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Are spine injuries sustained in battle truly different?
The Spine Journal 12 (2012) 824–829
Review Article
Are spine injuries sustained in battle truly different? James A. Blair, MDa,*, Jeanne C. Patzkowski, MDa, Andrew J. Schoenfeld, MDb, Jessica D. Cross Rivera, MDa, Eric S. Grenier, MDa, Ronald A. Lehman, MDc, Joseph R. Hsu, MDd, Skeletal Trauma Research Consortium (STReC)d a Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, Fort Sam Houston, TX 78234, USA Department of Surgery, Orthopaedics Service, William Beaumont Army Medical Center, 5005 North Piedras St, El Paso, TX 79920, USA c Department of Orthopaedics and Rehabilitation, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA d United States Army Institute of Surgical Research, 3851 Roger Brooke Dr, Fort Sam Houston, TX 78234, USA b
Received 8 May 2011; revised 22 June 2011; accepted 7 September 2011
Abstract
BACKGROUND CONTEXT: The severity and prognosis of combat-related injuries to the spine and spine injuries sustained unrelated to direct combat have not been previously compared. Differences may have implications on tactics, treatment strategies, and directions for future research. PURPOSE: Compare the severity and prognosis of battle and nonbattle injuries to the spine. STUDY DESIGN: Retrospective study. PATIENT SAMPLE: American military personnel who were injured in a combat zone and whose medical data were abstracted in the Joint Theater Trauma Registry (JTTR). METHODS: The JTTR was queried using International Statistical Classification of Diseases, Ninth Revision codes to identify all individuals who sustained battle and nonbattle injuries to the neck, back, spinal column, or spinal cord in Operation Iraqi Freedom or Operation Enduring Freedom from October 2001 to December 2009. Medical records of all identified servicemembers were individually reviewed. Demographic information, including sex, age, military rank, date of injury, and final disposition, was obtained for all patients. Spinal injuries were categorized according to anatomic location, associated neurologic involvement, precipitating mechanism of injury (MOI), and concomitant wounds. These data points were compared for the groups battle spine injuries (BSIs) and nonbattle spine injuries (NBSIs). RESULTS: Five hundred two servicemembers sustained a total of 1,834 battle injuries to the spinal column, including 1,687 fractures (92%), compared with 92 servicemembers sustaining 267 nonbattle spinal column injuries, with 241 (90%) fractures. Ninety-one BSI servicemembers (18% of patients) sustained spinal cord injuries (SCIs) with 41 (45%) complete SCIs, compared with 13 (14% of patients) nonbattle SCIs with six (46.2%) complete injuries (p5.92). The reported MOI for 335 BSI servicemembers (66.7%) was an explosion compared with one NBSI explosive injury. Eighty-four patients (17%) sustained gunshot wounds (GSWs) in battle compared with five (5.2%) nonbattle GSWs. Fifteen patients (3.0%) sustained a battle-related fall compared with 29 (30%) nonbattle-related falls. Battle spine injury servicemembers underwent significantly higher rates of surgical interventions (p!.0001), were injured by high-energy injury mechanisms at
FDA device/drug status: Not applicable. Author disclosures: JAB: Nothing to disclose. JCP: Nothing to disclose. AJS: Nothing to disclose. JDCR: Nothing to disclose. ESG: Nothing to disclose. RAL: Grants: Defense Advanced Research Projects Agency (I, Paid directly to institution/employer), Defense Medical Research and Development Program (H, Paid directly to institution/employer). JRH: The Geneva Foundation (D, Paid directly to institution). The disclosure key can be found on the Table of Contents and at www. TheSpineJournalOnline.com. This study was conducted under a protocol reviewed and approved by the Brooke Army Medical Center Institutional Review Board and in accordance with the approved protocol. 1529-9430/$ - see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.spinee.2011.09.012
The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. The authors acknowledge the Joint Theater Trauma Registry for providing data for this study. * Corresponding author. Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, Fort Sam Houston, TX 78234, USA. Tel.: (210) 916-3410; fax: (210) 916-7323. E-mail address: [email protected] (J.A. Blair)
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a significantly greater rate (p!.0001), and demonstrated a trend toward lower neurologic recovery rates after SCI (p5.16). CONCLUSIONS: Battle spine injury and NBSI are separate entities that may ultimately have disparate long-term prognoses. Nonbattle spine injury patients, although having similar MOIs compared with civilian spinal trauma, maintain a different patient demographic. Further research must be directed at accurately quantifying the long-term disabilities of all spine injuries sustained in a combat theater, whether they are the result of battle or not. Published by Elsevier Inc. Keywords:
