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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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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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Fathe MA, Farhat F, Karim SK, Moalla W. Spinal Cord Injuries in Iraq: A Teleassessment Survey of the Survivors from 2017 to 2018 Islamic State of Iraq and Syria War. Telemed J E Health 2024. [PMID: 38683594 DOI: 10.1089/tmj.2024.0037] [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: 05/01/2024] Open
Abstract
Introduction: The significance of comprehensive investigations specifically addressing the characteristics and implications of nervous system injuries (NSIs) and particularly war-related spinal cord injuries (SCI) remain limited. Iraq lacks comprehensive survey studies for quality of life for people after SCI. The objective of this work was to identify the number of NSIs and mortality of those injured during the Islamic State of Iraq and Syria (ISIS) war in Iraq and analyze events specifically as sociodemographic variables to assess quality of life healthy, psychological, and social disorders from onset of injury till the involving. Methods: A survey-based descriptive study, and analytical retrospective at community-based of Nineveh Governorate, in Iraq. The participants were 34 survivors of ISIS war with SCIs, ages between 9 and 60 years, and 7 females (20.59%) and 27 males (79.41%) as registered in Nineveh Center of Disability Rehabilitation. Data collection was conducted using Telephone Video Interviews and respondents' health information. Protocol-specific questions and some psychological and social scales (PTSD) (DSM-IV), (TAS-20), (SWLS), and (MSPSS) were also used. Results: There were 2,990 NSIs with the highest rate of injuries occurring from 2017 to 2018, and the SCIs were 267 injuries (8.93%), and (70.59%) at level T the mortalities were 57 cases, all participants suffered from physical and psychological chronic complications, while the results of the PTSD, GPC, and SWLS were at a moderate level. Conclusions: In urban warfare, there's a rise in NSIs, notably SCIs influenced by the type of weaponry. The survivors face significant physical, psychological, social, and financial burdens. More research is crucial to understanding their situations and developing strategies to alleviate their health, social, and financial challenges.
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Affiliation(s)
- Munib Abdullah Fathe
- College of Physical Education and Sport Sciences, University of Mosul, Mosul, Iraq
- LR 19JS01 EM2S, Education, Motricity, Sport and Health, Higher Institute for Sport and Physical Education at Sfax, University of Sfax, Sfax, Tunisia
| | - Faical Farhat
- LR 19JS01 EM2S, Education, Motricity, Sport and Health, Higher Institute for Sport and Physical Education at Sfax, University of Sfax, Sfax, Tunisia
| | | | - Wassim Moalla
- LR 19JS01 EM2S, Education, Motricity, Sport and Health, Higher Institute for Sport and Physical Education at Sfax, University of Sfax, Sfax, Tunisia
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Yoganandan N, Baisden J, Moore J, Pintar F, Vedantam A, Shabani S, Barnes D, Loftis K. Pelvis-Sacrum-Lumbar Spine Injury Characteristics From Underbody Blast Loading. Mil Med 2023; 188:393-399. [PMID: 37948210 DOI: 10.1093/milmed/usad168] [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: 12/12/2022] [Revised: 03/31/2023] [Accepted: 05/09/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION Combat-related injuries from improvised explosive devices occur commonly to the lower extremity and spine. As the underbody blast impact loading traverses from the seat to pelvis to spine, energy transfer occurs through deformations of the combined pelvis-sacrum-lumbar spine complex, and the time factor plays a role in injury to any of these components. Previous studies have largely ignored the role of the time variable in injuries, injury mechanisms, and warfighter tolerance. The objective of this study is to relate the time or temporal factor using a multi-component, pelvis-sacrum-lumbar spinal column complex model. MATERIALS AND METHODS Intact pelvis-sacrum-spine specimens from pre-screened unembalmed human cadavers were prepared by fixing at the superior end of the lumbar spine, pelvis and abdominal contents were simulated, and a weight was added to the cranial end of the fixation to account for torso effective mass. Prepared specimens were placed on the platform of a custom vertical accelerator device and aligned in a seated soldier posture. An accelerometer was attached to the seat platen of the device to record the time duration to peak velocity. Radiographs and computed tomography images were used to document and associate injuries with time duration. RESULTS The mean age, stature, weight, body mass index, and bone density of 12 male specimens were as follows: 65 ± 11 years, 1.8 ± 0.01 m, 83 ± 13 kg, 27 ± 5.0 kg/m2, and 114 ± 21 mg/cc. They were equally divided into short, medium, and long time durations: 4.8 ± 0.5, 16.3 ± 7.3, and 34.5 ± 7.5 ms. Most severe injuries associated with the short time duration were to pelvis, although they were to spine for the long time duration. CONCLUSIONS With adequate time for the underbody blast loading to traverse the pelvis-sacrum-spine complex, distal structures are spared while proximal/spine structures sustain severe/unstable injuries. The time factor may have implications in seat and/or seat structure design in future military vehicles to advance warfighter safety.
