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Homeier DD, Kang D, Molinari R, Mesfin A. The top-cited military relevant spine articles. J Orthop 2024; 54:38-45. [PMID: 38524362 PMCID: PMC10957343 DOI: 10.1016/j.jor.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 03/12/2024] [Indexed: 03/26/2024] Open
Abstract
Introduction Historically musculoskeletal injury has substantially affected United States (US) service members. Lumbosacral spine injuries are among the most common sites of injury for service members across all US military branches and usually presents with pain in the lower back and extremities. The aim of this study is to identify and describe the 50 most-cited articles relevant to military medicine on the subject of the spine. Methods In April 2020 Web of Science was used to search the key words: spinal cord injury, spine, thoracic spine, lumbar spine, cervical spine, sacrum, sacral, cervical fusion, lumbar fusion, sacral fracture, combat, back pain, neck pain, and military. Articles published from 1900 to 2020 were evaluated for relevance to military spine orthopaedics and ranked based on citation number. The 50 most-cited articles were characterized based on country of origin, journal of publication, affiliated institution, topic, military branch, and conflict. Results 1900 articles met search criteria. The 50 most-cited articles were cited 24 to 119 times and published between 1993 and 2017. 30 articles (60%) originated in the United States. Aviation, Space, and Environmental Medicine accounted for the most frequent (n = 10) destination journal followed by Spine (n = 8). 37 institutions contributed to the top 50 most-cited articles. The most common article type was clinically focused retrospective analysis 36% (n = 18), clinically focused cohort study 10% (n = 5), and clinically focused cohort questionnaire, cross-sectional analysis, and randomized study 8% each (n = 4). 90% of articles were non-surgical (n = 45). The US Army had the greatest number of associated articles. Operation Iraqi Freedom and Operation Enduring Freedom were the most-cited conflicts. Conclusion The 50 most-cited articles relevant to military spine orthopaedics are predominantly clinically focused, arising from the US, and published in Aviation, Space, and Environmental Medicine, Spine, and The Spine Journal.
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Affiliation(s)
- Daniel D. Homeier
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Daniel Kang
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, WA, USA
| | - Robert Molinari
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Addisu Mesfin
- Department of Orthopaedic Surgery, MedStar Health, Columbia, MD, USA
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2
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Wang P, Zhou S, Li B, Wang Y, Xu W. Investigating Research Hotspots of Combat-related Spinal Injuries: A 30-year Bibliometric Analysis Study. Mil Med 2024:usae178. [PMID: 38771111 DOI: 10.1093/milmed/usae178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/15/2024] [Accepted: 04/10/2024] [Indexed: 05/22/2024] Open
Abstract
INTRODUCTION Spinal cord injuries often lead to significant motor and sensory deficits, as well as autonomic dysfunction. Compared with normal spinal injuries, combat-related spinal injuries (CRSIs) are usually more complex and challenging to treat because of multiple traumas, firing-line treatments, and arduous initial treatments on a battlefield. Yet numerous issues remain unresolved about clinical treatment and scientific research. The enhancement of CRSI diagnosis and treatment quality by military surgeons and nurses is imperative. The objective of this study is to identify the frontiers, hotspots, and trends among recent research, summarize the development process of clinical trials, and visualize them systematically. MATERIALS AND METHODS We collected publications from CRSI based on the Core Collection of Web of Science for 30 years from January 1, 1993 to May 1, 2023.Visualizations of the knowledge maps were produced using VOSviewer and CiteSpace software. We examined annual trends of publications and distribution patterns, the number of publications, as well as the research hotspots. RESULTS Among 201 documents, it was found that there was a stable upward trend in publications. There were 2 rapid growth stages during the 30 years. Among all countries, the USA contributed the most publications, along with the highest influence and the most international cooperation. Military Medicine was the journal of the maximum publications, whereas the Spine journal was the most influential one. Keyword co-occurrence analysis and trend topics analysis revealed that these articles focused 5 distinct categories for CRSI. CONCLUSIONS As the first bibliometric study focused on CRSI, we demonstrated the evolution of the field and provided future research directions. We summarized the hotspots and 5 clusters published. This would serve as a useful guide for clinicians and scientists regarding CRSI global impacts.
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Affiliation(s)
- Pengru Wang
- Department of Orthopedic Oncology, Changzheng Hospital, Naval Military Medical University, Shanghai 200003, China
| | - Shangbin Zhou
- Department of Orthopedic Oncology, Naval Medical Center, Naval Military Medical University, Shanghai 200030, China
| | - Bo Li
- Department of Orthopedic Oncology, Changzheng Hospital, Naval Military Medical University, Shanghai 200003, China
| | - Yingtian Wang
- Medical Administration Division, Chinese PLA General Hospital, Beijing 100141, China
| | - Wei Xu
- Department of Orthopedic Oncology, Changzheng Hospital, Naval Military Medical University, Shanghai 200003, China
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Hawkins SC, Williams J, Bennett BL, Islas A, Quinn R. Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection: 2024 Update. Wilderness Environ Med 2024; 35:78S-93S. [PMID: 38379496 DOI: 10.1177/10806032241227232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
The Wilderness Medical Society reconvened an expert panel to update best practice guidelines for spinal cord protection during trauma management. This panel, with membership updated in 2023, was charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in wilderness environments. Recommendations are made regarding several parameters related to spinal cord protection. These recommendations are graded based on the quality of supporting evidence and balance the benefits and risks/burdens for each parameter according to American College of Chest Physicians methodology. Key recommendations include the concept that interventions should be goal-oriented (spinal cord/column protection in the context of overall patient and provider safety) rather than technique-oriented (immobilization). An evidence-based, goal-oriented approach excludes the immobilization of suspected spinal injuries via rigid collars or backboards.