Spine trauma; Spinal cord injury; Battle injury; Nonbattle injury; Military
Introduction Over the past decade, the US military has been engaged in two simultaneous conflicts within the Global War on Terror. Operation Iraqi Freedom (OIF: 2003–2010) and Operation Enduring Freedom (OEF: 2001–present) combine to form the largest battlefront since the Vietnam War. As of March 2011, there have been close to 50,000 casualties, 4,632 hostile deaths, and 1,253 nonhostile deaths in OIF and OEF [1]. Previous studies regarding these conflicts have documented an increased reliance on unconventional explosive devices, elevated lethality with respect to the weapons used, and increased survivability among American and coalition forces wounded in battle [2–7]. Recent literature has demonstrated that spine injuries are among the most disabling conditions affecting wounded servicemembers [6]. Some observations suggest that battle-incurred spinal injuries are more severe than those typically encountered in civilian trauma; however, no direct comparison has previously been made. Comparisons with civilian cohorts of spine injuries may introduce demographic differences that would confound results, such as patient age, pretrauma activity level, and mechanism of injury (MOI) [7–12]. A case-control analysis between groups of similar demographic and health status would allow a more refined determination of the influence of combat-related spinal trauma on outcome. Specifically, differences between soldiers who sustain spine injuries outside combat and those with war-related spinal trauma may have a substantial impact on future directions for warrior protection, tactics, treatment, and research. The purpose of this study is to compare the severity and prognosis of spinal injuries sustained by American military personnel during battle and in a nonbattle environment.
Classification of Diseases, Ninth Revision codes that were searched can be found in the Table. All patient medical records were individually abstracted by four reviewers (JAB, JCP, JDC, and ESG) for relevant data. Patients were excluded if medical records describing an injury to the spinal column or spinal cord could not be verified or if adequate documentation was not obtainable. Battle and nonbattle injuries were identified based on documentation in the patient’s medical records using the US Armed Forces Atlas of Injuries [13] definition of ‘‘battle injury:’’ any casualty incurred as the direct result of hostile action sustained in combat or sustained going to or from a combat mission. Included are persons killed or wounded accidentally by friendly fire directed at a hostile force or what was thought to be a hostile force. Anyone within this group was deemed a battle spine injury (BSI). The comparison group included individuals injured while in the theater of operations but not fitting into the criteria for ‘‘battle injury.’’ As per the US Armed Forces Atlas of Injuries [13], the following injuries are not battle casualties: self-inflicted wounds (except in unusual cases) and wounds or death inflicted by a friendly force while the soldier is absent without leave, dropped from the rolls, or is a voluntary absentee from his or her place of duty. Anyone within this group was deemed a nonbattle spine injury (NBSI). Injuries were classified and compared according to anatomic location, reported MOI, actual direct MOI, and concomitant injuries. Neurologic involvement was graded according to the criteria of the American Spinal Injury Association (ASIA) [14] whenever possible. Focused Table Joint Theater Trauma Registry ICD-9 search terms ICD-9 codes used for patient search
Methods After approval from the institutional investigational review board, the Joint Theater Trauma Registry (JTTR) [7] was queried via International Statistical Classification of Diseases, Ninth Revision codes for all US servicemembers serving in OIF or OEF sustaining injuries to the back, spinal cord, and spinal column from October 2001 to December 2009. The specific International Statistical
192, 225 336 721–724 805 806 839 876 952
ICD-9 interpretation Cauda equina syndrome Unspecified disease of spine Other spinal disorders and intervertebral disc disorders Spine fracture Spine fracture with cord injury Spine dislocation Open wound of back Spinal cord injury
ICD-9, International Statistical Classification of Diseases, Ninth Revision.
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comparisons were made for data points related to the severity of the injury and the prognosis between the BSIs and NBSIs groups. All data were securely stored in the Skeletal Trauma Research Consortium Spine Database using Microsoft Access Database 2007 (Microsoft Corporation, Seattle, WA, USA). A Student t test was used to detect significant differences between groups, with a p value of .05 identified as the threshold for significance.
