Neurosurgical workload during US combat operations: 2002 to 2016

Telemedicine for Potential Application in Austere Military Environments: Neurosurgical Support for a Decompressive Craniectomy

INTRODUCTION

The main goal of this study was to assess the feasibility of a head-mounted display (HMD) providing telemedicine neurosurgical support during a decompressive craniectomy by a military surgeon who is isolated from readily available neurosurgical care. The secondary aim was to assess the usability perceived by the military surgeon and to evaluate technical aspects of the head-mounted display.

MATERIALS AND METHODS

After a standard concise lecture, 10 military surgeons performed a decompressive craniectomy on a AnubiFiX-embalmed post-mortem human head. Seven military surgeons used a HMD to receive telemedicine neurosurgical support. In the control group, three military surgeons performed a decompressive craniectomy without guidance. The performance of the decompressive craniectomy was evaluated qualitatively by the supervising neurosurgeon and quantified with the surgeons' operative performance tool. The military surgeons rated the usability of the HMD with the telehealth usability questionnaire.

RESULTS

All military surgeons performed a decompressive craniectomy adequately directly after a standard concise lecture. The HMD was used to discuss potential errors and reconfirmed essential steps. The military surgeons were very satisfied with the HMD providing telemedicine neurosurgical support. Military surgeons in the control group were faster. The HMD showed no hard technical errors.

CONCLUSIONS

It is feasible to provide telemedicine neurosurgical support with a HMD during a decompressive craniectomy performed by a non-neurosurgically trained military surgeon. All military surgeons showed competence in performing a decompressive craniectomy after receiving a standardized concise lecture. The use of a HMD clearly demonstrated the potential to improve the quality of these neurosurgical procedures performed by military surgeons.

Emergency Cranial Surgeries Without the Support of a Neurosurgeon: Experience of the French Military Surgeons

INTRODUCTION

Unlike orthopedic or visceral surgeons, French military neurosurgeons are not permanently deployed on the conflict zone. Thus, craniocerebral war casualties are often managed by general surgeons in the mobile field surgical team. The objective of the study was to provide the feedback of French military surgeons who operated on craniocerebral injuries during their deployment in a role 2 surgical hospital without a neurosurgeon.

MATERIALS AND METHODS

A cross-sectional survey was conducted by phone in March 2020, involving every military surgeon currently working in the French Military Training Hospitals, with an experience of cranial surgery without the support of a neurosurgeon during deployment. We strived to obtain contextual, clinical, radiological, and surgical data.

RESULTS

A total of 33 cranial procedures involving 64 surgeons were reported from 1993 to 2018. A preoperative CT scan was not available in 18 patients (55%). Half of the procedures consisted in debridement of craniocerebral wounds (52%, n = 17), followed by decompressive craniectomies (30%, n = 10), craniotomy with hematoma evacuation (15%, n = 5), and finally one (3%) surgery with exploratory burr holes were performed. The 30-day survival rate was 52% (n = 17) and 50% (n = 10/20) among the patients who sustained severe traumatic brain injury.

CONCLUSIONS

This survey demonstrates the feasibility and the plus-value of a neurosurgical damage control procedure performed on the field by a surgeon nonspecialized in cranial surgery. The stereotyped neurosurgical techniques used by the in-theater surgeon were learned during a specific predeployment training course. However, the use of a live telemedicine neurosurgical support seems indispensable and could benefit the general surgeon in strained resources setting.

Global Neurosurgery Advances From Trenches to Bedside: Lessons From Neurosurgical Care in War, Humanitarian Assistance, and Disaster Response

INTRODUCTION

War has influenced the evolution of global neurosurgery throughout the past century. Armed conflict and mass casualty disasters (MCDs), including Humanitarian Assistance Disaster Relief missions, require military surgeons to innovate to meet extreme demands. However, the military medical apparatus is seldom integrated into the civilian health care sector. Neurosurgeons serving in the military have provided a pragmatic template for global neurosurgeons to emulate in humanitarian disaster responses. In this paper, we explore how wars and MCD have influenced innovations of growing interest in the resource-limited settings of global neurosurgery.

METHODS

We performed a narrative review of the literature examining the influence of wars and MCD on contemporary global neurosurgery practices.