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Affiliation(s)
- Narayan Yoganandan
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Jamie Baisden
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Jason Moore
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Frank Pintar
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Aditya Vedantam
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Saman Shabani
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - David Barnes
- SURVICE Engineering Co., Aberdeen Proving Ground, Belcamp, MD 21005, USA
| | - Kathryn Loftis
- US Army DEVCOM Analysis Center, Aberdeen Proving Ground, MD 21005, USA
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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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Abstract
STUDY DESIGN Retrospective. OBJECTIVE To evaluate functional outcomes and characteristics associated with gunshot wound (GSW) to the spine. METHODS Patients with GSW to the spine managed at a Level 1 Trauma Center from January 2003 to December 2017 were enrolled. Patient demographics, diagnoses, level of injury, American Spinal Injury Association (ASIA) score, ambulatory status at follow-up, bowel and bladder function, clinical improvement, and mortality were evaluated. Clinical improvement was defined as a progression in ambulatory status category at latest follow up. RESULTS 51 patients with GSW of the spine were identified. 48 (94.1%) were male and 3 (5.9%) were female, with a mean age of 27 years-old (range 15-56). 38 (74.5%) were Caucasian, 7 (13.7%) were African American, 1 (2.0%) Asian-American, and 5 (9.8%) were Other/Unknown. 46 (90.2%) patients had GSW related spinal fractures and 44 (86.3%) had neurological deficits. Among patients with neurologic deficits, 5 (9.8%) had Cauda Equina Syndrome, 1 (2%) had Brown-Sequard Syndrome, and 38 (74.5%) spinal cord injuries: ASIA A 26 (68.4%); ASIA B 3 (7.9%); ASIA C 7 (18.4%); ASIA D 2 (5.3%). At mean follow-up time of 4.2 years (SD 3.9), 27 (52.9%) patients were wheelchair bound, 11 (21.6%) were ambulating with assistance, and 13 (25.5%) had normal ambulation. ASIA grade (A or B) was significantly, P < 0.00001, associated with being wheelchair bound and having neurogenic bowel or bladder at follow-up. CONCLUSIONS Most spinal GSW patients (70.6%) did not have any clinical improvement in ambulatory status and most injuries were ASIA A.
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Affiliation(s)
- Laurence Ge
- Department of Orthopaedics & Rehabilitation, University of Rochester School of Medicine and Dentistry, Rochester, New York, NY, USA
| | - Ayodeji Jubril
- Department of Orthopaedics & Rehabilitation, University of Rochester School of Medicine and Dentistry, Rochester, New York, NY, USA
| | - Addisu Mesfin
- Department of Orthopaedics & Rehabilitation, University of Rochester School of Medicine and Dentistry, Rochester, New York, NY, USA,Addisu Mesfin, Orthopaedic Surgery, Neurosurgery & Public Health, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Box 665, Rochester, New York, NY 14642, USA.
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Kolaja CA, Roenfeldt K, Armenta RF, Schuyler AC, Orman JA, Stander VA, LeardMann CA. Sexual Health Problems among Service Men: The Influence of Posttraumatic Stress Disorder. JOURNAL OF SEX RESEARCH 2022; 59:413-425. [PMID: 33428452 DOI: 10.1080/00224499.2020.1855622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Military operational stressors, such as combat exposure, may increase the risk of sexual health problems. This study examined factors associated with sexual health problems, and tested the mediating effect of probable posttraumatic stress disorder (PTSD) on the association between stressors (i.e., combat deployment and sexual assault) and sexual health problems among U.S. service men. Using multivariable logistic regression (n = 16,603) and Cox proportional hazards models (n = 15,330), we estimated the risk of self-reported sexual health difficulties and sexual dysfunction medical encounters, respectively. Mediation analyses examined the effect of probable PTSD as an intermediate factor between high combat deployment and sexual assault on sexual health problems. Approximately 9% endorsed sexual health difficulties and 8% had a sexual dysfunction. Risk factors for these sexual health problems included older age, lower education level, enlisted rank, disabling injury, certain medical conditions, and higher body mass index. Probable PTSD significantly mediated the associations between high combat with sexual health problems and sexual assault with sexual dysfunction. Additionally, high combat was directly associated with sexual health difficulties. These findings indicate a relationship between these stressors and sexual health problems which suggests that treatment options should be expanded, especially to include psychogenic sexual dysfunctions.
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Affiliation(s)
- Claire A Kolaja
- Leidos, Reston, VA, USA
- Deployment Health Research Department, Naval Health Research Center
| | - Kimberly Roenfeldt
- Leidos, Reston, VA, USA
- Deployment Health Research Department, Naval Health Research Center
| | - Richard F Armenta
- Leidos, Reston, VA, USA
- Deployment Health Research Department, Naval Health Research Center
- Department of Kinesiology, College of Education, Health, and Human Services, California State University
| | - Ashley C Schuyler
- College of Public Health and Human Sciences, Oregon State University, San Marcos
| | - Jean A Orman
- Department of Epidemiology & Biostatistics, University of Texas Health at San Antonio, Texas
| | | | - Cynthia A LeardMann
- Leidos, Reston, VA, USA
- Deployment Health Research Department, Naval Health Research Center
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Kolaja CA, Schuyler AC, Armenta RF, Orman JA, Stander VA, LeardMann CA. Sexual health difficulties among service women: the influence of posttraumatic stress disorder. J Affect Disord 2021; 292:678-686. [PMID: 34157663 DOI: 10.1016/j.jad.2021.05.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/19/2021] [Accepted: 05/31/2021] [Indexed: 11/18/2022]
Abstract
Background Sexual health among service women remains understudied, yet is related to health and quality of life. This study examined if the associations between recent combat and sexual assault with sexual health difficulties were mediated by mental disorders and identified factors associated with sexual health difficulties among service women. Methods Data from two time points (2013 and 2016) of the Millennium Cohort Study, a large military cohort, were used. The outcome was self-reported sexual health difficulties. Mediation analyses examined probable posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) as intermediate variables between recent combat and sexual assault with the sexual health difficulties. Multivariable logistic regression modeling was used to examine the association of demographic, military, historical mental health, life stressors, and physical health factors with sexual health difficulties. Results Of the 6,524 service women, 13.5% endorsed experiencing sexual health difficulties. Recent combat and sexual assault were significantly associated with sexual health difficulties. Probable PTSD mediated the associations of recent combat and sexual assault with sexual health difficulties; probable MDD did not mediate these relationships. Other significant factors associated with sexual health difficulties included enlisted rank, historical mental disorders, childhood trauma, and disabling injury. Limitations Use of self-reported data, outcome not assessed using a standardized measure and future studies may benefit from examining other mediators. Conclusion Our findings that combat and sexual assault may have negative effects on service women's sexual health suggest that treatment options and insurance coverage for sexual health problems should be expanded.