Results Between October 2001 and December 2009, 10,979 evacuated battle casualties were registered in the JTTR. Among these 10,979 individuals, 598 sustained spine injuries. Five hundred two servicemembers (84%) sustained 1,834 battle-related spine injuries (87% of all spine injuries), resulting in an average of 3.7 spine injuries per patient. The remaining 96 servicemembers (16%) sustained 267 nonbattle-related injuries (13% of all spine injuries), resulting in an average of 2.8 spine injuries per patient. The average age at the time of injury was 26.3 (range, 18–56) and 27.3 (range, 19–56) for the BSI and NBSI cohorts, respectively. Ninety-eight percent of the BSI cohort were males (n5496) and 90% (n5452) were enlisted, whereas 92% of the NBSI cohort were males (n588) and 92% were enlisted (n588). The mean rank for battle- and nonbattle-injured enlisted servicemembers was E-5 (Sergeant). The mean rank for battle-injured officers was O-3 (Captain), whereas it was O-4 (Major) for nonbattleinjured officers. Explosive mechanisms accounted for 336 of 598 (56%) of all spine injuries, of which 335 (99.7%) were sustained in battle (p!.0001). The single nonbattle explosion causing a spine injury was because of a tire explosion. A total of 175 servicemembers (29.2% of all spine-injured patients) sustained spine injuries caused by motor vehicle collisions. Of these, 123 (73.2% of servicemembers injured by motor vehicle collisions and 24.5% of all BSIs) were battle related and 52 were nonbattle related (31.1% of servicemembers injured by motor vehicle collisions [p!.0001] and 54% of all NBSIs). Gunshot wounds were responsible for spine injuries to 89 servicemembers (14.9% of all spine-injured servicemembers), and 94% (n584/89) of these were sustained in combat (p5.009), which accounts for 16.7% (n584/502) of all BSIs and 5.2% of all NBSIs (n55/96). Falls from height accounted for 44 (7.4%) spine injuries among all servicemembers with 34% (n515) of falls occurring in battle (3.0% of all BSIs) and 66% (n529, 30.2% of all NBSIs) of falls related to the nonbattle environment (p!.0001). The anatomic distribution of spine injuries was comparable between the battle and nonbattle cohorts, with an increasing incidence of injury from cephalad to caudad. Within the cervical spine, 82% (n5262) of injuries were
battle related and 18% (n557) were nonbattle related. This comprised 14% of all spine injuries in the BSI cohort and 21% of all spine injuries in the NBSI cohort (p5.003). Battle spine injury constituted 86% (n5511) of thoracic injuries compared with 14% (n580) of NBSI. Thoracic spine injuries were documented in 28% of BSI and 30% of NBSI (p5.53). Battle spine injurie represented 88% (n5758) of all lumbar spine fractures, whereas NBSI represented 12% (n599) of lumbar spine fractures (p5.015). There were 210 (11%) BSIs and 20 (7%) NBSIs to the sacrum (p5.048) (Fig. 1). Transverse process fractures were the most commonly documented injuries for BSI, identified in 223 battle servicemembers (44%) (Fig. 2), and the second most common nonbattle injury was found in 35 nonbattle servicemembers (36%) (Fig. 3). Twenty-four servicemembers (11% of servicemembers sustaining transverse process fractures) sustained transverse process fractures to the cervical spine with 20 considered BSIs and four considered NBSIs. Thoracic transverse process fractures were sustained by 64 servicemembers (29% of servicemembers sustaining transverse process fractures) with 89% considered BSIs (n557/ 64). Lumbar transverse process fractures were sustained by 205 servicemembers (92% of servicemembers sustaining transverse process fractures), of which 176 were BSIs and 29 were NBSIs. Of these 205 servicemembers sustaining lumbar transverse process fractures, 47 (23%) involved the L5 vertebral level (42 BSIs and 7 NBSIs). Compression fractures were the next most common injuries for BSI, whereas they were the most common injuries for NBSI (battle: 34% [n5171] and nonbattle: 41% [n536]). Burst fractures were the third most common injuries within both cohorts (battle: 26% [n5123] and nonbattle: 17% [n516]). One hundred sixty-three (32%, n5163/502) BSI servicemembers underwent an operative intervention for their
Fig. 1. Anatomic distribution of spine injuries sustained in Operation Iraqi Freedom and Operation Enduring Freedom.