RESULTS

Wartime innovations that influenced global neurosurgery include the development of triage systems and modernization with airlifts, the implementation of ambulance corps, early operation on cranial injuries in hospital camps near the battlefield, the use of combat body armor, and the rise of damage control neurosurgery. In addition to promoting task-shifting and task-sharing, workforce shortages during wars and disasters contributed to the establishment of the physician assistant/physician associate profession in the USA. Low- and middle-income countries (LMICs) face similar challenges in developing trauma systems and obtaining advanced technology, including neurosurgical equipment like battery-powered computed tomography scanners. These challenges-ubiquitous in low-resource settings-have underpinned innovations in triage and wound care, rapid evacuation to tertiary care centers, and minimizing infection risk.

CONCLUSION

War and MCDs have catalyzed significant advancements in neurosurgical care both in the pre-hospital and inpatient settings. Most of these innovations originated in the military and subsequently spread to the civilian sector as military neurosurgeons and reservist civilian neurosurgeons returned from the battlefront or other low-resource locations. Military neurosurgeons have utilized their experience in low-resource settings to make volunteer global neurosurgery efforts in LMICs successful. LMICs have, by necessity, responded to challenges arising from resource shortages by developing innovative, context-specific care paradigms and technologies.

Nonfatal Injuries From Falls Among U.S. Military Personnel Deployed for Combat Operations, 2001-2018

INTRODUCTION

Falls are a leading mechanism of injury. Hospitalization and outpatient clinic visits due to fall injury are frequently reported among both deployed and non-deployed U.S. Military personnel. Falls have been previously identified as a leading injury second only to sports and exercise as a cause for non-battle air evacuations.

MATERIALS AND METHODS

This retrospective study analyzed the Department of Defense Trauma Registry fall injury data from September 11, 2001 to December 31, 2018. Deployed U.S. Military personnel with fall listed as one of their mechanisms of injury were included for analysis.

RESULTS

Of 31,791 injured U.S. Military personnel captured by the Department of Defense Trauma Registry within the study time frame, a total of 3,101 (9.8%) incurred injuries from falls. Those who had fall injuries were primarily 21 to 30 years old (55.4%), male (93.1%), Army (75.6%), and enlisted personnel (56.9%). The proportion of casualties sustaining injuries from falls generally increased through the years of the study. Most fall injuries were classified as non-battle injury (91.9%). Falls accounted for 24.2% of non-battle injury hospital admissions with a median hospital stay of 2 days. More non-battle-related falls were reported in Iraq-centric military operations (62.7%); whereas more battle-related falls were reported in Afghanistan-centric military operations (58.3%).

CONCLUSIONS

This study is the largest analysis of deployed U.S. Military personnel injured by falls to date. Highlighted are preventive strategies to mitigate fall injury, reduce workforce attrition, and preserve combat mission capability.

LEVEL OF EVIDENCE

Level III Epidemiologic.

Craniotomies at an overseas military treatment facility: Maintaining readiness for the unit and the surgeon

INTRODUCTION

Craniotomy and craniectomy are common neurosurgical procedures with wide applications in both civilian and military practice. Skill maintenance for these procedures is required for military providers in the event they are called to support forward deployed service members suffering from combat and non-combat injuries. The presents investigation details the performance of such procedures at a small, overseas military treatment facility (MTF).

MATERIALS AND METHODS

A retrospective review of craniotomy procedures performed at an overseas military treatment facility (MTF) over a 2-year period (2019-2021) was performed. Patient and procedural data were collected for all elective and emergent craniotomies including surgical indications, outcomes, complications, military rank, and impact on duty status and tour curtailment.

RESULTS

A total of 11 patients underwent a craniotomy or craniectomy procedure with an average follow-up of 496.8 days (range 103-797). Seven of the 11 patients were able to undergo surgery, recovery, and convalesce without transfer to a larger hospital network or MTF. Of the 6 patients that were active duty (AD), one returned to full duty while three separated and two remain in partial duty status at latest follow-up. There were four complications in four patients with one death.

CONCLUSIONS

In this series, we demonstrate that cranial neurosurgical procedures can be performed safely and effectively while at an overseas MTF. There are potential benefits to the AD service members, their unit, and family as well as to the hospital treatment team and surgeon as this represents a clinical capability requisite to maintain trauma readiness for future conflicts.