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Affiliation(s)
- Claire A Kolaja
- Leidos, San Diego, CA, USA; Deployment Health Research Department, Naval Health Research Center, San Diego, CA, USA.
| | - Ashley C Schuyler
- School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA
| | - Richard F Armenta
- Department of Kinesiology, College of Education, Health, and Human Services, California State University, San Marcos, CA, USA
| | - Jean A Orman
- University of Texas Health at San Antonio, TX, USA
| | - Valerie A Stander
- Deployment Health Research Department, Naval Health Research Center, San Diego, CA, USA
| | - Cynthia A LeardMann
- Leidos, San Diego, CA, USA; Deployment Health Research Department, Naval Health Research Center, San Diego, CA, USA
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Khaing ZZ, Cates LN, Hyde J, DeWees DM, Hammond R, Bruce M, Hofstetter CP. Contrast-Enhanced Ultrasound for Assessment of Local Hemodynamic Changes Following a Rodent Contusion Spinal Cord Injury. Mil Med 2020; 185:470-475. [DOI: 10.1093/milmed/usz296] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
ABSTRACT
Introduction
Severe trauma to the spinal cord leads to a near complete loss of blood flow at the injury site along with significant hypoperfusion of adjacent tissues. Characterization and monitoring of local tissue hypoperfusion is currently not possible in clinical practice because available imaging techniques do not allow for assessment of blood flow with sufficient spatial and temporal resolutions. The objective of the current study was to determine whether ultrafast contrast-enhanced ultrasound (CEUS) imaging could be used to visualize and quantify acute hemodynamic changes in a rat traumatic spinal cord injury (SCI) model.
Materials and Methods
We used novel ultrasound acquisition and processing methods that allowed for measurements of local tissue perfusion as well as for assessment of structural and functional integrity of spinal vasculature.
Results
CEUS imaging showed that traumatic SCI results in (1) an area with significant loss of perfusion, which increased during the first hour after injury, (2) structural alterations of the spinal cord vasculature, and (3) significant slowing of arterial blood flow velocities around the injury epicenter.
Conclusion
We conclude that CEUS has the spatial and temporal sensitivity and resolution to visualize local tissue perfusion and vessel architecture, which maybe useful clinically to determine injury extent and severity in patients with SCI.
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Affiliation(s)
- Zin Z Khaing
- Department of Neurological Surgery, The University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Lindsay N Cates
- Department of Neurological Surgery, The University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Jeffrey Hyde
- Department of Neurological Surgery, The University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Dane M DeWees
- Department of Neurological Surgery, The University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Ryan Hammond
- Applied Physics Laboratory, Center for Industrial and Medical Ultrasound, The University of Washington, 1013 NE 40th Street, Seattle, WA 98105, USA
| | - Matthew Bruce
- Applied Physics Laboratory, Center for Industrial and Medical Ultrasound, The University of Washington, 1013 NE 40th Street, Seattle, WA 98105, USA
| | - Christoph P Hofstetter
- Department of Neurological Surgery, The University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA
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Menger R, LeFever DC, Zuckerman SL, Robbins JW, Bell R. Analysis of Factors and Conditions Influencing Military Neurosurgery Recruitment and Retention. Mil Med 2020; 185:583-589. [PMID: 31863095 DOI: 10.1093/milmed/usz382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 09/08/2019] [Accepted: 09/10/2019] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The Defense Health Agency has shifted focus of military medicine to operational readiness. As such, neurosurgery remains a critical wartime specialty. We investigate the factors impacting recruitment and retention of military neurosurgeons. METHODS Survey of military neurosurgeons was performed via the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Committee of Military Neurosurgeons and the Council of State Neurosurgical Societies. Retention and recruitment were queried. RESULTS 93/119 (78.2%) current or previously affiliated military neurosurgeons would recommend service as a military neurosurgeon to a colleague. Those who felt a sense of patriotism were 4.3 times more likely to recommend military service (P = 0.027, CI 1.19-16.82). Those who developed a sense of camaraderie showed a trend to recommending military neurosurgery (P = 0.058, CI 0.95-9.78). Those with a current military obligation were.28 times (P = 0.02, CI 0.09-0.85) as likely to recommend service. Military physicians who felt a need for reform to increase salary were 2.5 times less likely to be retained. DISCUSSION Service in the US military is a positive experience with camaraderie, patriotism, and unique military experiences predictive of recruitment. Meanwhile, focus on pay discrepancy can result in lost retention. These factors should be explored regarding recruitment and retention of military neurosurgeons.
