The combat burst fracture study--results of a cohort analysis of the most prevalent combat specific mechanism of major thoracolumbar spinal injury

Landmine Injury Resulting in Comminuted Lumbar Facet Fracture as a Cause of Lumbar Stenosis and Spondylolisthesis

Lumbar facet fractures are rarely reported and have been linked to sports and spine surgery. We describe the case of a 77-year-old patient who sustained an injury from multiple landmine blasts during the Vietnam War. He had low back pain since that time, which was initially managed conservatively. However, the pain progressed over decades to severe neurogenic claudication that greatly restricted his quality of life. Neuroimaging revealed the presence of bone fragments impinging on the spinal canal at the L5/6 level (transitional anatomy) that resulted from a comminuted fracture of the lumbar facet at the inferior articular process. We performed an L5/6 decompressive laminectomy, with removal of these fragments, and posterior instrumented fusion, with substantial improvement in symptoms. This case illustrates a unique mechanism of lumbar facet fracture and the biomechanic origination, natural history, and optimal treatment of this entity. We expand on the spectrum of lumbosacral injuries associated with the combat blast injury that have only increased in prevalence in recent conflicts.

A comparison of fracture response in female and male lumbar spine in simulated under body blast component tests

Underbody blasts (UBB) from mines and improvised explosive devices in military combat can cause debilitating spine injuries to vehicle mounted soldiers. Due to the exclusion of females in combat roles in prior US Department of Defense policy, UBB exposure and injury have predominantly affected male soldiers. Recent policy changes have opened many combat roles to women serving in the US Military (Carter, 2015) and have increased the need to understand the injury potential for female Warfighters. The goal of this study was to investigate the fracture response of adult female lumbar spines compared to adult male spines in UBB relevant loading to identify potential differences in either fracture mechanism or force. Results are presented for 15 simulated UBB spine compression tests using three small female (SF), five large female (LF), and seven mid-sized male (MM) post-mortem human subjects (PMHS). These PMHS groups align to 5th- and 75th-percentile female and 50th-percentile males, based on height and weight from the 2012 Anthropometric Survey of U.S. Army Personnel (Gordon et al., 2014). Both small females and large females (similar in size to the males) were included to assess the role of size and/or sex in the response. Tests were conducted at Virginia Tech on a cam-driven linear compression rig, which included a 6-axis load cell and ram accelerometer to evaluate the fracture. Fracture was visualized through high-speed x-ray video. All female and male spines exhibited similar fracture initiation at the end plates and progression through the vertebral body. The resulting severe compression and burst fractures were representative of reported theatre injuries (Freedman et al., 2014). Mean axial fracture forces were -4182 ± 940 N (SF), -6225 ± 1180 N (LF), -5459 ± 1472 N (All Females) and -7993 ± 2445 N (MM). The SF group was found to have statistically significant differences in mean fracture force compared to both LF and MM groups, while no significant difference was found between LF and MM groups, although the mean force at initial fracture was lower for the LF group. The All-Females group Fz mean was significantly different from the MM group. These data suggest that the significant difference in weight between the SF and LF groups, did have an influence on the Fz outcome, when controlling for sex. Conversely, controlling for size in the LF and MM comparison, sex did influence the mean Fz, but was not statistically significant. Groups with combined sex and size differences, however, did show significant differences in mean Fz. Further study is warranted to understand whether sex or size has a larger effect on fracture force. Mean ram displacement (spine compression) values at fracture initiation were -6.0 ± 5.3 mm (SF), -4.4 ± 0.8 mm (LF), -5.0 ± 3.0 mm (All Females), -6.2 ± 4.5 mm (MM). Spine compression did not seem to be largely influenced by either sex or size, and none of the groups was found to have significant differences in mean displacement values.