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Fig. 2. Battle spine injuries sustained in Operation Iraqi Freedom and Operation Enduring Freedom. Fx, fracture.
spinal injuries either at Landstuhl Regional Medical Center or in the United States, compared with only 19 (20%) of those NBSIs (p!.0001). One hundred seventeen (23%) BSI servicemembers received spinal instrumentation compared with 16 (17%) NBSI servicemembers (p!.0001). Arthrodesis was performed on 129 (26%) BSI servicemembers compared with 15 (16%) NBSI servicemembers (p!.0001). A spinal decompression was performed on 98 (20%) BSI servicemembers compared with 10 (10%) NBSI servicemembers (p!.0001). Forty-eight BSI and six NBSI servicemembers did not have documentation of their treatment. Spinal cord injuries (SCIs) were sustained by 13 (5%) NBSI servicemembers compared with 91 (5%) in the BSI group (p5.92). Of the 13 nonbattle SCIs, six were complete SCIs, whereas 41 of 91 (45%) of the SCIs sustained in battle were complete injuries. Initial ASIA grades were available for 77 battle spine–injured servicemembers and eight nonbattle spine–injured patients. At least one follow-up ASIA grade was available for 53 battle-injured servicemembers and six nonbattle-injured servicemembers. Of the 53 battle-injured servicemembers with follow-up ASIA
grades, 26 (49%) had an improved ASIA grade on followup with six of these servicemembers regaining full neurologic function below the level of injury (ASIA E). Nineteen of the 26 (73%) that demonstrated improved ASIA grade at follow-up had undergone a surgical intervention. There was a significantly higher rate of neurologic improvement for servicemembers undergoing a surgical intervention after a nonbattle injury (75%, n53/4) versus a surgical intervention after a battle injury (50%, n519/38) (p5.0068). There was no significant difference between the rates of neurologic improvement between battle (n57/12) and nonbattle (n51/2) groups treated nonoperatively (p5.12) Four of the six patients with a normal ASIA grade at follow-up had also received surgery. Four nonbattle-injured servicemembers had an improved ASIA grade at follow-up, and three of these had undergone a surgical intervention. Twenty-six (49%) BSI servicemembers and two NBSI servicemembers had no change in their ASIA grade over the course of follow-up. Only one servicemember (battle injured) was found to have a decline in neurologic status over the course of treatment.
Fig. 3. Nonbattle spine injuries sustained in Operation Iraqi Freedom and Operation Enduring Freedom. Fx, fracture.
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Discussion As participants in the Global War on Terrorism, US military personnel have been deployed to two separate theaters in Iraq and Afghanistan. The nature and epidemiology of battle wounds sustained during OIF and OEF have been described on both general [2,7,15] and unit-specific scales [5]. Although these reports have demonstrated the substantial incidence of musculoskeletal injuries and extensive musculoskeletal burden of disease [16], few studies have specifically addressed injuries to the spinal column [17,18]. Furthermore, to date, no study has examined prognostic differences between combat-related and nonbattle spinal trauma. The present investigation is the first to directly compare differences between spinal trauma sustained as a result of battle versus those occurring in the nonbattle environment. The findings in this report indicate that the overall incidence of spinal column and SCIs during OEF/OIF is 5.45%, 83% of which are the result of battle injuries, whereas 17% occurred outside battle. The vast majority of all spine injuries in both cohorts were fractures. As expected, most BSIs were sustained as a result of explosions, gunshot wounds, and motor vehicle collisions, whereas NBSIs occurred primarily as the result of motor vehicle collisions and falls from height. Surprisingly, whether injured in battle or not, the anatomic location of injuries was similar between groups. Moreover, no significant differences in the incidence of SCI as a whole, or the rate of complete SCI, were encountered between cohorts. Significantly higher rates of vertebral arthrodeses, spinal instrumentation, and decompression were noted in the BSI group. However, it seems plausible that the higher rate of surgical intervention and the use of internal fixation and arthrodesis is indicative of more substantial spinal injuries in the BSI group. Greater degrees of spinal instability and a high-energy MOI may also be responsible for the decreased rate of neurologic improvement after surgical intervention among those with SCI. The findings in this study are consistent with the reports of previous works. Schoenfeld et al. [17] reported a 7.4% incidence of spine injuries among soldiers in a US Army Brigade Combat Team, which closely approximates the overall incidence reported here. Belmont and Goodman [3] evaluated the same Brigade Combat Team for disease nonbattle injuries during the unit’s deployment and found a 10% incidence of spinal conditions. Lumbago was the most common complaint, followed by cervicalgia, thoracic pain, and degenerative disc conditions. Contrary to our study, there were no fractures or SCIs reported. The vast majority of these individuals returned to duty without medical evacuation and do not provide a meaningful comparison to our population, where every servicemember was evacuated for medical reasons. The large proportion of battle injuries because of explosive mechanisms is consistent with prior works describing injuries sustained in OIF and OEF [3,7,15,17–20].
