Evolution of the Role 4 UK Military Pain Service

Perioperative and early rehabilitation outcomes following osseointegration in UK military amputees

Introduction

This paper examines the pain management, from surgery to specialist rehabilitation, of the first seven military transfemoral amputee patients treated in the UK with femoral osseointegration. All the patients had sustained complex ballistic injuries on the battlefield. The patients were characterised by long-standing problems with functional rehabilitation due to limitations with conventional prostheses, including stump soft tissue issues and impaired biomechanics.

Methods

A prospective service investigation was undertaken to evaluate the effectiveness of the pain management of patients undergoing osseointegration. Data were collected by daily direct patient contact, supplemented by a focused review of perioperative and rehabilitation case notes. Physiological and medication details were recorded with specific reference to systemic and regional analgesia and the impact of postoperative complications, including infection and accidental injury.

Results

Seven patients underwent femoral osseointegration and were followed up for a period of up to 3 years following surgery. The perioperative recovery was associated with significant escalation of analgesic requirements. Postoperative systemic inflammatory response syndrome was identified in six patients, with wound infection persisting in some cases into the rehabilitation phase. Three patients suffered femoral fractures following accidental injuries secondary to increased mobilisation following surgery.

Conclusions

Successful surgical outcomes were achieved in a difficult patient cohort disadvantaged by previously restricted functional recovery from complex injuries. The importance of supporting the operative and recovery phases with a multidisciplinary pain service is emphasised. We offer this data and the lessons learnt to assist clinicians contemplating the establishment and service development of osseointegration services.

Neuropathic pain treatment and research: experiences from the United Kingdom mission to Afghanistan and future prospects

The Defence Medical Services (DMS) of the United Kingdom (UK) assumed command of the Role 3 Medical Treatment Facility field hospital during Operation HERRICK in Afghanistan from April 2006 until the final drawdown in November 2014. The signature injury sustained by coalition personnel during this period was traumatic amputation from improvised explosive devices. Many patients who had suffered extensive tissue damage experienced both nociceptive and neuropathic pain (NeuP). This presented as a heterogeneous collection of symptoms that are resistant to treatment. This paper discusses the relationship of NeuP in the context of ballistic injury, drawing in particular on clinical experience from the UK mission to Afghanistan, Operation HERRICK. The role of this paper is to describe the difficulties of assessment, treatment and research of NeuP and make recommendations for future progress within the DMS.

Lessons learned from early rehabilitation of complex trauma at the Royal Centre for Defence Medicine

During the recent conflicts in Iraq and Afghanistan, substantial numbers of service personnel survived devastating injuries, presenting significant challenges for early rehabilitation at Queen Elizabeth Hospital Birmingham. Royal Centre for Defence Medicine personnel augmented NHS therapy provision, gaining significant experience in rehabilitating complex trauma. Multidisciplinary working was key to delivering this service, with a unique rehabilitation coordinating officer position established to manage the rehabilitation pathway. A military exercise rehabilitation instructor provided daily gym-based rehabilitation, developing exercise tolerance. Emphasis was placed on early independence, reducing pain, eliminating complications and optimising function. Innovative solutions and non-standard combinations of rehabilitation were required, with therapy working practices redesigned that, we believe, exceed provision elsewhere, including novel applications such as unique patient transfers, specialist seating, additional equipment, problem-solving teaching and early upper limb prosthetic provision. Active pain management allowed engagement in rehabilitation. With limited evidence available, therapeutic modalities attempting to alleviate phantom limb pain centred on patients' ability to engage in treatment. Finally, the requirement to measure change in early trauma rehabilitation was identified, leading to the development of the preprosthetic functional outcome measure. This article aims to document advances made, lessons learned, encourage debate and identify priorities for future research for military complex trauma rehabilitation.

Clinical and microbiological evaluation of epidural and regional anaesthesia catheters in injured UK military personnel

INTRODUCTION

The adoption of regional and epidural analgesia in UK military personnel injured in action during Op HERRICK increased from 2008, in line with structural and environmental developments in the UK medical treatment facility. Historically, there have been concerns that invasive analgesic techniques could carry an increased risk of infection, due to the mechanism of injury and the environmental conditions in which the injuries were sustained. Consequently, the epidural and continuous peripheral nerve blockade (CPNB) catheters that were inserted in UK military personnel during a 33-month period of Op HERRICK were clinically and microbiologically examined, after subsequent admission to the University Hospitals Birmingham (UHB) NHS Trust.

METHODS

Data on epidural and CPNB insertions were collected via the specialist pain service at UHB over the study period, including de novo and replacement insertions performed in both Afghanistan and the UK. Patients were regularly reviewed and relevant clinical concerns were documented in patients' case notes as necessary. The anatomical site, duration of placement and the results of microbiological culture of the epidural and CPNB catheter tips were all recorded.

RESULTS

Overall, 236 catheters were assessed, of which 151 catheter tips (64%) were cultured (85 epidural, 66 CPNB). Of these, 48 grew bacteria (34% of cultured epidurals and 29% of cultured CPNB). There was no difference between the colonisation rates of epidurals inserted in Afghanistan and the UK. Only one infection related to a misplaced epidural catheter was confirmed.

CONCLUSIONS

With the exception of the epidural (34%) and proximal sciatic (42%) catheters, these figures, in a military cohort characterised by significant injury scores, are consistent with those reported for civilian surgical patients. The results strongly support the expansion of regional analgesia during Op HERRICK from 2008 onwards. The outcomes suggest a possible translation into civilian major trauma practice.