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Affiliation(s)
- Seth C Hawkins
- Department of Emergency Medicine, Wake Forest University, Winston-Salem, NC
| | - Jason Williams
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM
| | - Brad L Bennett
- Military & Emergency Medicine Department, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Arthur Islas
- Department of Family and Community Medicine, University of Nevada, Reno School of Medicine, Reno, NV
| | - Robert Quinn
- Department of Orthopaedic Surgery, University of Texas Health Science Center, San Antonio, TX
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Eyal Y, Tsur N, Gendler S, Almog O, Beer Z. Spinal Backboard-Necessity or Hazard? The IDF Clinical Practice Guidelines and Policy. Mil Med 2023; 188:e1781-e1787. [PMID: 36173127 DOI: 10.1093/milmed/usac279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/14/2022] [Accepted: 09/08/2022] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Prehospital spinal immobilization using a cervical collar and a backboard has been standard practice for suspected spinal cord injuries (SCIs) since the 1960s. Multiple studies have shown that the disadvantages of the spinal backboard outweigh its advantages. This report aims to present a review of the current literature along with the revised IDF protocol regarding patients with suspected SCI. METHODS In 2019, the IDF Medical Corps (IDFMC) convened a multidisciplinary expert committee to revise the IDFMC protocols regarding the use of spinal backboards. Prior to convening the committee, a review of the pertinent literature was done by conducting a thorough clinical evaluation in "PubMed" and "Google Scholar" databases to identify recent studies investigating traumatic SCI and the prehospital military use of spinal backboards. RESULTS There were no documented studies that have managed to prove the efficacy of spinal backboards to prevent exacerbation of spinal injuries during mobilization. Despite being a good tool for extraction from vehicles and combat arenas, more than 11 studies have shown that backboards may even result in adverse outcomes such as pain due to the contact between board and skin, the formation of decubitus ulcers, hypothermia, and inadequate ventilation. CONCLUSION In light of the evidence showing the potential harmful effects of the routine use of spinal backboards, the IDF guidelines have been revised and now recommends avoiding the routine use of spinal backboards and using a standard stretcher for transporting potential SCI patients. Current IDF guidelines recommend using a backboard for the extraction of an entrapped patient and for obtunded or unconscious patients with obvious deformity or mechanism for spinal trauma.
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Affiliation(s)
- Yaakov Eyal
- Israel Defense Forces Medical Corps, Ramat Gan 2149, Israel
| | - Nir Tsur
- Israel Defense Forces Medical Corps, Ramat Gan 2149, Israel
- Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Tel Aviv University, Petach Tikva 4941492, Israel
| | - Sami Gendler
- Israel Defense Forces Medical Corps, Ramat Gan 2149, Israel
| | - Ofer Almog
- Israel Defense Forces Medical Corps, Ramat Gan 2149, Israel
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem 12000, Israel
| | - Zivan Beer
- Israel Defense Forces Medical Corps, Ramat Gan 2149, Israel
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem 12000, Israel
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Cingoz ID, Kaya I, Sahin MC, Kilcarslan B, Yuceer N. Spine and spinal cord injuries in Syria war: treatment and outcome. Spinal Cord 2023; 61:169-174. [PMID: 36575225 DOI: 10.1038/s41393-022-00870-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 12/28/2022]
Abstract
STUDY DESIGN This was a retrospective, comparative 6-year study. OBJECTIVES This study aimed to retrospectively analyze patients who were treated at Kilis State Hospital for spine and spinal cord injuries during the Syrian civil war and to compare the treatment results with the literature. SETTING Kilis State Hospital, Kilis, Turkey. METHODS In our study, 84 patients who were treated for spine and spinal cord injuries between December 2011 and May 2017 were examined. Patient age, sex, injury type, injury region, neurological status, time from injury to treatment, treatment methods, surgical methods applied, and complications were evaluated. RESULTS Of the patients, 72 were male, and 12 were female. The mean age of the patients was 23.2 ± 7.3 years. Fifty-two patients were treated surgically. Surgical treatment was applied to 44 patients with neurological deficits. At least 1-grade neurological improvement was observed in 77.3% (n = 34) of patients with neurological deficits who underwent surgical treatment. Surgical treatment was performed on 18 (34.6%) patients in the first 24 h, 27 (51.9%) patients within 24-72 h, and 7 patients (13.5%) between 72 h and 5 days. Neurological improvement was observed in all patients with neurological deficits who underwent surgical treatment in the first 24 h. CONCLUSIONS Early surgery (in the first 24 h) had a positive effect on the neurological recovery of the patients in our study. Thus, patients with spine and spinal cord injuries rendered a surgical-treatment decision should be operated on in a timely manner, particularly within the first 24 h.
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Affiliation(s)
- Ilker D Cingoz
- Department of Neurosurgery, Faculty of Medicine, Usak University, Usak, Turkey.
| | - Ismail Kaya
- Department of Neurosurgery, Faculty of Medicine, Usak University, Usak, Turkey
| | - Meryem C Sahin
- Department of Medical Services and Techniques, Vocational School of Health Services, Usak University, Usak, Turkey
| | - Bilal Kilcarslan
- Department of Neurosurgery, Denizli State Hospital, Denizli, Turkey
| | - Nurullah Yuceer
- Department of Neurosurgery, Faculty of Medicine, Izmir Katip Çelebi University, Izmir, Turkey
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Iovine JA, Villanueva RD, Werth CM, Hlavacek NL, Rollstin AD, Tawil I, Sarangarm P. Contemporary hemodynamic management of acute spinal cord injuries with intravenous and enteral vasoactive agents: A narrative review. Am J Health Syst Pharm 2022; 79:1521-1530. [PMID: 35677966 DOI: 10.1093/ajhp/zxac164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE The pathophysiology and hemodynamic management of acute spinal cord injuries, including the use of intravenous and enteral vasoactive agents, are reviewed. SUMMARY Spinal cord injuries are devastating neurological insults that in the acute setting lead to significant hemodynamic disturbances, including hypotension and bradycardia, that are influenced by the level of injury. High thoracic (usually defined as at or above T6) and cervical injuries often manifest with hypotension and bradycardia due to destruction of sympathetic nervous system activity and unopposed vagal stimulation to the myocardium, whereas lower thoracic injuries tend to result in hypotension alone due to venous pooling. Initial management includes maintaining euvolemia with crystalloids and maintaining or augmenting mean arterial pressure with the use of intravenous vasoactive agents to improve neurological outcomes. Choice of vasopressor should be based on patient-specific factors, particularly level of injury and presenting hemodynamics. This review includes the most recent literature on intravenous vasopressors as well as the limited evidence supporting the use of enteral vasoactive agents. Enteral vasoactive agents may be considered, when clinically appropriate, as a strategy to wean patients off of intravenous agents and facilitate transfer outside of the intensive care unit. CONCLUSION The hemodynamic management of acute spinal cord injuries often requires the use of vasoactive agents to meet mean arterial pressure goals and improve neurological outcomes. Patient-specific factors must be considered when choosing intravenous and enteral vasoactive agents.