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Affiliation(s)
- Richard Menger
- Department of Neurosurgery, University of South Alabama, CCCRP, 722 Doughten Street, Fort Detrick, MD 21702.,Department of Political Science, University of South Alabama, CCCRP, 722 Doughten Street, Fort Detrick, MD 21702
| | - Devon C LeFever
- Department of Neurosurgery, Louisiana State University Health Sciences Center, 1501 Kings Highway, PO Box 33932, Shreveport, LA 71130-3932
| | - Scott L Zuckerman
- Department of Neurosurgery, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232
| | - J Will Robbins
- 88th Surgical Operations Squadron, 4881 Sugar Maple Dr, Wright Patterson Air Force Base, OH 45433
| | - Randy Bell
- Uniformed Services University of Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814
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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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Zong ZW, Qin H, Chen SX, Yang JZ, Yang L, Zhang L, Du WQ, Zhong X, Zhou RJ, Tan D, Wu H. Chinese expert consensus on the treatment of modern combat-related spinal injuries. Mil Med Res 2019; 6:6. [PMID: 30786926 PMCID: PMC6381715 DOI: 10.1186/s40779-019-0196-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 02/07/2019] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Zhao-Wen Zong
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China.
| | - Hao Qin
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Si-Xu Chen
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Jia-Zhi Yang
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Lei Yang
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Lin Zhang
- Department of Tactical Health Service, NCO School of Army Medical University, Shijiazhuang, 050000, China
| | - Wen-Qiong Du
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Xin Zhong
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Ren-Jie Zhou
- Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Dan Tan
- Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Hao Wu
- Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
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15
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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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Stewart SK, Pearce AP, Clasper JC. Fatal head and neck injuries in military underbody blast casualties. J ROY ARMY MED CORPS 2018; 165:18-21. [PMID: 29680818 PMCID: PMC6581151 DOI: 10.1136/jramc-2018-000942] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 03/16/2018] [Accepted: 03/19/2018] [Indexed: 11/28/2022]
Abstract
Introduction Death as a consequence of underbody blast (UBB) can most commonly be attributed to central nervous system injury. UBB may be considered a form of tertiary blast injury but is at a higher rate and somewhat more predictable than injury caused by more classical forms of tertiary injury. Recent studies have focused on the transmission of axial load through the cervical spine with clinically relevant injury caused by resultant compression and flexion. This paper seeks to clarify the pattern of head and neck injuries in fatal UBB incidents using a pragmatic anatomical classification. Methods This retrospective study investigated fatal UBB incidents in UK triservice members during recent operations in Afghanistan and Iraq. Head and neck injuries were classified by anatomical site into: skull vault fractures, parenchymal brain injuries, base of skull fractures, brain stem injuries and cervical spine fractures. Incidence of all injuries and of each injury type in isolation was compared. Results 129 fatalities as a consequence of UBB were identified of whom 94 sustained head or neck injuries. 87 casualties had injuries amenable to analysis. Parenchymal brain injuries (75%) occurred most commonly followed by skull vault (55%) and base of skull fractures (32%). Cervical spine fractures occurred in only 18% of casualties. 62% of casualties had multiple sites of injury with only one casualty sustaining an isolated cervical spine fracture. Conclusion Improvement of UBB survivability requires the understanding of fatal injury mechanisms. Although previous biomechanical studies have concentrated on the effect of axial load transmission and resultant injury to the cervical spine, our work demonstrates that cervical spine injuries are of limited clinical relevance for UBB survivability and that research should focus on severe brain injury secondary to direct head impact.
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Affiliation(s)
- Sarah K Stewart
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - A P Pearce
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK.,Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, UK
| | - Jon C Clasper
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, UK.,Department of Trauma and Orthopaedics, Frimley Park Hospital, Frimley, UK
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Musculoskeletal Injuries in Iraq and Afghanistan: Epidemiology and Outcomes Following a Decade of War. J Am Acad Orthop Surg 2016; 24:341-8. [PMID: 27115793 DOI: 10.5435/jaaos-d-15-00123] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The combined wars in Afghanistan and Iraq represent the longest ongoing conflicts in American military history, with a combined casualty estimate of >59,000 service members. The nature of combat over the last decade has led to precipitous increases in severe orthopaedic injuries, including traumatic amputations and injuries to the spine. Nearly 75% of all injuries sustained in combat now are caused by explosive mechanisms, and fractures comprise 40% of all musculoskeletal injuries. Injuries to the axial skeleton are more frequent among personnel exposed to combat, and spinal trauma is identified in nearly 40% of those killed. Musculoskeletal injuries are expensive and generate some of the highest rates of long-term disability. Noncombat musculoskeletal injuries are endemic within deployed military service members and occur at a greater than threefold rate compared with combat musculoskeletal injuries. Service members with musculoskeletal injuries or behavioral health conditions, such as posttraumatic stress disorder, depression, and psychosis, and those occupying a low socioeconomic status, have an increased risk of inferior outcomes.
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George E, Elman I, Becerra L, Berg S, Borsook D. Pain in an era of armed conflicts: Prevention and treatment for warfighters and civilian casualties. Prog Neurobiol 2016; 141:25-44. [PMID: 27084355 DOI: 10.1016/j.pneurobio.2016.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 03/23/2016] [Accepted: 04/08/2016] [Indexed: 12/13/2022]
Abstract
Chronic pain is a common squealae of military- and terror-related injuries. While its pathophysiology has not yet been fully elucidated, it may be potentially related to premorbid neuropsychobiological status, as well as to the type of injury and to the neural alterations that it may evoke. Accordingly, optimized approaches for wounded individuals should integrate primary, secondary and tertiary prevention in the form of thorough evaluation of risk factors along with specific interventions to contravene and mitigate the ensuing chronicity. Thus, Premorbid Events phase may encompass assessments of psychological and neurobiological vulnerability factors in conjunction with fostering preparedness and resilience in both military and civilian populations at risk. Injuries per se phase calls for immediate treatment of acute pain in the field by pharmacological agents that spare and even enhance coping and adaptive capabilities. The key objective of the Post Injury Events is to prevent and/or reverse maladaptive peripheral- and central neural system's processes that mediate transformation of acute to chronic pain and to incorporate timely interventions for concomitant mental health problems including post-traumatic stress disorder and addiction We suggest that the proposed continuum of care may avert more disability and suffering than the currently employed less integrated strategies. While the requirements of the armed forces present a pressing need for this integrated continuum and a framework in which it can be most readily implemented, this approach may be also instrumental for the care of civilian casualties.