Wounding characteristics and treatment principle of ground anti-armored vehicle ammunition against armored crew

The wound mechanism, injury characteristics and treatment principle of anti-armored vehicle ammunition against armored crew in the past 20 years are summarized in this paper. Shock vibration, metal jet, depleted uranium aerosol and post armor breaking effect are the main factors for wounding armored crew. Their prominent characteristics are severe injury, high incidence of bone fracture, high rate of depleted uranium injury, and high incidence of multiple/combined injuries. During the treatment, attention must be paid on that the space of armored vehicle is limited, and the casualties should be moved outside of the cabin for comprehensive treatment. Especially, the management of depleted uranium injury and burn/inhalation injury are more important than other injuries for the armored wounds.

Incidence and Epidemiology of Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

This review aims to search the epidemiology and incidence rates of thoracolumbar spine fractures. A systematic review of the literature of the last 10 years gave 586 results with “incidence,” and 387 results with “epidemiology,” of which 39 papers were analyzed. The review results were discussed and voted in 2 consensus meetings of the WFNS (World Federation of Neurosurgical Societies) Spine Committee. Out of 39 studies, 15 studies have focused on thoracolumbar trauma, remaining 24 studies have looked at all spine trauma. Most were retrospective in nature; few were prospective and multicenter. Some studies have focused on specific injuries. The annual incidence of TL fractures is about 30/100,000 inhabitants including osteoporotic fractures. There is a trend to increase the fractures in elderly population especially in developed countries, while an increase of motor vehicle accidents in developing countries. The mortality rate among male elderly patients is relatively high. The incidence of thoracolumbar spine fractures is increasing because of low-velocity falls in the elderly population. The main reasons are falls and traffic accidents. Learning the regional differences and some special forms of trauma such as extreme sports, war, and gunshot injuries will help the prevention of the thoracolumbar spine fractures.

Cervical and Thoracolumbar Spine Injury Evaluation, Transport, and Surgery in the Deployed Setting

This Cervical and Thoracolumbar Spine Injury Evaluation, Transport, and Surgery Clinical Practice Guideline (CPG) is designed to provide guidance to the deployed provider when they are treating a combat casualty who has sustained a spine or spinal cord injury. The CPG objective for the treatment and the movement of these patients is to maintain spinal stability through transport, perform decompression when urgently needed, achieve definitive stabilization when appropriate, avoid secondary injury, and prevent deterioration of the patient's neurological condition. Thorough and accurate documentation of the patient's neurological examination is crucial to ensure appropriate management decisions are made as the patient transits through the evacuation system. The use of this CPG should be in conjunction with good clinical judgment.

Chinese expert consensus on the treatment of modern combat-related spinal injuries

The battlefield treatments of spinal and spinal cord injury vary from civilian settings. However, there is no unified battlefield treatment guidelines for spine trauma in PLA. An expert consensus is reached, based on spine trauma epidemiology and the concepts of battlefield treatment combined with the existing levels of military medical care in modern warfare. Since the specialized treatment for spine trauma are no significant difference between civilian settings and modern war, the first aid, emergency treatment and early treatment of spine trauma are introduced separately in three levels in this consensus. In Level I facilities, the fast and accurate evaluation of spine trauma followed by fixation and stabilization are recommended during the first-aid stage. Re-evaluation, further treatment for possible hemorrhagic shock, dyspnea and infection are recommended at Level II facilities. At Level III facilities, it is recommended to strengthen the intensive care and the prevention of urinary system and lung infection for the wounded with severe spinal injury, however, spinal surgery is not recommended in a battlefield hospital. The grading standard for evidence evaluation and recommendation was used to reach this expert consensus.

Devastating neurologic injuries in the Syrian war

Background

Since 2011, hundreds of thousands of Syrians have been displaced and injured due to the ongoing Syrian civil war. In this study, we report the prevalence of neurologic injuries in a major rehabilitation center on the Turkish-Syrian border where death and injury tolls continue to rise.