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Affiliation(s)
- Joseph A Iovine
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Ruben D Villanueva
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Christopher M Werth
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Nicole L Hlavacek
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Amber D Rollstin
- Department of Critical Care and Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Isaac Tawil
- Department of Critical Care and Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM, USA
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Bin-Alamer O, Bhenderu LS, Stuebe C, Sagoo NS, Palmisciano P, Haider M, Aoun SG, Haider AS. Penetrating spinal cord injury: a systematic review and meta-analysis of clinical features and treatment outcomes. Spinal Cord 2022; 60:845-853. [DOI: 10.1038/s41393-022-00813-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 05/08/2022] [Accepted: 05/12/2022] [Indexed: 11/09/2022]
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Penetrating Spinal Cord Injury in civilians: analysis of a national database. World Neurosurg 2020; 146:e985-e992. [PMID: 33220486 DOI: 10.1016/j.wneu.2020.11.059] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Spinal trauma is common in polytrauma; spinal cord injury (SCI) is present in a subset of these patients. Penetrating SCI has been studied in the military; however, civilian SCI is less studied. Civilian injury pathophysiology varies given the generally lower velocity of the projectiles. We sought to investigate civilian penetrating SCI in the United States. METHODS We queried the National Inpatient Sample for data regarding penetrating spinal cord injury from the past 10 years (2006-2015). The National Inpatient Sample includes data of 20% of discharged patients from U.S. hospitals. We analyzed trends of penetrating SCI regarding its diagnosis, demographics, surgical management, length of stay, and hospital costs. RESULTS In the past 10 years the incidence of penetrating SCI in all SCI patients has remained stable with a mean of 5.5% (range 4.3%-6.6%). Of the patients with penetrating SCI, only 17% of them underwent a surgical procedure, compared with 55% for nonpenetrating SCI. Patients with penetrating SCI had a longer length of stay (average 23 days) compared with nonpenetrating SCI (15 days). Hospital charges were higher for penetrating SCI: $230,186 compared with $192,022 for closed SCI. Males patients were more affected by penetrating SCI, as well as black and Hispanic populations compared with whites. CONCLUSIONS Penetrating SCI represents 5.5% of all SCI patients. Men, blacks, and Hispanics are disproportionally more affected by penetrating SCI. Patients with penetrating SCI have fewer surgical interventions, but their overall length of stay and hospital costs are greater compared with nonpenetrating SCI.
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Gutierrez A, Su YS, Vaughan KA, Miranda S, Chen HI, Petrov D, Malhotra NR, Schuster JM. Penetrating Spinal Column Injuries (pSI): An Institutional Experience with 100 Consecutive Cases in an Urban Trauma Center. World Neurosurg 2020; 138:e551-e556. [DOI: 10.1016/j.wneu.2020.02.173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 02/27/2020] [Accepted: 02/28/2020] [Indexed: 10/24/2022]
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Fyffe DC, Williams J, Tobin P, Gibson-Gill C. Spinal Cord Injury Veterans' Disability Benefits, Outcomes, and Health Care Utilization Patterns: Protocol for a Qualitative Study. JMIR Res Protoc 2019; 8:e14039. [PMID: 31588906 PMCID: PMC6800461 DOI: 10.2196/14039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 07/26/2019] [Accepted: 07/28/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND An estimated 42,000 people currently living with chronic spinal cord injury (SCI) are veterans. SCI was a common combat-related injury in the World Wars and Vietnam era and now affects more than 11% of military personnel injured in Operation Iraqi Freedom and Operation Enduring Freedom. The Veterans Benefits Administration primarily offers financial compensation for disabilities sustained or re-aggravated during military service, called service-connected disability compensation. With the overwhelming cost of living with an SCI, this monthly financial compensation can provide service-connected veterans and their families with access to additional supportive resources (eg, assistive devices and personal aide) and maintain their quality of life (QOL). Little is known about personal, health, functional, and QOL outcomes associated with service-connected and nonservice-connected status for veterans living with an SCI. OBJECTIVE The aim of this study is to compare the ways in which Veterans Affairs' (VA) service-connected and nonservice-connected status may be associated with health and functional outcomes, choice of health care provider, and overall QOL for veterans living with an SCI and their caregivers. METHODS This cross-sectional qualitative study will gather data using retrospective chart reviews, semistructured interviews, and focus groups. After obtaining institutional review board (IRB) approval, purposeful sampling techniques will be used to recruit and enroll the following key stakeholders: veterans living with an SCI, family caregivers, and SCI health care providers. Concurrent data collection will take place at 2 sites: Veterans Administration New Jersey Healthcare System and Northern New Jersey Spinal Cord Injury System. RESULTS This study was funded in July 2015. IRB approval was obtained by November 2016 at both sites. Enrollment and data collection for phase 1 to phase 4 are complete. A total of 69 veterans, 18 caregivers, and 19 SCI clinicians enrolled in the study. Data analyses for these phases are underway. In phase 5, the follow-up focus group activities are scheduled. The final results are expected by the end of 2019. CONCLUSIONS The factors that contribute to veterans living with SCI seeking and not seeking VA disability compensation benefits are not well understood in rehabilitation research. Triangulation of these data sources will allow us to compare, contrast, and integrate the results, which can be used to develop clinical guidelines, caregiver training, and patient education programs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/14039.