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Affiliation(s)
- E George
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Anesthesia, Critical Care and Pain Medicine, MGH, HMS, Boston, MA, United States; Commander, MC, USN (Ret), United States
| | - I Elman
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Psychiatry, Boonshoft School of Medicine and Dayton VA Medical Center, United States; Veterans Administration Medical Center, Dayton, OH, United States
| | - L Becerra
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Anesthesia, Critical Care and Pain Medicine, BCH, HMS, Boston, MA, United States; Departments of Psychiatry and Radiology, MGH, Boston, MA, United States
| | - Sheri Berg
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Anesthesia, Critical Care and Pain Medicine, MGH, HMS, Boston, MA, United States
| | - D Borsook
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Anesthesia, Critical Care and Pain Medicine, BCH, HMS, Boston, MA, United States; Departments of Psychiatry and Radiology, MGH, Boston, MA, United States.
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Formby PM, Wagner SC, Kang DG, Van Blarcum GS, Pisano AJ, Lehman RA. Reoperation after in-theater combat spine surgery. Spine J 2016; 16:329-34. [PMID: 26639623 DOI: 10.1016/j.spinee.2015.11.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Revised: 09/30/2015] [Accepted: 11/16/2015] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Peter M Formby
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD, 20889, USA
| | - Scott C Wagner
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD, 20889, USA
| | - Daniel G Kang
- Department of Orthopaedic Surgery, Madigan Army Medical Center, 9040 Jackson Avenue, Tacoma, WA, 98431, USA.
| | - Gregory S Van Blarcum
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD, 20889, USA
| | - Alfred J Pisano
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD, 20889, USA
| | - Ronald A Lehman
- Department of Orthopaedic Surgery, The Spine Hospital, Columbia University Medical Center, 5141 Broadway, New York Presbyterian, New York, NY, 10034, USA
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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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Abstract
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.
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Jakoi A, Iorio J, Howell R, Zampini JM. Gunshot injuries of the spine. Spine J 2015; 15:2077-85. [PMID: 26070284 DOI: 10.1016/j.spinee.2015.06.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 05/11/2015] [Accepted: 06/01/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal gunshot injuries (spinal GSIs) are a major cause of morbidity and mortality in both military and civilian populations. These injuries are likely to be encountered by spine care professionals in many treatment settings. A paucity of resources is available to summarize current knowledge of spinal GSI evaluation and management. PURPOSE The aim was to summarize the ballistics, epidemiology, evaluation, treatment, and outcomes of spinal GSI among civilian and military populations. STUDY DESIGN This was a review of the current literature reporting spinal GSI management. METHODS MEDLINE (PubMed) was queried for recent studies and case reports of spinal GSI evaluation and management. RESULTS Spinal GSI now comprise the third most common cause of spinal injury. Firearms that produce spinal GSI can be divided into categories of high- and low-energy depending on the initial velocity of the projectile. Neural and mechanical spinal damage varies with these types and results from several factors including direct impact, concussion waves, tissue cavitation, and thermal energy. Management of spinal GSI also depends on several factors including neurologic function and change over time, spinal stability, missile tract through the body, and concomitant injury. Surgical treatment is typically indicated for progressive neurologic changes, spinal instability, persistent cerebrospinal fluid leak, and infection. Surgical treatment for GSI affecting T12 and caudal often has a better outcome than for those cranial to T12. Surgical exploration and removal of missile fragments in the spinal canal are typically indicated for incomplete or worsening neurologic injury. CONCLUSIONS Treatment of spinal GSI requires a multidisciplinary approach with the goal of maintaining or restoring spinal stability and neurologic function and minimizing complications. Concomitant injuries and complications after spinal GSI can present immediate and ongoing challenges to the medical, surgical and rehabilitative care of the patient.
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Affiliation(s)
- Andre Jakoi
- Department of Orthopaedic Surgery, Drexel University College of Medicine, 245 N 15th St, MS 420, Philadelphia, PA 19102, USA
| | - Justin Iorio
- Department of Orthopaedic Surgery, Temple University, 3401 N Broad Street, Philadelphia, PA 19140, USA
| | - Richard Howell
- Department of Orthopaedic Surgery, Drexel University College of Medicine, 245 N 15th St, MS 420, Philadelphia, PA 19102, USA
| | - Jay M Zampini
- Department of Orthopaedic Surgery, Harvard Medical School, Division of Spine Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, 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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Sharma HS, Muresanu DF, Lafuente JV, Sjöquist PO, Patnaik R, Sharma A. Nanoparticles Exacerbate Both Ubiquitin and Heat Shock Protein Expressions in Spinal Cord Injury: Neuroprotective Effects of the Proteasome Inhibitor Carfilzomib and the Antioxidant Compound H-290/51. Mol Neurobiol 2015; 52:882-98. [DOI: 10.1007/s12035-015-9297-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Indexed: 12/22/2022]
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Abstract
STUDY DESIGN Retrospective analysis of inpatient and outpatient data from a single academic trauma center. OBJECTIVE To test the effectiveness of a conservative treatment algorithm for civilian spinal gunshot wounds (CSGSWs) by comprehensively evaluating neurological status and recovery, fracture type, concomitant injuries, indications for surgery, and complications. SUMMARY OF BACKGROUND DATA Few large studies exist to guide treatment of CSGSWs, and none have been published in nearly 20 years. METHODS A search of International Classification of Diseases, Ninth Revision (ICD-9) codes was performed for all hospital patients treated from 2003 to 2011 by either neurosurgery or orthopedic surgery to identify 159 consecutive patients who sustained CSGSWs. Mean follow-up was 13.6 months. American Spinal Injury Association grading was used to assess neurological injury. RESULTS Fifty percent of patients had neurological deficits from CSGSW. Complete spinal injury was the most common injury grade; thoracic injuries had the most risk of complete injury (P < 0.001). Nearly 80% of patients had concomitant injuries to other organs. Operative treatment was more likely in patients with severe neurological injuries (P = 0.008) but was not associated with improved neurological outcomes (P = 1.00). Nonoperative treatment did not lead to any cases of late spinal instability or neurological deterioration. Overall, 31% of patients had an improvement of at least 1 American Spinal Injury Association grade by final follow-up. Nearly half of patients experienced at least 1 GSW-related complication; risk of complications was associated with neurological injury grade (P < 0.001) and operative treatment (P = 0.04). CONCLUSION The vast majority of CSGSWs should be managed nonoperatively, regardless of neurological grade or number of spinal columns injured. Indications for surgery include spinal infection and persistent cerebrospinal fluid leaks. LEVEL OF EVIDENCE 3.