Method

Based on several on-site visits from 2013 to 2016, medical practitioners collected data from patients in the major rehabilitation center on the border of Turkey and Syria. The clinical data, which included the type and cause of injury, laterality, paralysis, areas injured, and treatment offered, were analyzed.

Results

A total of 230 patients were identified as having sustained a neurologic injury, 221/230 (96.1%) male and 9/230 (3.91%) female, ranging from ages 2-52 years. A total of 305 total injuries were documented over the course of a 4-year analysis due to several patients having multiple injuries. Gunshot wounds were the dominant mechanism of injury in 125/230 (54.3%) patients. Patients more frequently sustained single injuries 152/230 (66.1%) than multiple injuries 78/230 (33.9%). Peripheral nerve injuries were the most prevalent injuries, at 92.5% of all neurologic injuries (282/305), specifically injury to the radial nerve, at 19.1% (54/282) of peripheral injuries. Patients with spinal cord injuries made up 20/230 (8.7%) of all patients, with thoracic spine injuries composing 50% (10/20). Traumatic brain injuries were the least prevalent, 3/230 (1.3%), with an equal distribution of subtypes.

Conclusion

This study and critical analysis of the devastation in Syria suggests the desperate need for emergency aid.

The tell-tale thigh

A body of a 91-year-old donor underwent whole-body CT scanning before being transferred for use in an anatomical dissection course. Metallic objects were detected in the thigh muscles, extensive bone abnormalities were found in the left femur and the diaphysis of the left femur was 50% wider than that of the right diaphysis. History revealed that the body donor had been seriously wounded at the end of World War II by a rocket explosion. His multiple fractures and lesions had not been surgically treated either in an Austrian military hospital or in a French prisoner of war camp. The patient suffered for almost 70 years from this violation of the Geneva Conventions. In the light of current armed conflicts, the present case is an example of how one injustice can result in severe, lifelong medical consequences. It also shows that the history behind a wounded thigh can have an enormous impact on teaching ethics to today's medical students.

Reoperation after in-theater combat spine surgery

BACKGROUND CONTEXT

The ideal timing of surgical decompression or stabilization following combat-related spine injury remains unclear.

PURPOSE

The study aims to determine the etiology and factors related to reoperation following evacuation to the United States after undergoing in-theater spine surgery.

STUDY DESIGN

This is a retrospective analysis.

PATIENT SAMPLE

The sample includes 13 patients with combat-related spine injuries undergoing revision spine surgery.

OUTCOME MEASURES

The outcome measures were time to arrival in the United States, time to reoperation, indications for revision, operative details, further revision surgery, infection rate, complications after reoperation, and most recent clinical follow-up information.

METHODS

This is a retrospective analysis of patients undergoing spine surgery designated as injured during the Global War on Terrorism between July 2003 and July 2013. Inpatient and outpatient medical records, operative reports, and imaging studies were reviewed.

RESULTS

The mean time to index surgery was 1.6 days. The mechanisms of injury included five gunshot wounds, three improvised explosive devices (IED), two helicopter crashes, one motor vehicle accident, and two other mechanisms (fall and crush injury). The mean injury severity score (ISS) was 22.7 (range: 13-45). There were six cervical, seven thoracic, eight lumbar, and two sacral injuries, with a mean of 1.8±1.0 spinal regions injured per patient. Twelve patients had a spinal cord injury, four of which were AIS (American Spinal Association Impairment Scale). Three patients underwent spinal stabilization on the date of injury, and one patient had three separate spine surgeries while downrange before arrival. Four patients underwent fixation in theater. There was a mean of 5.5 days from injury to arrival in the United States, and the mean time to revision fixation was 11.2 days post-index surgery (range: 4-14 days). Revision indications included instability or progressive kyphosis (N=6), and two of these patients had decompression without instrumentation downrange. Other indications included inadequate decompression (N=4), infection, persistent drainage, and epidural hematoma. At a mean of 5.5-year follow-up, all patients were medically retired from service, with minimal neurologic improvement.