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Affiliation(s)
- Denise C Fyffe
- Kessler Foundation, Spinal Cord Injury/Outcomes and Assessment Research Center, West Orange, NJ, United States.,Rutgers, New Jersey Medical School, Newark, NJ, United States
| | - Joyce Williams
- VA New Jersey Health Care System, Spinal Cord Injury and Disorders Service (128), East Orange, NJ, United States
| | - Paul Tobin
- Quality of Life Advisors, Fort Myers, FL, United States
| | - Carol Gibson-Gill
- Rutgers, New Jersey Medical School, Newark, NJ, United States.,VA New Jersey Health Care System, Spinal Cord Injury and Disorders Service (128), East Orange, NJ, United States
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Furlan JC, Gulasingam S, Craven BC. Epidemiology of War-Related Spinal Cord Injury Among Combatants: A Systematic Review. Global Spine J 2019; 9:545-558. [PMID: 31431879 PMCID: PMC6686388 DOI: 10.1177/2192568218776914] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
- Julio C. Furlan
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
- Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Sivakumar Gulasingam
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
- Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - B. Catharine Craven
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
- Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
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12
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Furlan JC, Kurban D, Craven BC. Traumatic spinal cord injury in military personnel versus civilians: a propensity score-matched cohort study. BMJ Mil Health 2019; 166:e57-e62. [PMID: 31154341 DOI: 10.1136/jramc-2019-001197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/04/2019] [Accepted: 04/10/2019] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Military personnel are exposed to mechanisms of bodily injuries that may differ from civilians. A retrospective cohort study (RCS) and a propensity score-matched cohort study (PSMCS) were undertaken to examine the potential differences in injury epidemiology, management and outcomes after spinal cord injury (SCI) between military personnel and civilians. METHODS Using a Canadian multicentre SCI database, data of all individuals with sufficient data from October 2013 to January 2017 were included in the RCS (n=1043). In the PSMCS, a group of 50 military personnel with SCI was compared with a group of 50 civilians with SCI who were matched regarding sex, age, and level, severity and mechanism of SCI. RESULTS In the RCS, military personnel with SCI (n=61) were significantly older and predominantl males when compared with civilians with SCI (n=982). However, the study groups were not statistically different with regards to their: level, severity and mechanisms of SCI; frequency of associated bodily injuries; and need for mechanical ventilation after SCI. In the PSMCS, the group of military individuals with SCI (n=50) was similar to the group of civilians with SCI (n=50) regarding pre-existing medical comorbidities, degree of motor impairment at admission, initial treatment for SCI and clinical and neurological outcomes after SCI. CONCLUSIONS The results of these studies suggest that military SCI group has disproportionally older men at the time of injury compared with civilians with SCI. However, the military and civilian SCI groups had similar outcomes of alike initial treatment when both groups were matched regarding their demographic profile and injury characteristics.
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Affiliation(s)
- Julio C Furlan
- Division of Physicial Medicine and Rehabilitation, Toronto Rehabilitation Institute - Lyndhurst Centre, Toronto, Ontario, Canada .,Division of Physicial Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - D Kurban
- Rick Hansen Institute, Vancouver, British Columbia, Canada
| | - B C Craven
- Division of Physicial Medicine and Rehabilitation, Toronto Rehabilitation Institute - Lyndhurst Centre, Toronto, Ontario, Canada.,Division of Physicial Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
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Neal CJ, McCafferty RR, Freedman B, Helgeson MD, Rivet D, Gwinn DE, Rosner MK. Cervical and Thoracolumbar Spine Injury Evaluation, Transport, and Surgery in the Deployed Setting. Mil Med 2019; 183:83-91. [PMID: 30189075 DOI: 10.1093/milmed/usy096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Indexed: 01/26/2023] Open
Abstract
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.
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Affiliation(s)
- Chris J Neal
- Joint Trauma System, 3698 Chambers Pass, JBSA Fort Sam Houston, TX
| | | | - Brett Freedman
- Joint Trauma System, 3698 Chambers Pass, JBSA Fort Sam Houston, TX
| | | | - Dennis Rivet
- Joint Trauma System, 3698 Chambers Pass, JBSA Fort Sam Houston, TX
| | - David E Gwinn
- Joint Trauma System, 3698 Chambers Pass, JBSA Fort Sam Houston, TX
| | - Michael K Rosner
- Joint Trauma System, 3698 Chambers Pass, JBSA Fort Sam Houston, TX
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Morrow KD, Podet AG, Spinelli CP, Lasseigne LM, Crutcher CL, Wilson JD, Tender GC, DiGiorgio AM. A case series of penetrating spinal trauma: comparisons to blunt trauma, surgical indications, and outcomes. Neurosurg Focus 2019; 46:E4. [DOI: 10.3171/2018.12.focus18577] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 12/07/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEWhile blunt spinal trauma accounts for the majority of spine trauma, penetrating injuries affect a substantial number of patients. The goal of this study was to examine the epidemiology of penetrating spine injuries compared with blunt injuries and review the operative interventions and outcomes in the penetrating spine injury group.METHODSThe prospectively maintained trauma database was queried for spinal fractures from 2012 to 2018. Charts from patients with penetrating spine trauma were reviewed.RESULTSA total of 1130 patients were evaluated for traumatic spinal fractures; 154 injuries (13.6%) were secondary to penetrating injuries. Patients with penetrating injuries were significantly younger (29.2 years vs 44.1 years, p < 0.001), more likely male (87.7% vs 69.2%, p < 0.001), and more commonly African American (80.5% vs 33.3%, p < 0.05). When comparing primary insurers, the penetrating group had a significantly higher percentage of patients covered by Medicaid (60.4% vs 32.6%, p < 0.05) or prison (3.9% vs 0.1%, p < 0.05) or being uninsured (17.5% vs 10.3%, p < 0.05). The penetrating group had a higher Injury Severity Score on admission (20.2 vs 15.6, p < 0.001) and longer hospital length of stay (20.1 days vs 10.3 days, p < 0.001) and were less likely to be discharged home (51.3% vs 65.1%, p < 0.05). Of the penetrating injuries, 142 (92.2%) were due to firearms. Sixty-three patients (40.9%) with penetrating injuries had a concomitant spinal cord or cauda equina injury. Of those, 44 (69.8%) had an American Spinal Injury Association Impairment Scale (AIS) grade of A. Ten patients (15.9%) improved at least 1 AIS grade, while 2 patients (3.2%) declined at least 1 AIS grade. Nine patients with penetrating injuries underwent neurosurgical intervention: 5 for spinal instability, 4 for compressive lesions with declining neurological examination results, and 2 for infectious concerns, with some patients having multiple indications. Patients undergoing neurosurgical intervention did not show a significantly greater change in AIS grade than those who did not. No patient experienced a complication directly related to neurosurgical intervention.CONCLUSIONSPenetrating spinal trauma affects a younger, more publicly funded cohort than blunt spinal trauma. These patients utilize more healthcare resources and are more severely injured. Surgery is undertaken for limiting progression of neurological deficit, stabilization, or infection control.