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Enhanced casualty care from a Global Military Orthopaedic Teleconsultation Program. Injury 2014; 45:1736-40. [PMID: 24810665 DOI: 10.1016/j.injury.2014.03.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 02/07/2014] [Accepted: 03/14/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Since its advent, telemedicine has facilitated access to subspecialty medical care for the treatment of patients in remote and austere settings. The United States military introduced a formal orthopaedic teleconsultation system in 2007, but few reports have explored its scope of practice and efficacy, particularly in a deployed environment during a time of conflict. METHODS All teleconsultations placed to the orthopaedic service between April 2009 and December 2012 were obtained and retrospectively reviewed. Case files were abstracted and anatomical location of injury, type of injury, origin of consult (country or Navy Afloat), branch of service, and treatment recommendations, were recorded for descriptive analysis. The final result of the consult was also determined, with service members transported from the combat theatre or deployment location defined as medically evacuated. Instances where teleconsultations averted a medical evacuation were also documented as a separate outcome. RESULTS Over a 32-month period, 597 orthopaedic teleconsultations were placed, with the majority derived from Army (46%) and Navy (32%) personnel deployed in Afghanistan, Iraq, or with Navy Afloat. Approximately 51% of consults involved the upper extremity, including 197 hand injuries, followed by lower extremity (37%) and spine (7.8%) complaints. Fractures comprised over half of all injuries, with the hand and foot most commonly affected. The average response time for teleconsultations was 7.54h. A total of 56 service members required immediate evacuation for further orthopaedic management, while at least 26 medical evacuations were prevented due to the teleconsultation system. CONCLUSIONS The teleconsultation system promotes early access to orthopaedic subspecialty care in a resource-limited, deployed military setting. The telemedicine network also appears to mitigate unnecessary aeromedical evacuations, reducing healthcare costs, lost duty time, and treatment delays. These findings have important meaning for the future of telemedicine in both the military and civilian setting. LEVEL OF EVIDENCE IV.
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Freedman BA, Serrano JA, Belmont PJ, Jackson KL, Cameron B, Neal CJ, Wells R, Yeoman C, Schoenfeld AJ. The combat burst fracture study--results of a cohort analysis of the most prevalent combat specific mechanism of major thoracolumbar spinal injury. Arch Orthop Trauma Surg 2014; 134:1353-9. [PMID: 25107602 DOI: 10.1007/s00402-014-2066-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Indexed: 11/30/2022]
Abstract
INTRODUCTION In 2009-2010, military physicians hypothesized that a new pattern of spinal injury had emerged, resulting from improvised explosive device assault on up-armored vehicles, associated with a high rate of point of first contact fracture and neurological injury-the combat burst fracture. We sought to determine the incidence of all thoracolumbar (TL) burst fractures and combat burst fractures in 2009-2010 as compared to two antecedent years. METHODS A screening process identified all individuals who sustained TL burst fractures in the time-period studied. Demographics, injury-specific characteristics, mechanism of injury, surgical interventions and early complications were recorded. Incidence rates were calculated for the three time periods using total deployed troop-strength and number of LRMC combat admissions as denominators. The incidences of TL burst fractures within each year group and by mechanism were compared, and clinical characteristics and process of care were described. RESULTS Between 2007-2010, 65 individuals sustained a TL burst fracture. The incidence of these injuries in 2009-2010 was 2.1 per 10,000 soldier-years and accounted for 3.0 % of LRMC combat-casualty admissions, a significant increase from 0.6 % and 1.1 % in 2007-2008 and 2008-2009, respectively (p ≤ 0.001). In 2009-2010, US soldiers were 3.4-4.6 times more likely to sustain a TL burst fracture compared to 2008-2009 and 2007-2008 (p < 0.001), and the most common mechanism of injury was IED vs. vehicle (65 %)-the combat burst fracture mechanism. Neurological deficits were present in 43 % of TL burst fractures and 1/3 were complete injuries. Spinal fixation was performed in 68 % overall and 74 % of combat burst fractures. CONCLUSIONS There was a 3.4- to 4.6-fold increase in TL burst fractures in 2009-2010 compared to antecedent years. The primary driver of this phenomenon was the marked increased in combat burst fractures. Mitigating/preventing the mechanism behind this major spinal injury is a key research initiative for the US military. Level of Evidence III (Case-control).