Epidemiology, patterns of care and outcomes of traumatic brain injury in deployed military settings: implications for future military operations

BACKGROUND

Traumatic brain injury (TBI) is prevalent and highly morbid among Service Members. A better understanding of TBI epidemiology, outcomes, and care patterns in deployed settings could inform potential approaches to improve TBI diagnosis and management.

METHODS

A retrospective cohort analysis of Service Members who sustained a TBI in deployed settings between 2001 and 2018 was conducted. Among individuals hospitalized with TBI, we compared the demographic characteristics, mechanism of injury, injury type, and severity between combat and non-combat injuries. We compared diagnostic tests and procedures, evacuation patterns, return to duty rates and days in care between individuals with concussion and those with severe TBI.

RESULTS

There were 46,309 Service Members with TBI and 9,412 who were hospitalized; of those hospitalized, 55% (4,343) had isolated concussion and 9% (796) had severe TBI, of whom 17% (132/796) had polytrauma. Overall mortality was 2% and ranged from 0.1% for isolated concussion to 18% for severe TBI. The vast majority of TBI were evacuated by rotary wing to Role 3 or higher, including those with isolated concussion. As compared to severe TBI, individuals with isolated concussion had fewer diagnostic or surgical procedures performed. Only 6% of Service Members with severe TBI were able to return to duty as compared to 54% of those with isolated concussion. TBI resulted in 123,677 lost duty days; individuals with isolated concussion spent a median of 2 days in care and those with severe TBI spent a median of 17 days in care and a median of 6 days in the intensive care unit.

CONCLUSIONS

While most TBI in the deployed setting is mild, TBI is frequently associated with hospitalization and polytrauma. Over-triage of mild TBI is common. Improved TBI capabilities applicable to forward settings will be critical to the success of future multi-domain operations with limitations in air superiority.

LEVEL OF EVIDENCE

Prognostic, Level III.

Head Face and Neck Surgical Workload From a Contemporary Military Role 3 Medical Treatment Facility

INTRODUCTION

Previous analyses of head, face, and neck (HFN) surgery in the deployed military setting have focused on the treatment of injuries using trauma databases. Little has been written on the burden of disease and the requirement for follow-up care. The aim of this analysis was to provide the most comprehensive overview of surgical workload in a contemporary role 3 MTF to facilitate future planning.

METHOD

The operating room database and specialty surgical logbooks from a U.S.-led role 3 MTF in Afghanistan were analyzed over a 5-year period (2016-2020). These were then matched to the deployed surgical TC2 database to identify reasons for treatment and a return to theatre rate. Operative records were finally matched to the deployed Armed Forces Health Longitudinal Technology Application-Theater outpatient database to determine follow up frequency.

RESULTS

During this period, surgical treatment to the HFN represented 389/1989 (19.6%) of all operations performed. Surgery to the HFN was most commonly performed for battle injury (299/385, 77.6%) followed by disease (63/385, 16%). The incidence of battle injury-related HFN cases varied markedly across each year, with 117/299 (39.1%) being treated in the three summer months (June to August). The burden of disease, particularly to the facial region, remained constant throughout the period analyzed (mean of 1 case per month).

CONCLUSIONS

Medical planning of the surgical requirements to treat HFN pathology is primarily focused on battle injury of coalition service personnel. This analysis has demonstrated that the treatment of disease represented 16% of all HFN surgical activities. The presence of multiple HFN sub-specialty surgeons prevented the requirement for multiple aeromedical evacuations of coalition service personnel which may have affected mission effectiveness as well as incurring a large financial burden. The very low volume of surgical activity demonstrated during certain periods of this analysis may have implications for the maintenance of surgical competencies for subspecialty surgeons.

Survival after traumatic brain injury improves with deployment of neurosurgeons: a comparison of US and UK military treatment facilities during the Iraq and Afghanistan conflicts

INTRODUCTION

Traumatic brain injury (TBI) is the most common cause of death on the modern battlefield. In recent conflicts in Iraq and Afghanistan, the US typically deployed neurosurgeons to medical treatment facilities (MTFs), while the UK did not. Our aim was to compare the incidence, TBI and treatment in US and UK-led military MTF to ascertain if differences in deployed trauma systems affected outcomes.