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Affiliation(s)
| | | | - Casey P. Spinelli
- 2School of Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana
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Schulz C, Mauer UM, Mathieu R, Freude G. Spine surgery in the International Security Assistance Force Role 3 combat support hospital in Mazar-e-Sharif, northern Afghanistan, 2007-2014. Neurosurg Focus 2018; 45:E13. [PMID: 30544323 DOI: 10.3171/2018.9.focus18389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 09/12/2018] [Indexed: 11/06/2022]
Abstract
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.
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Piatt J. Penetrating spinal injury in childhood: the influence of mechanism on outcome. An epidemiological study. J Neurosurg Pediatr 2018; 22:384-392. [PMID: 29979127 DOI: 10.3171/2018.3.peds1890] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Penetrating injury of the spine in childhood commonly causes profound and life-long disability, but it has been the object of very little study. The goal of the current report is to document temporal trends in the nationwide incidence of this condition and to highlight the differences between penetrating injuries and closed injuries. METHODS The Kids' Inpatient Database was queried for spinal injuries in 1997, 2000, 2003, 2006, 2009, and 2012. Penetrating mechanism was determined by diagnostic coding for open injuries and by mechanistic codes for projectiles and knives. Nationwide annual incidences were calculated using weights provided for this purpose. Unweighted data were used as a cross-sectional sample to compare closed and penetrating injuries with respect to demographic and clinical factors. The effect of penetrating mechanism was analyzed in statistical models of death, adverse discharge, and length of stay (LOS). RESULTS The nationwide incidence of penetrating spinal injury in patients less than 18 years of age trended downward over the study period. Patients with penetrating injury were older and much more predominantly male than patients with closed injuries. They resided predominantly in zip codes with lower median household incomes, and they were much more likely to have public health insurance or none at all. They were predominantly black or Hispanic. The risk of hospital death was no different, but penetrating injuries were associated with much higher rates of adverse discharge after LOS, averaging twice as long as closed injuries. Brain, visceral, and vascular injuries were powerful predictors of hospital death, as was upper cervical level of injury. The most powerful predictor of adverse discharge and LOS was spinal cord injury, followed by brain, visceral, and vascular injury and penetrating mechanism. CONCLUSIONS Because its pathophysiology requires no elucidation, because the consequences for quality of life are dire, and because the population at risk is well defined, penetrating spinal injury in childhood ought to be an attractive target for public health interventions.
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Analysis of isolated transverse process fractures sustained during blast-related events. J Trauma Acute Care Surg 2018; 85:S129-S133. [DOI: 10.1097/ta.0000000000001815] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Yoganandan N, Moore J, Pintar FA, Banerjee A, DeVogel N, Zhang J. Role of disc area and trabecular bone density on lumbar spinal column fracture risk curves under vertical impact. J Biomech 2018; 72:90-98. [DOI: 10.1016/j.jbiomech.2018.02.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 02/22/2018] [Accepted: 02/23/2018] [Indexed: 10/17/2022]
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Lawless MH, Lytle EJ, McGlynn AF, Engler JA. Surgical management of penetrating spinal cord injury primarily due to shrapnel and its effect on neurological outcome: a literature review and meta-analysis. J Neurosurg Spine 2018; 28:63-71. [DOI: 10.3171/2017.5.spine161037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThis 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.METHODSIn 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.RESULTSFive 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).CONCLUSIONSThis 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.
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Affiliation(s)
| | - Evan J. Lytle
- 3Neurosurgery, Providence-Providence Park Hospital, Michigan State University College of Human Medicine, Southfield, Michigan; and
| | | | - John A. Engler
- 4Department of Neurosurgery, Naval Medical Center, Portsmouth, Virginia
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Joubert C, Dulou R, Delmas JM, Desse N, Fouet M, Dagain A. Military neurosurgery in operation: experience in the French role-3 medical treatment facility of Kabul. Acta Neurochir (Wien) 2016; 158:1453-63. [PMID: 27287215 DOI: 10.1007/s00701-016-2843-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 05/17/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND In 2009, during the war in Afghanistan, the increasing number of head injuries led to the deployment of a military neurosurgeon at the Kabul International Airport (KaIA) medical treatment facility, in March 2010. The main goal of this study was to depict the neurosurgical activity in this centre and to analyse its different aspects. METHOD A retrospective study of all the neurosurgical patients treated in KaIA from March 2010 to June 2013. RESULTS Three hundred and seventy-three interventions performed by the neurosurgeon deployed were reported for 373 surgeries, in 335 patients, representing 10.6 % of the overall surgical activity of the centre. Among the 69 interventions performed on soldiers, 57 surgeries were undertaken in emergency (82.6 %), while 12 were elective procedures (17.4 %). On the other hand, 289 surgeries were performed in civilian Afghans, with 126 emergency procedures in (43.6 %), against 163 elective interventions (56.4 %). Among the 44.5 % (n = 149) of the traumatic casualties, cerebral lesions represented 28.7 % (n = 96) and spinal lesions 12.4 % (n = 42). Ninety patients had multiple injuries. Additionally, patients without trauma accounted for 55.5 % (n = 186) of the overall population. Thus, 49 % (n = 164) were operated on for non-traumatic lesion of the spine. These were mostly civilian Afghans treated under medical aid to the population (90.2 %, n = 148/164). CONCLUSIONS The military neurosurgeon had two roles in KaIA: both to support the armed forces and to manage medical aid to the civilian population. This study gives food for thought on the neurosurgical needs in modern warfare, and on the skills required for the military neurosurgeon.