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Affiliation(s)
- Brett A Freedman
- Spine and Neurosurgery Service, Landstuhl Regional Medical Center, APO AE 09180-0402, Landstuhl, Germany,
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Fritz HA, Lysack C, Luborsky MR, Messinger SD. Long-term community reintegration: concepts, outcomes and dilemmas in the case of a military service member with a spinal cord injury. Disabil Rehabil 2014; 37:1501-7. [PMID: 25270306 DOI: 10.3109/09638288.2014.967415] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE Despite growing knowledge about medical and functional recovery in clinical settings, the long-term issue of community reintegration with a spinal cord injury (SCI) in the military context remains virtually unexamined. Thus, the U.S. Department of Defense created the SCI Qualitative Research Program to advance knowledge about service members' reintegration into civilian life. The purpose of this paper is to better characterize the long-term outcomes related to the community participation experienced and desired vis-à-vis a case study of a military veteran who suffered a service-related traumatic SCI. METHODS An in-depth anthropological interview was used with Jake, a 28-year old marine with a service-related C5/C6 SCI. Data were analyzed using content analysis. FINDINGS Three significant themes were identified: opportunities for better engaging socially meaningful others may not be adequately included in so-called "client-centered" interventions; how management of the social self in inter-personal interactions and public spaces is critical to gaining broader societal acceptance; and how meaningful age normative relationships and activities are essential to establish lasting inclusive social connections. CONCLUSIONS Jake's case challenges existing models of rehabilitation predominantly focused on physical capacity building. Study findings point to the need for rehabilitation to invest more resources in efforts to address the existential and social elements of long-term social reintegration. Implications for Rehabilitation Both the veteran with SCI and their meaningful support network face challenges socially reintegrating after injury and rehabilitation. Empowering clients to envision future possibilities in terms of family, intimate relationships, and meaningful work are important to successful long-term social reintegration. Addressing the existential desires and social capacities of the individual may be as important as addressing physical functioning skills after SCI.
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Affiliation(s)
- Heather Ann Fritz
- Institute of Gerontology, Wayne State University , Detroit, MI , USA
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Galvin JW, Freedman BA, Schoenfeld AJ, Cap AP, Mok JM. Morbidity of early spine surgery in the multiply injured patient. Arch Orthop Trauma Surg 2014; 134:1211-7. [PMID: 25077784 DOI: 10.1007/s00402-014-2068-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The optimal timing of surgery for multiply injured patients with operative spinal injuries remains unknown. The purported benefits of early intervention must be weighed against the morbidity of surgery in the early post-injury period. The performance of spine surgery in the Afghanistan theater permits analysis of the morbidity of early surgery on military casualties. The objective is to compare surgical morbidity of early spinal surgery in multiply injured patients versus stable patients. MATERIALS AND METHODS Patients were retrospectively categorized as stable or borderline unstable depending on the presence of at least one of the following: ISS >40, ISS >20 and chest injury, exploratory laparotomy or thoracotomy, lactate >2.5 mEq/L, platelet <110,000/mm(3), or >10 U PRBCs transfused pre-operatively. Surgical morbidity, complications, and neurologic improvement between the two groups were compared retrospectively. RESULTS 30 casualties underwent 31 spine surgeries during a 12-month period. 16 of 30 patients met criteria indicating a borderline unstable patient. Although there were no significant differences in the procedures performed for stable and borderline unstable patients as measured by the Surgical Invasiveness Index (7.5 vs. 6.9, p = 0.8), borderline unstable patients had significantly higher operative time (4.3 vs. 3.0 h, p = 0.01), blood loss (1,372 vs. 366 mL, p = 0.001), PRBCs transfused intra-op (3.88 vs. 0.14 U, p < 0.001), and total PRBCs transfused in theater (10.18 vs. 0.31 U, p < 0.001). CONCLUSIONS The results indicate that published criteria defining a borderline unstable patient may have a role in predicting increased morbidity of early spine surgery. The perceived benefits of early intervention should be weighed against the greater risks of performing extensive spinal surgeries on multiply injured patients in the early post-injury period, especially in the setting of combat trauma.
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Affiliation(s)
- J W Galvin
- Orthopaedic Surgery Service, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, Washington, 98431, USA
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Evaluation of immediate postoperative complications and outcomes among military personnel treated for spinal trauma in Afghanistan: a cohort-control study of 50 cases. ACTA ACUST UNITED AC 2014; 27:376-81. [PMID: 24999556 DOI: 10.1097/bsd.0b013e3182a355c6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective case-control study. OBJECTIVE The objective of the study was to compare neurological outcomes and complication rates between a series of combat-injured patients treated in Afghanistan (AFG) and those treated at Landstuhl Regional Medical Center (LRMC). SUMMARY OF BACKGROUND DATA At present, no studies have addressed the ideal timing and setting for surgical stabilization in combat-injured soldiers who sustain spinal trauma. METHODS Soldiers who sustained spine injuries while deployed to Afghanistan and who underwent surgery in theater or at LRMC between 2010 and 2011 were identified. Demographic information, injury-specific data, neurological status, type of surgical intervention, postoperative complications, and need for additional surgery were abstracted for all patients. Neurological improvement was the primary dependent variable. Secondary variables included the risk of developing complications and the need for additional surgery. Statistical analysis was performed using t tests, and the Fisher exact test was used for categorical variables. RESULTS Between 2010 and 2011, 30 individuals were treated in AFG, and 20 received surgery at LRMC. Neurological improvement occurred in 10% of AFG patients and 5% of those treated at LRMC. Complications occurred in 40% of AFG patients and in 20% of the LRMC group. Twenty-three percent of AFG patients required additional spine surgery after leaving Afghanistan. There was no statistical difference in neurological improvement between the AFG and LRMC groups (P=0.64). Soldiers who received surgery in AFG were at significantly increased risk of requiring additional procedures (P=0.03). CONCLUSIONS Soldiers treated in theater did not have statistically higher rates of neurological improvement as compared with those treated at LRMC. Patients treated in-theater were at elevated risk for the need for additional surgery. This study is among the first to evaluate clinical outcomes after surgical intervention for war-related spinal trauma. LEVEL OF EVIDENCE Level III (case-control).
