afforded by the vehicle. Dismounted soldiers had more complications in all groups regardless of type of management or injury mechanism.

Neurological disorders in complex humanitarian emergencies and natural disasters

Complex humanitarian emergencies include the relatively acute, severe, and overwhelming health consequences of armed conflict, food scarcity, mass displacement, and political strife. Neurological manifestations of complex humanitarian emergencies are important and underappreciated consequences of emergencies in populations worldwide. This review critically assesses the existing knowledge of the range of neurological disorders that accompany complex humanitarian emergencies and natural disasters in both the acute phase of crisis and the "long shadow" that follows.

Can surgery improve neurological function in penetrating spinal injury? A review of the military and civilian literature and treatment recommendations for military neurosurgeons

Object

Penetrating spinal injury (PSI), although an infrequent injury in the civilian population, is not an infrequent injury in military conflicts. Throughout military history, the role of surgery in the treatment of PSI has been controversial. The US is currently involved in 2 military campaigns, the hallmark of both being the widespread use of various explosive devices. The authors reviewed the evidence for or against the use of decompressive laminectomy to treat PSI to provide a triservice (US Army, Navy, and Air Force) consensus and treatment recommendations for military neurosurgeons and spine surgeons.

Methods

A US National Library of Medicine PubMed database search that identified all literature dealing with acute management of PSI from military conflicts and civilian urban trauma centers in the post–Vietnam War period was undertaken.

Results

Nineteen retrospective case series (11 military and 8 civilian) met the study criteria. Eleven military articles covered a 20-year time span that included 782 patients who suffered either gunshot or blast-related projectile wounds. Four papers included sufficient data that analyzed the effectiveness of surgery compared with nonoperative management, 6 papers concluded that surgery was of no benefit, 2 papers indicated that surgery did have a role, and 3 papers made no comment. Eight civilian articles covered a 9-year time span that included 653 patients with spinal gunshot wounds. Two articles lacked any comparative data because of treatment bias. Two papers concluded that decompressive laminectomy had a beneficial role, 1 paper favored the removal of intracanal bullets between T-12 and L-4, and 5 papers indicated that surgery was of no benefit.

Conclusions

Based on the authors' military and civilian PubMed literature search, most of the evidence suggests that decompressive laminectomy does not improve neurological function in patients with PSI. However, there are serious methodological shortcomings in both literature groups. For this and other reasons, neurosurgeons from the US Air Force, Army, and Navy collectively believe that decompression should still be considered for any patient with an incomplete neurological injury and continued spinal canal compromise, ideally within 24–48 hours of injury; the patient should be stabilized concurrently if it is believed that the spinal injury is unstable. The authors recognize the highly controversial nature of this topic and hope that this literature review and the proposed treatment recommendations will be a valuable resource for deployed neurosurgeons. Ultimately, the deployed neurosurgeon must make the final treatment decision based on his or her opinion of the literature, individual abilities, and facility resources available.

Prevention and management of infections associated with combat-related central nervous system injuries

Combat-related injuries to the central nervous system (CNS) are of critical importance because of potential catastrophic outcomes. Although the overall infection rate of combat-related CNS injuries is less than 5%, if an infection develops there is a very high associated morbidity and mortality. This review focuses on the management and prevention of infections related to injuries to the brain or the spinal cord. Management strategies emphasize the importance of expert evaluation and management by a neurosurgeon. This review provides evidence-based recommendations from military and civilian data to the management of combat-related CNS injuries. Areas of focus include bacteria cultures, antimicrobial therapy, irrigation and debridement, timing of surgical care, and wound coverage. Given these recommendations are not supported by randomized control trials or adequate cohorts studies in a military population, further efforts are needed to answer best treatment strategies.

The health condition of spinal cord injuries in two Afghan towns

STUDY DESIGN

Cross-sectional.

OBJECTIVES

To describe the population with spinal cord injury (SCI) in two major towns of Afghanistan.

SETTING

Kabul and Herat, Afghanistan, March-July 2001.

METHODS

The residents of Kabul and Herat (N=311) with traumatic SCI were retrieved and investigated. They underwent standardised interviews and clinical examinations assessing socio-demographic characteristics and information on health condition, injury, quality of life and rehabilitation outcome.

RESULTS

The study population could be considered as the survivors in the harsh living conditions in Afghanistan of a supposedly much larger group, counting proportionately fewer females and fewer cervical lesions than expected. Acute care was practically nonexistent. Prevalences of urinary tract infections and pressure sores were high as no good management was available. Basic rehabilitation helped persons with SCI to attain a fairly good level of independence (total functional independence measure score mean=95, SD=19). Their quality of life was significantly lower than their neighbours of same age and sex (P< 0.0001). Along with the economic security and good access to the home, the use of the orthopaedic centre of the International Committee of the Red Cross (ICRC) contributed to a better quality of life.

CONCLUSION

Thanks to the rehabilitation programme of the ICRC providing a basic but comprehensive rehabilitation, persons with SCI in Afghanistan are coping rather well. This result is remarkable considering the difficult economic and sanitary circumstances in the poorest country in the world.

The military medical management of missile injury to the spine: a review of the literature and proposal of guidelines

The management of missile injury to the spinal cord is controversial. The literature is reviewed and recommendations made about the management of these injuries. To surgeons in a country that is relatively safe such injuries are rare, this review provides useful information about this condition.