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Margul DJ, Park J, Boehler RM, Smith DR, Johnson MA, McCreedy DA, He T, Ataliwala A, Kukushliev TV, Liang J, Sohrabi A, Goodman AG, Walthers CM, Shea LD, Seidlits SK. Reducing neuroinflammation by delivery of IL-10 encoding lentivirus from multiple-channel bridges. Bioeng Transl Med 2016; 1:136-148. [PMID: 27981242 PMCID: PMC5125399 DOI: 10.1002/btm2.10018] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 06/24/2016] [Accepted: 07/01/2016] [Indexed: 12/25/2022] Open
Abstract
The spinal cord is unable to regenerate after injury largely due to growth‐inhibition by an inflammatory response to the injury that fails to resolve, resulting in secondary damage and cell death. An approach that prevents inhibition by attenuating the inflammatory response and promoting its resolution through the transition of macrophages to anti‐inflammatory phenotypes is essential for the creation of a growth permissive microenvironment. Viral gene delivery to induce the expression of anti‐inflammatory factors provides the potential to provide localized delivery to alter the host inflammatory response. Initially, we investigated the effect of the biomaterial and viral components of the delivery system to influence the extent of cell infiltration and the phenotype of these cells. Bridge implantation reduces antigen‐presenting cell infiltration at day 7, and lentivirus addition to the bridge induces a transient increase in neutrophils in the spinal cord at day 7 and macrophages at day 14. Delivery of a lentivirus encoding IL‐10, an anti‐inflammatory factor that inhibits immune cell activation and polarizes the macrophage population towards anti‐inflammatory phenotypes, reduced neutrophil infiltration at both day 7 and day 28. Though IL‐10 lentivirus did not affect macrophages number, it skewed the macrophage population toward an anti‐inflammatory M2 phenotype and altered macrophage morphology. Additionally, IL‐10 delivery resulted in improved motor function, suggesting reduced secondary damage and increased sparing. Taken together, these results indicate that localized expression of anti‐inflammatory factors, such as IL‐10, can modulate the inflammatory response following spinal cord injury, and may be a key component of a combinatorial approach that targets the multiple barriers to regeneration and functional recovery.
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Affiliation(s)
- Daniel J Margul
- Dept. of Biomedical Engineering Northwestern University Evanston IL, 48109; Dept. of Biomedical Engineering University of Michigan Ann Arbor MI, 48109
| | - Jonghyuck Park
- Dept. of Biomedical Engineering University of Michigan Ann Arbor MI, 48109
| | - Ryan M Boehler
- Dept. of Chemical and Biological Engineering Northwestern University Evanston IL, 48109
| | - Dominique R Smith
- Dept. of Biomedical Engineering Northwestern University Evanston IL, 48109; Dept. of Biomedical Engineering University of Michigan Ann Arbor MI, 48109
| | - Mitchell A Johnson
- Dept. of Biomedical Engineering University of Michigan Ann Arbor MI, 48109
| | - Dylan A McCreedy
- Dept. of Biomedical Engineering University of Michigan Ann Arbor MI, 48109; Dept. of Chemical and Biological Engineering Northwestern University Evanston IL, 48109
| | - Ting He
- Dept. of Chemical and Biological Engineering Northwestern University Evanston IL, 48109
| | - Aishani Ataliwala
- Dept. of Bioengineering University of California Los Angeles Los Angeles CA, 90095
| | - Todor V Kukushliev
- Dept. of Chemical and Biological Engineering Northwestern University Evanston IL, 48109
| | - Jesse Liang
- Dept. of Bioengineering University of California Los Angeles Los Angeles CA, 90095
| | - Alireza Sohrabi
- Dept. of Bioengineering University of California Los Angeles Los Angeles CA, 90095
| | - Ashley G Goodman
- Dept. of Chemical and Biological Engineering Northwestern University Evanston IL, 48109
| | | | - Lonnie D Shea
- Dept. of Biomedical Engineering University of Michigan Ann Arbor MI, 48109; Dept. of Chemical Engineering University of Michigan Ann Arbor MI, 48109
| | - Stephanie K Seidlits
- Dept. of Chemical and Biological Engineering Northwestern University EvanstonIL, 48109; Dept. of Bioengineering University of California Los Angeles Los Angeles CA, 90095; Brain Research Institute University of California Los Angeles Los Angeles CA, 90095; Jonsson Comprehensive Cancer Center University of California Los Angeles Los Angeles CA, 90024
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Readdy WJ, Saigal R, Whetstone WD, Mefford AN, Ferguson AR, Talbott JF, Inoue T, Bresnahan JC, Beattie MS, Pan J, Manley GT, Dhall SS. Failure of Mean Arterial Pressure Goals to Improve Outcomes Following Penetrating Spinal Cord Injury. Neurosurgery 2016; 79:708-714. [DOI: 10.1227/neu.0000000000001249] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Increased spinal cord perfusion and blood pressure goals have been recommended for spinal cord injury (SCI). Penetrating SCI is associated with poor prognosis, but there is a paucity of literature examining the role of vasopressor administration for the maintenance of mean arterial pressure (MAP) goals in this patient population.
OBJECTIVE:
To elucidate this topic and to determine the efficacy of vasopressor administration in penetrating SCI by examining a case series of consecutive penetrating SCIs.
METHODS:
We reviewed consecutive patients with complete penetrating SCI who met inclusion and exclusion criteria, including the administration of vasopressors to maintain MAP goals. We identified 14 patients with complete penetrating SCIs with an admission American Spinal Injury Association grade of A from 2005 to 2011. The neurological recovery, complications, interventions, and vasopressor administration strategies were reviewed and compared with those of a cohort with complete blunt SCI.
RESULTS:
In our patient population, only 1 patient with penetrating SCI (7.1%) experienced neurological recovery, as determined by improvement in the American Spinal Injury Association grade, despite the administration of vasopressors for supraphysiological MAP goals for an average of 101.07 ± 34.96 hours. Furthermore, 71.43% of patients with penetrating SCI treated with vasopressors experienced associated cardiogenic complications.
CONCLUSION:
Given the decreased likelihood of neurological improvement in penetrating injuries, it may be important to re-examine intervention strategies in this population. Specifically, the use of vasopressors, in particular dopamine, with their associated complications is more likely to cause complications than to result in neurological improvement. Our experience shows that patients with acute penetrating SCI are unlikely to recover, despite aggressive cardiopulmonary management.
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Affiliation(s)
- William J. Readdy
- Brain and Spinal Injury Center, Departments of Neurological Surgery, San Francisco, San Francisco, California
- Emergency Medicine, San Francisco, California
| | - Rajiv Saigal
- Brain and Spinal Injury Center, Departments of Neurological Surgery, San Francisco, San Francisco, California
- Emergency Medicine, San Francisco, California
| | - William D. Whetstone
- Emergency Medicine, San Francisco, California
- Radiology and Biomedical Imaging, San Francisco, California
| | | | | | - Jason F. Talbott
- Emergency Medicine, San Francisco, California
- Anesthesia, University of California, San Francisco, San Francisco, California
| | - Tomoo Inoue
- Emergency Medicine, San Francisco, California
| | | | | | - Jonathan Pan
- Emergency Medicine, San Francisco, California
- Anesthesia, University of California, San Francisco, San Francisco, California
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Abstract
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.
