Committee on Surgical Combat Casualty Care Position Statement: Neurosurgical Capability for the Optimal Management of Traumatic Brain injury During Deployed Operations. Including Invited Commentaries

BACKGROUND

Experiences over the last 3 decades of war have demonstrated a high incidence of Traumatic Brain Injury (TBI) resulting in a persistent need for a neurosurgical capability within the deployed theatre of operations. Despite this, no doctrinal requirement for a deployed neurosurgical capability exists. Through an iterative process, the Joint Trauma System Committee on Surgical Combat Casualty Care (CoSCCC) developed a Position Statement to inform medical and non-medical military leaders about the risks of the lack of a specialized neurosurgical capability.

METHODS

The need for deployed neurosurgical capability Position Statement was identified during the spring 2021 CoSCCC meeting. A tri-service working group of experienced forward-deployed caregivers developed a preliminary statement. An extensive iterative review process was then conducted to ensure that the intended messaging was clear to senior medical leaders and operational commanders. To provide additional context and a civilian perspective, statement commentaries were solicited from civilian clinical experts including a recently retired military trauma surgeon boarded in Neurocritical Care, a trauma surgeon instrumental in developing the Brain Injury Guidelines (BIG), a practicing neurosurgeon with world-renowned expertise in TBI, and the Chair of the Committee on Trauma (COT).

RESULTS

After multiple revisions, Position Statement was finalized it was approved by the CoSCCC membership in February 2023. Challenges identified include: 1) military neurosurgeon attrition; 2) the lack of a doctrinal neurosurgical capabilities requirement during deployed combat operations; 3) the need for neurosurgical telemedicine capability and in-theatre CT scans to triage TBI casualties requiring neurosurgical care.

CONCLUSION

Challenges identified regarding neurosurgical capabilities within the deployed trauma system include military neurosurgeon attrition and the lack of a doctrinal requirement for neurosurgical capability during deployed combat operations. To mitigate risk to the force in a future peer-peer conflict several evidence-based recommendations are made. The solicited civilian commentaries strengthen these recommendations by putting them into the context of civilian TBI management. These neurosurgical capabilities position statement is intended to be a forcing function and a communication tool to inform operational commanders and military medical leaders on the use of these teams on current and future battlefields.

LEVEL OF EVIDENCE

Brief Report, 3.

Effect of fish oil supplementation in a rat model of multiple mild traumatic brain injuries

PURPOSE

Repetitive mild traumatic brain injury (TBI) is a major military and sports health concern. The purpose of this study was to determine if a diet rich in omega-3 fatty acids would reduce cognitive deficits and neuronal cell death in a novel fluid percussion rat model of repetitive mild TBIs.

METHODS

Thirty-two Sprague-Dawley rats were assigned to either an experimental rat chow enhanced with 6% fish oil (source of omega-3 fatty acids) or a control rat chow. Both rat chows contained equivalent quantities of calories, oil, and nutrients. After four weeks, both groups received mild repetitive bilateral fluid percussion TBIs on two sequential days. Pre-injury diets were resumed, and the animals were monitored for two weeks. On post-injury days 10-14, Morris Water Maze testing was performed to assess spatial learning and cognitive function. Animals were euthanized at 14 days post-injury to obtain specimens for neurohistopathology.

RESULTS

There was no difference in pre-injury weight gain between groups. Post-injury, animals on the fish oil diet lost less weight and recovered their weight significantly faster. By 14 days, the fish oil diet group performed significantly better in the Morris Water Maze. Neurohistopathology identified a non-significant trend toward a higher density of hippocampal neurons in the fish oil diet group.

CONCLUSIONS

Pre-injury dietary supplementation with fish oil improves recovery of body weight and provides a small improvement in cognitive performance in a rat model of multiple mild TBIs.