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Schoenfeld AJ, Dunn JC, Belmont PJ. Pelvic, spinal and extremity wounds among combat-specific personnel serving in Iraq and Afghanistan (2003-2011): A new paradigm in military musculoskeletal medicine. Injury 2013; 44:1866-70. [PMID: 23998993 DOI: 10.1016/j.injury.2013.08.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 07/16/2013] [Accepted: 08/04/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Previous studies regarding musculoskeletal injuries sustained during war have been limited by a lack of specificity regarding wounds incurred by combat-specific personnel. This investigation endeavoured to develop a comprehensive catalogue of the extent of musculoskeletal trauma, as well as the frequency of distinct injuries, among soldiers possessing a single combat-specific specialty. METHODS The Department of Defense Trauma Registry (DoDTR) and the Armed Forces Medical Examiner System (AFMES) were queried for all individuals with the combat-specific designation of cavalry scout who sustained injuries during deployment between the years 2003 and 2011. This data was refined to include only those soldiers found to have injuries involving the spine, pelvis, or extremities. Soldier age, rank, injury location (Afghanistan or Iraq), injury scenario (combat vs. non-combat) and mechanism of wounding were recorded, as were injury-specific data. Statistical comparisons for categorical variables were made using the chi-square statistic. RESULTS Sixty-seven percent (n=472) of 701 cavalry scouts injured during deployment sustained one or more injuries to the musculoskeletal system. Mean age for the group was 25.9 (range 18-54) years and 3.3 musculoskeletal injuries were incurred on average per casualty. The majority of casualties occurred during combat and in the Iraq theatre. Sixty-nine percent (n=328) of musculoskeletal casualties were incurred following explosion, and 20% (n=94) occurred due to gunshot. No significant difference (p>0.05) was encountered for the risk of musculoskeletal injury by wound mechanism. Forty-six percent of all injuries involved the lower extremities, while 32% occurred in the upper extremities. Tibial fractures were the most common injury encountered (8%), while amputations comprised 11% of all wounds. Spinal cord injury occurred in 12% of all casualties and represented 4% of all musculoskeletal wounds. CONCLUSIONS This effort is among the first to combine complimentary data from the DoDTR and AFMES over a multi-year period in order to comprehensively catalogue musculoskeletal wounds sustained by combat-specific soldiers. This investigation highlights a 49% incidence of injuries involving the spine, pelvis, and/or extremities within a cohort of combat-specific soldiers. Elevated rates of amputations, spinal injuries, and pelvic trauma were also appreciated as compared to earlier reports.
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Affiliation(s)
- Andrew J Schoenfeld
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, Texas Tech University Health Sciences Center, El Paso, TX, United States
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Spinal injuries in United States military personnel deployed to Iraq and Afghanistan: an epidemiological investigation involving 7877 combat casualties from 2005 to 2009. Spine (Phila Pa 1976) 2013; 38:1770-8. [PMID: 23759821 DOI: 10.1097/brs.0b013e31829ef226] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis of a prospective data set. OBJECTIVE Determine the incidence and epidemiology of combat-related spinal injuries for the wars in Afghanistan and Iraq. SUMMARY OF BACKGROUND DATA Recent studies have identified a marked increase in the rate of combat-related spine trauma among casualties in Afghanistan and Iraq. Limitations in these previous works, however, limit their capacity for generalization. METHODS A manual search of casualty records stored in the Department of Defense Trauma Registry was performed for the years 2005 to 2009. Demographic information, nature of spinal wounding, injury mechanism, concomitant injuries, year, and location of injury were recorded for all soldiers identified as having sustained combat-related spine trauma. Incidence rates were constructed by comparing the frequencies of spine casualties against defense manpower deployment data. Multivariate Poisson regression was used to identify statistically significant factors associated with spinal injury. RESULTS In the years 2005 to 2009, 872 (11.1%) casualties with spine injuries were identified among a total of 7877 combat wounded. The mean age of spine casualties was 26.6 years. Spine fractures were the most common injury morphology, comprising 83% of all spinal wounds. The incidence of combat-related spinal trauma was 4.4 per 10,000, whereas that of spine fractures was 4.0 per 10,000. Spinal cord injuries occurred at a rate of 4.0 per 100,000. Spinal cord injuries were most likely to occur in Afghanistan (incident rate ratio: 1.96; 95% confidence interval: 1.68-2.28), among Army personnel (incident rate ratio: 16.85; 95% confidence interval: 8.39-33.84), and in the year 2007 (incident rate ratio: 1.90; 95% confidence interval: 1.55-2.32). Spinal injuries from gunshot were significantly more likely to occur in Iraq (17%) than in Afghanistan (10%, P = 0.02). CONCLUSION The incidence of spine trauma in modern warfare exceeds reported rates from earlier conflicts. The study design and population size may enhance the capacity for generalization of our findings. LEVEL OF EVIDENCE 3.
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The nature and extent of war injuries sustained by combat specialty personnel killed and wounded in Afghanistan and Iraq, 2003–2011. J Trauma Acute Care Surg 2013; 75:287-91. [DOI: 10.1097/ta.0b013e31829a0970] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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