METHODS

The US and UK Combat Trauma Registries were scrutinised for patients with HI at deployed MTFs between March 2003 and October 2011. Registry datasets were adapted to stratify TBI using the Mayo Classification System for Traumatic Brain Injury Severity. An adjusted multiple logistic regression model was performed using fatality as the binomial dependent variable and treatment in a US-MTF or UK-MTF, surgical decompression, US military casualty and surgery performed by a neurosurgeon as independent variables.

RESULTS

15 031 patients arrived alive at military MTF after TBI. Presence of a neurosurgeon was associated with increased odds of survival in casualties with moderate or severe TBI (p<0.0001, OR 2.71, 95% CI 2.34 to 4.73). High injury severity (Injury Severity Scores 25-75) was significantly associated with a lower survival (OR 4×10⁴, 95% CI 1.61×10⁴ to 110.6×10⁴, p<0.001); however, having a neurosurgeon present still remained significantly positively associated with survival (OR 3.25, 95% CI 2.71 to 3.91, p<0.001).

CONCLUSIONS

Presence of neurosurgeons increased the likelihood of survival after TBI. We therefore recommend that the UK should deploy neurosurgeons to forward military MTF whenever possible in line with their US counterparts.

Direct enhancement of readiness for wartime critical specialties by civilian-military partnerships for neurosurgical care: residency training and beyond

Military neurosurgery has played an integral role in the development and innovation of neurosurgery and neurocritical care in treating battlefield injuries. It is of paramount importance to continue to train and prepare the next generation of military neurosurgeons. For the Army, this is currently primarily achieved through the military neurosurgery residency at the National Capital Consortium and through full-time out-service positions at the Veterans Affairs-Department of Defense partnerships with the University of Florida, the University of Texas-San Antonio, and Baylor University. The authors describe the application process for military neurosurgery residency and highlight the training imparted to residents in a busy academic and level I trauma center at the University of Florida, with a focus on how case variety and volume at this particular civilian-partnered institution produces neurosurgeons who are prepared for the complexities of the battlefield. Further emphasis is also placed on collaboration for research as well as continuing education to maintain the skills of nondeployed neurosurgeons. With ongoing uncertainty regarding future conflict, it is critical to preserve and expand these civilian-military partnerships to maintain a standard level of readiness in order to face the unknown with the confidence befitting a military neurosurgeon.

Spine surgery in the International Security Assistance Force Role 3 combat support hospital in Mazar-e-Sharif, northern Afghanistan, 2007-2014

OBJECTIVESince 2007, a continuous neurosurgery emergency service has been available in the International Security Assistance Force (ISAF) field hospital in Mazar-e-Sharif (MeS), Afghanistan. The object of this study was to assess the number and range of surgical procedures performed on the spine in the period from 2007 to 2014.METHODSThis is a retrospective analysis of the annual neurosurgical caseload statistics from July 2007 to October 2014 (92 months). The distribution of surgical urgency (emergency, delayed urgency, or elective), patient origin (ISAF, Afghan National Army, or civilian population), and underlying causes of diseases and injuries (penetrating injury, blunt injury/fracture, or degenerative disease) was analyzed. The range and pattern of diagnoses in the neurosurgical outpatient department from 2012 and 2013 were also evaluated.RESULTSA total of 341 patients underwent neurosurgical operations in the period from July 2007 to October 2014. One hundred eighty-eight (55.1%) of the 341 procedures were performed on the spine, and the majority of these surgeries were performed for degenerative diseases (127/188; 67.6%). The proportion of spinal fractures and penetrating injuries (61/188; 32.4%) increased over the study period. These spinal trauma diagnoses accounted for 80% of the cases in which patients had to undergo operations within 12 hours of presentation (n = 70 cases). Spinal surgeries were performed as an emergency in 19.8% of cases, whereas 17.3% of surgeries had delayed urgency and 62.9% were elective procedures. Of the 1026 outpatient consultations documented, 82% were related to spinal issues.CONCLUSIONSCompared to the published numbers of cases from neurosurgery units in the rest of the ISAF area, the field hospital in MeS had a considerably lower number of operations. In addition, MeS had the highest rates of both elective neurosurgical operations and Afghan civilian patients. In comparison with the field hospital in MeS, none of the other ISAF field hospitals showed such a strong concentration of degenerative spinal conditions in their surgical spectrum. Nevertheless, the changing pattern of spine-related diagnoses and surgical therapies in the current conflict represents a challenge for future training and material planning in comparable missions.