CONCLUSIONS

Our study found that instability or progressive kyphosis and incomplete decompression were the most common indications for reoperation after evacuation to the United States. Our data provide additional understanding of the potential etiologies of failure and reoperation following in-theater combat spine surgery, and may help avoid such complications.

Identifying Spinal Injury Patterns in Underbody Blast to Develop Mechanistic Hypotheses

STUDY DESIGN

A retrospective case series of UK victims of blast injury.

OBJECTIVE

To identify the injury patterns in the spine caused by under-vehicle blast, and attempt to derive the mechanism of those injuries.

SUMMARY OF BACKGROUND DATA

The Improvised Explosive Device has been a feature of recent conflicts with frequent attacks on vehicles, leading to devastating injuries. Vehicle design has evolved to reduce the risk of injury to occupants in underbody blast, where the device detonates beneath the vehicle. The mechanism of spinal injury in such attacks is not well understood; understanding the injury mechanism is necessary to produce evidence-based mitigation strategies.

METHODS

A Joint Theatre Trauma Registry search identified UK victims of blast between 2008 and 2013. Each victim had their initial scan reviewed to classify spinal fractures.

RESULTS

Seventy-eight victims were identified, of whom 53 were survivors. There were a total of 284 fractures, including 101 thoracolumbar vertebral body fractures and 39 cervical spine fractures. Most thoracolumbar fractures were wedge compression injuries. Most cervical spine fractures were compression-extension injuries.The most common thoracic and lumbar body fractures in this group suggest a flexed posture at the time of injury. Most cervical spine fractures were in extension, which might be compatible with the head having struck another object.

CONCLUSION

Modifying the seated posture might reduce the risk of thoracolumbar injury, or allow the resulting injury patterns to be controlled. Cervical spine injuries might be mitigated by changing vehicle design to protect the head.

LEVEL OF EVIDENCE

N/A.

Outcomes After Operative Management of Combat-Related Low Lumbar Burst Fractures

STUDY DESIGN

Retrospective review.

OBJECTIVE

Report the 2-year operative and clinical outcomes of these service members with low lumbar fractures.

SUMMARY OF BACKGROUND DATA

The majority of spinal fractures occur at the thoracolumbar level, with fractures caudal to L2 accounting for only 1% of spine fractures. A previous report from this institution regarding combat-related spine burst fractures documented an increased incidence of low lumbar burst fractures in injured service members.

METHODS

Review of inpatient and outpatient medical records in addition to radiographs for all patients treated at our institution with combat-related burst fractures occurring at the L3-L5 levels.

RESULTS

Twenty-four patients with a mean age of 28.1± 7.2 underwent surgery for low lumbar (L3-L5) burst fractures. The mean number of thoracolumbar levels injured was 2.9 ± 1.4. Eleven patients had neurological injury, 4 of which were complete. The mean days to surgery were 16.8 ± 24.5. The mean number of levels fused was 4.3 ± 2.1, with fixation extending to the pelvis in 4 patients (17%). Fourteen (61%) patients had at least 1 postoperative complication, with 7 (30%) requiring reoperation. Five patients had a postoperative wound infection. Five patients had deep venous thromboses, 3 had pulmonary emboli. Mean clinical follow-up was 3.3± 2.2 years. At latest follow-up, all were separated from military service, 10 experienced persistent bowel/bladder dysfunction, 15 had lower extremity motor deficits, and 10 had documented persistent low back pain. Nineteen had chronic pain with 18 patients still taking pain medications and/or muscle relaxers.

CONCLUSION

Low lumbar burst fractures are a rare injury with an increased incidence in combat casualties engaged in the wars in Iraq and Afghanistan. We found a high rate of acute postoperative complications (61%), as well as a high reoperation rate (30%). At approximately 3 years of follow-up, most of these patients had persistent neurological symptoms and chronic pain.

LEVEL OF EVIDENCE

4.