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Rosenfeld JV, Bell RS, Armonda R. Current concepts in penetrating and blast injury to the central nervous system. World J Surg 2015; 39:1352-62. [PMID: 25446474 PMCID: PMC4422853 DOI: 10.1007/s00268-014-2874-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Aim To review the current management, prognostic factors and outcomes of penetrating and blast injuries to the central nervous system and highlight the differences between gunshot wound, blast injury and stabbing. Methods A review of the current literature was performed. Results Of patients with craniocerebral GSW, 66–90 % die before reaching hospital. Of those who are admitted to hospital, up to 51 % survive. The patient age, GCS, pupil size and reaction, ballistics and CT features are important factors in the decision to operate and in prognostication. Blast injury to the brain is a component of multisystem polytrauma and has become a common injury encountered in war zones and following urban terrorist events. GSW to the spine account for 13–17 % of all gunshot injuries. Conclusions Urgent resuscitation, correction of coagulopathy and early surgery with wide cranial decompression may improve the outcome in selected patients with severe craniocerebral GSW. More limited surgery is undertaken for focal brain injury due to GSW. A non-operative approach may be taken if the clinical status is very poor (GCS 3, fixed dilated pupils) or GCS 4–5 with adverse CT findings or where there is a high likelihood of death or poor outcome. Civilian spinal GSWs are usually stable neurologically and biomechanically and do not require exploration. The indications for exploration are as follows: (1) compressive lesions with partial spinal cord or cauda equina injury, (2) mechanical instability and (3) complications. The principles of management of blast injury to the head and spine are the same as for GSW. Multidisciplinary specialist management is required for these complex injuries.
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Moisi MD, Page J, Gahramanov S, Oskouian RJ. Bullet Fragment of the Lumbar Spine: The Decision Is More Important Than the Incision. Global Spine J 2015; 5:523-6. [PMID: 26682104 PMCID: PMC4671882 DOI: 10.1055/s-0035-1566231] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Study Design Case report. Objective Treatment of gunshot wounds to the spine is a topic of continued discussion and controversy. The following case study provides a description of a patient with a gunshot wound to the lumbar spine with a retained bullet in the intrathecal space. Methods Immediately after gunshot injury, a patient developed lumbar and radicular pain, as well as neurologic deficits. He was taken for surgery to remove the retained bullet. Results Following surgery, pain and neurologic function improved. The operative techniques and the postoperative clinical management are discussed in this report. Conclusion In our opinion, it was necessary to remove the bullet to avoid migration and possible worsening of neurologic function. However, surgical intervention is not appropriate in every case, and ultimately decisions should be based on patient presentation, symptomology, and imaging.
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Affiliation(s)
- Marc D. Moisi
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, United States,Address for correspondence Marc D. Moisi, MD Swedish Neuroscience Institute, Swedish Medical Center550 17th Avenue, Seattle, WA 98122United States
| | - Jeni Page
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, United States
| | - Seymour Gahramanov
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, United States
| | - Rod J. Oskouian
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, United States
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Pawar K, Cummings BJ, Thomas A, Shea LD, Levine A, Pfaff S, Anderson AJ. Biomaterial bridges enable regeneration and re-entry of corticospinal tract axons into the caudal spinal cord after SCI: Association with recovery of forelimb function. Biomaterials 2015; 65:1-12. [PMID: 26134079 PMCID: PMC4523232 DOI: 10.1016/j.biomaterials.2015.05.032] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 05/18/2015] [Indexed: 12/16/2022]
Abstract
Severed axon tracts fail to exhibit robust or spontaneous regeneration after spinal cord injury (SCI). Regeneration failure reflects a combination of factors, including the growth state of neuronal cell bodies and the regeneration-inhibitory environment of the central nervous system. However, while spared circuitry can be retrained, target reinnervation depends on longitudinally directed regeneration of transected axons. This study describes a biodegradable implant using poly(lactide-co-glycolide) (PLG) bridges as a carrier scaffold to support regeneration after injury. In order to detect regeneration of descending neuronal tracts into the bridge, and beyond into intact caudal parenchyma, we developed a mouse cervical implantation model and employed Crym:GFP transgenic mice. Characterization of Crym:GFP mice revealed that descending tracts, including the corticospinal tract, were labeled by green fluorescent protein (GFP), while ascending sensory neurons and fibers were not. Robust co-localization between GFP and neurofilament-200 (NF-200) as well as GFP and GAP-43 was observed at both the rostral and caudal bridge/tissue interface. No evidence of similar regeneration was observed in mice that received gelfoam at the lesion site as controls. Minimal co-localization between GFP reporter labeling and macrophage markers was observed. Taken together, these data suggest that axons originating from descending fiber tracts regenerated, entered into the PLG bridge at the rostral margin, continued through the bridge site, and exited to re-enter host tissue at the caudal edge of the intact bridge. Finally, regeneration through implanted bridges was associated with a reduction in ipsilateral forelimb errors on a horizontal ladder task.
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Affiliation(s)
- Kiran Pawar
- Institute for Memory Impairments and Neurological Disorders (iMIND), University of California, Irvine, CA, USA
| | - Brian J Cummings
- Institute for Memory Impairments and Neurological Disorders (iMIND), University of California, Irvine, CA, USA; Sue and Bill Gross Stem Cell Research Center, University of California, Irvine, USA; Department of Physical Medicine and Rehabilitation, University of California, Irvine, CA, USA; Department of Anatomy and Neurobiology, University of California, Irvine, CA, USA
| | - Aline Thomas
- Department of Chemical and Biological Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL, USA
| | - Lonnie D Shea
- Department of Chemical and Biological Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL, USA
| | | | | | - Aileen J Anderson
- Institute for Memory Impairments and Neurological Disorders (iMIND), University of California, Irvine, CA, USA; Sue and Bill Gross Stem Cell Research Center, University of California, Irvine, USA; Department of Physical Medicine and Rehabilitation, University of California, Irvine, CA, USA; Department of Anatomy and Neurobiology, University of California, Irvine, CA, USA.