With respect to the civilian literature, it is evident that active duty servicemembers sustaining NBSI in a hostile environment are not comparable to the standard spine-injured patient in a trauma setting. In Pirouzmand’s [8] analysis of more than 2,800 civilian trauma patients sustaining spine injuries, several differences are noted when compared with the present analysis. Foremost, patients were older than the average NBSI servicemember and the male:female injury ratio was markedly higher than the 8% reported in the current effort. Similar, however, was the high rate of motor vehicle collisions as the principal MOI and resultant rates of SCI. However, when one considers civilians sustaining spinal injuries in conjunction with polytrauma, similarities appear more readily. For example, in their analysis of patients with thoracolumbar spine injuries and injury severity scores greater than 15, Chipman et al. [21] reported an average patient age comparable to that documented in the present work. Similarly, they found the incidence of substantial neurologic improvement to be poor in their high injury severity score spine injury cohort. Likewise, the study of McLain and Benson [22], investigating outcomes among 27 individuals with spinal fractures and associated polytrauma, documented a 7% mortality and only fair neurologic improvement after surgery, ranging from 0.2 to 1.5 Frankel grades. Several limitations to this study should be noted. This study is dependent on data entered in the JTTR, a database that was only initiated at the beginning of the Global War on Terror. Therefore, many casualties that occurred early in OIF and OEF were not logged in the database. Similarly, as this is a registry study, the details of this work are entirely dependent on the quality of data entered in the JTTR. Servicemembers whose spinal injuries were not documented, or miscoded, may not be represented in this analysis. Furthermore, as information regarding combat wounds resulting in death is not recorded in the JTTR, the complete scope of combat-related spinal injuries is not represented in this investigation. Along these same lines, the current analysis excludes spinal conditions, such as herniated discs, radiculopathy, spondylolisthesis, or degenerative disease, that did not result in a servicemember’s evacuation from theater. Consequently, our assessment of the total burden of nonbattle-related spinal conditions is underestimated and represents a worst-case scenario. However, we chose to include only acute traumatic conditions to garner a more meaningful direct comparison with the cohort injured in combat. Although the results of this study emphasize the tremendous burden spine injuries incurred on the battlefield have on military personnel, nonbattle spine injuries also impact the fighting force during an armed conflict. Battle and nonbattle spine injuries impart substantial disability, with longterm ramifications for wounded servicemembers, their families, the military, and the Veterans’ Administration system [3,6]. The results presented in this analysis emphasize that battle and nonbattle spine injuries are clearly
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separate entities and should not be considered together in further research, although such injuries may arise in the same operational theater. Furthermore, battle and nonbattle spine injuries sustained during military conflicts, and the population in which they occur, are most comparable to severe spinal injuries sustained in conjunction with polytrauma among civilians [21,22]. As civilian research among such a select population is exceedingly difficult to conduct, further work among military patients with war-related spinal injuries may have important implications for future best practices in the civilian sector. Ultimately, more work of a prospective nature must be conducted on the epidemiology, management, and outcome of both battle and nonbattle spine injuries before more definitive recommendations, or treatment algorithms, can be devised. References [1] Directorate for Information Operations and Reports. Department of Defense. Available at: http://siadapp.dmdc.osd.mil/personnel/CASUALTY/ castop.htm. Accessed March 27, 2011. [2] Covey DC. From the frontlines to the home front: the crucial role of military orthopaedic surgeons. J Bone Joint Surg Am 2009;91: 998–1006. [3] Belmont PJ Jr, Goodman GP. The combat environment and epidemiology of musculoskeletal combat casualties. In: Owens BD, Belmont PJ, eds. Combat orthopaedic surgery: lessons learned in Iraq and Afghanistan. Thorofare, NJ: Slack Incorporated; 2011:13–22. [4] Bell RS, Vo AH, Neal CJ, et al. Military traumatic brain and spinal column injury: a 5-year study of the impact blast and other military grade weaponry on the central nervous system. J Trauma 2009;66: S104–11. [5] Belmont PJ, Thomas D, Goodman GP, et al. Combat musculoskeletal wounds in a US Army Brigade Combat Team during Operation Iraqi Freedom. J Trauma 2011;71:E1–7. [6] Cross JD, Ficke JR, Hsu JR, et al. Battlefield orthopaedic injuries cause the majority of long term disabilities. J Am Acad Orthop Surg 2011;19:S1–7. [7] Owens BD, Kragh JF Jr, Wenke JC, et al. Battle wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 2008;64: 295–9.