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Breeze J, Lewis EA, Fryer R, Hepper AE, Mahoney PF, Clasper JC. Defining the essential anatomical coverage provided by military body armour against high energy projectiles. J ROY ARMY MED CORPS 2015; 162:284-90. [PMID: 26272950 DOI: 10.1136/jramc-2015-000431] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 07/05/2015] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- John Breeze
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK Biomedical Sciences Department, Dstl Porton Down, Salisbury, Wiltshire, UK
| | - E A Lewis
- Defence Equipment and Support, Ministry of Defence Abbey Wood, Bristol, UK
| | - R Fryer
- Land Battlespace Systems Department, Defence Science & Technology Laboratory, Fareham, Hampshire, UK
| | - A E Hepper
- Biomedical Sciences Department, Dstl Porton Down, Salisbury, Wiltshire, UK
| | - Peter F Mahoney
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | - Jon C Clasper
- The Royal British Legion Centre for Blast Injury Studies at Imperial College London, London, UK
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Is it worth performing suture of the cauda equina roots after traumatic penetrating lumbar injury in a combat support Hospital? Acta Neurochir (Wien) 2015; 157:1087-8. [PMID: 25433922 DOI: 10.1007/s00701-014-2283-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 11/13/2014] [Indexed: 10/24/2022]
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Combat-related intradural gunshot wound to the thoracic spine: significant improvement and neurologic recovery following bullet removal. Asian Spine J 2015; 9:127-32. [PMID: 25705346 PMCID: PMC4330208 DOI: 10.4184/asj.2015.9.1.127] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 02/19/2014] [Accepted: 02/25/2014] [Indexed: 11/17/2022] Open
Abstract
The vast majority of combat-related penetrating spinal injuries from gunshot wounds result in severe or complete neurological deficit. Treatment is based on neurological status, the presence of cerebrospinal fluid (CSF) fistulas, and local effects of any retained fragment(s). We present a case of a 46-year-old male who sustained a spinal gunshot injury from a 7.62-mm AK-47 round that became lodged within the subarachnoid space at T9-T10. He immediately suffered complete motor and sensory loss. By 24-48 hours post-injury, he had recovered lower extremity motor function fully but continued to have severe sensory loss (posterior cord syndrome). On post-injury day 2, he was evacuated from the combat theater and underwent a T9 laminectomy, extraction of the bullet, and dural laceration repair. At surgery, the traumatic durotomy was widened and the bullet, which was laying on the dorsal surface of the spinal cord, was removed. The dura was closed in a water-tight fashion and fibrin glue was applied. Postoperatively, the patient made a significant but incomplete neurological recovery. His stocking-pattern numbness and sub-umbilical searing dysthesia improved. The spinal canal was clear of the foreign body and he had no persistent CSF leak. Postoperative magnetic resonance imaging of the spine revealed contusion of the spinal cord at the T9 level. Early removal of an intra-canicular bullet in the setting of an incomplete spinal cord injury can lead to significant neurological recovery following even high-velocity and/or high-caliber gunshot wounds. However, this case does not speak to, and prior experience does not demonstrate, significant neurological benefit in the setting of a complete injury.
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Quinn RH, Williams J, Bennett BL, Stiller G, Islas AA, McCord S. Wilderness Medical Society Practice Guidelines for Spine Immobilization in the Austere Environment: 2014 Update. Wilderness Environ Med 2014; 25:S105-17. [DOI: 10.1016/j.wem.2014.05.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 05/22/2014] [Accepted: 05/25/2014] [Indexed: 01/21/2023]
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Wilderness Medical Society practice guidelines for spine immobilization in the austere environment. Wilderness Environ Med 2013; 24:241-52. [PMID: 23827829 DOI: 10.1016/j.wem.2013.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 03/03/2013] [Accepted: 03/07/2013] [Indexed: 11/22/2022]
Abstract
In an effort to produce best-practice guidelines for spine immobilization in the austere environment, the Wilderness Medical Society convened an expert panel charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in an austere (dangerous or compromised) environment. Recommendations are made regarding several factors related to spinal immobilization. These recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks or burdens for each factor according to the methodology stipulated by the American College of Chest Physicians. A treatment algorithm based on the guidelines is presented.
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Yoganandan N, Stemper BD, Pintar FA, Maiman DJ, McEntire BJ, Chancey VC. Cervical spine injury biomechanics: Applications for under body blast loadings in military environments. Clin Biomech (Bristol, Avon) 2013; 28:602-9. [PMID: 23796847 DOI: 10.1016/j.clinbiomech.2013.05.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Revised: 05/03/2013] [Accepted: 05/08/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND While cervical spine injury biomechanics reviews in motor vehicle and sports environments are available, there is a paucity of studies in military loadings. This article presents an analysis on the biomechanics and applications of cervical spine injury research with an emphasis on human tolerance for underbody blast loadings in the military. METHODS Following a brief review of published military studies on the occurrence and identification of field trauma, postmortem human subject investigations are described using whole body, intact head-neck complex, osteo-ligamentous cervical spine with head, subaxial cervical column, and isolated segments subjected to differing types of dynamic loadings (electrohydraulic and pendulum impact devices, free-fall drops). FINDINGS Spine injuries have shown an increasing trend over the years, explosive devices are one of the primary causal agents and trauma is attributed to vertical loads. Injuries, mechanisms and tolerances are discussed under these loads. Probability-based injury risk curves are included based on loading rate, direction and age. INTERPRETATION A unique advantage of human cadaver tests is the ability to obtain fundamental data to delineate injury biomechanics and establish human tolerance and injury criteria. Definitions of tolerances of the spine under vertical loads based on injuries have implications in clinical and biomechanical applications. Primary outputs such as forces and moments can be used to derive secondary variables such as the neck injury criterion. Implications are discussed for designing anthropomorphic test devices that may be used to predict injuries in underbody blast environments and improve the safety of military personnel.
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Affiliation(s)
- Narayan Yoganandan
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Carragee EJ. Commentary: penetrating neck injury: George Orwell is "Struck by Lighting". Spine J 2012; 12:769-70. [PMID: 23036144 DOI: 10.1016/j.spinee.2012.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 09/13/2012] [Indexed: 02/03/2023]
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Marching home, again: spine casualties, combat exposure, and the long wars. Spine J 2012; 12:723-6. [PMID: 23036141 DOI: 10.1016/j.spinee.2012.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 09/13/2012] [Indexed: 02/03/2023]
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