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[8] Pirouzmand F. Epidemiological trends of spine and spinal cord injuries in the largest Canadian adult trauma center from 1986 to 2006. J Neurosurg Spine 2010;12:131–40. [9] Prasad VS, Schwartz A, Bhutani R, et al. Characteristics of injuries to the cervical spine and spinal cord in polytrauma patient population: experience from a regional trauma unit. Spinal Cord 1999;37:560–8. [10] Kattail D, Furlan JC, Fehlings MG. Epidemiology and clinical outcomes of acute spine trauma and spinal cord injury: experience from a specialized spine trauma center in Canada in comparison with a large national registry. J Trauma 2009;67:936–43. [11] Dodwell ERR, Kwon BK, Hughes B, et al. Spinal column and spinal cord injuries in mountain bikers: a 13-year review. Am J Sports Med 2010;38:1647–52. [12] Belmont PJ Jr, Goodman GP, Waterman B, et al. Disease and nonbattle injuries sustained by a U.S. Army Brigade Combat Team during Operation Iraqi Freedom. Mil Med 2010;175:469–76. [13] Atlas of injuries in the U.S. Armed Forces. Mil Med 1999;164 (8 Suppl):S1–89. [14] American Spinal Injury Association/International Medical Society of Paraplegia. International standards for neurological classification of spinal cord injury. Chicago, IL: American Spinal Injury Association; 2002. [15] Owens BD, Kragh JF Jr, Macaitis J, et al. Characterization of extremity wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma 2007;21:254–7. [16] Masini BD, Waterman SM, Wenke JC, et al. Resource utilization and disability outcome assessment of combat casualties from Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma 2009;23:261–6. [17] Schoenfeld AJ, Goodman GP, Belmont PJ. Characterization of combat-related spinal injuries sustained by a US Army Brigade Combat Team during Operation Iraqi Freedom. Spine J 2012;12:771–6. [18] Ragel BT, Allred CD, Brevard S, et al. Fractures of the thoracolumbar spine sustained by soldiers in vehicles attacked by improvised explosive devices. Spine 2009;34:2400–5. [19] Ramasamy A, Midwinter M, Mahoney P, Clasper J. Learning the lessons from conflict: pre-hospital cervical spine stabilisation following ballistic neck trauma. Injury 2009;40:1342–5. [20] Helgeson MD, Lehman RA Jr, Cooper P, et al. Retrospective review of lumbosacral dissociation injuries in blast injuries. Spine 2011;36: E469–75. [21] Chipman JG, Deuser WE, Beilman GJ. Early surgery for thoracolumbar spine injuries decreases complications. J Trauma 2004;56:52–7. [22] McLain RF, Benson DR. Urgent surgical stabilization of spinal fractures in polytrauma patients. Spine 1999;24:1646–54.
Review Article
Are spine injuries sustained in battle truly different? James A. Blair, MDa,*, Jeanne C. Patzkowski, MDa, Andrew J. Schoenfeld, MDb, Jessica D. Cross Rivera, MDa, Eric S. Grenier, MDa, Ronald A. Lehman, MDc, Joseph R. Hsu, MDd, Skeletal Trauma Research Consortium (STReC)d a Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, Fort Sam Houston, TX 78234, USA Department of Surgery, Orthopaedics Service, William Beaumont Army Medical Center, 5005 North Piedras St, El Paso, TX 79920, USA c Department of Orthopaedics and Rehabilitation, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA d United States Army Institute of Surgical Research, 3851 Roger Brooke Dr, Fort Sam Houston, TX 78234, USA b
Received 8 May 2011; revised 22 June 2011; accepted 7 September 2011
Abstract
BACKGROUND CONTEXT: The severity and prognosis of combat-related injuries to the spine and spine injuries sustained unrelated to direct combat have not been previously compared. Differences may have implications on tactics, treatment strategies, and directions for future research. PURPOSE: Compare the severity and prognosis of battle and nonbattle injuries to the spine. STUDY DESIGN: Retrospective study. PATIENT SAMPLE: American military personnel who were injured in a combat zone and whose medical data were abstracted in the Joint Theater Trauma Registry (JTTR). METHODS: The JTTR was queried using International Statistical Classification of Diseases, Ninth Revision codes to identify all individuals who sustained battle and nonbattle injuries to the neck, back, spinal column, or spinal cord in Operation Iraqi Freedom or Operation Enduring Freedom from October 2001 to December 2009. Medical records of all identified servicemembers were individually reviewed. Demographic information, including sex, age, military rank, date of injury, and final disposition, was obtained for all patients. Spinal injuries were categorized according to anatomic location, associated neurologic involvement, precipitating mechanism of injury (MOI), and concomitant wounds. These data points were compared for the groups battle spine injuries (BSIs) and nonbattle spine injuries (NBSIs). RESULTS: Five hundred two servicemembers sustained a total of 1,834 battle injuries to the spinal column, including 1,687 fractures (92%), compared with 92 servicemembers sustaining 267 nonbattle spinal column injuries, with 241 (90%) fractures. Ninety-one BSI servicemembers (18% of patients) sustained spinal cord injuries (SCIs) with 41 (45%) complete SCIs, compared with 13 (14% of patients) nonbattle SCIs with six (46.2%) complete injuries (p5.92). The reported MOI for 335 BSI servicemembers (66.7%) was an explosion compared with one NBSI explosive injury. Eighty-four patients (17%) sustained gunshot wounds (GSWs) in battle compared with five (5.2%) nonbattle GSWs. Fifteen patients (3.0%) sustained a battle-related fall compared with 29 (30%) nonbattle-related falls. Battle spine injury servicemembers underwent significantly higher rates of surgical interventions (p!.0001), were injured by high-energy injury mechanisms at
FDA device/drug status: Not applicable. Author disclosures: JAB: Nothing to disclose. JCP: Nothing to disclose. AJS: Nothing to disclose. JDCR: Nothing to disclose. ESG: Nothing to disclose. RAL: Grants: Defense Advanced Research Projects Agency (I, Paid directly to institution/employer), Defense Medical Research and Development Program (H, Paid directly to institution/employer). JRH: The Geneva Foundation (D, Paid directly to institution). The disclosure key can be found on the Table of Contents and at www. TheSpineJournalOnline.com. This study was conducted under a protocol reviewed and approved by the Brooke Army Medical Center Institutional Review Board and in accordance with the approved protocol. 1529-9430/$ - see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.spinee.2011.09.012
The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. The authors acknowledge the Joint Theater Trauma Registry for providing data for this study. * Corresponding author. Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, Fort Sam Houston, TX 78234, USA. Tel.: (210) 916-3410; fax: (210) 916-7323. E-mail address: [email protected] (J.A. Blair)
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a significantly greater rate (p!.0001), and demonstrated a trend toward lower neurologic recovery rates after SCI (p5.16). CONCLUSIONS: Battle spine injury and NBSI are separate entities that may ultimately have disparate long-term prognoses. Nonbattle spine injury patients, although having similar MOIs compared with civilian spinal trauma, maintain a different patient demographic. Further research must be directed at accurately quantifying the long-term disabilities of all spine injuries sustained in a combat theater, whether they are the result of battle or not. Published by Elsevier Inc. Keywords:
Spine trauma; Spinal cord injury; Battle injury; Nonbattle injury; Military
Introduction Over the past decade, the US military has been engaged in two simultaneous conflicts within the Global War on Terror. Operation Iraqi Freedom (OIF: 2003–2010) and Operation Enduring Freedom (OEF: 2001–present) combine to form the largest battlefront since the Vietnam War. As of March 2011, there have been close to 50,000 casualties, 4,632 hostile deaths, and 1,253 nonhostile deaths in OIF and OEF [1]. Previous studies regarding these conflicts have documented an increased reliance on unconventional explosive devices, elevated lethality with respect to the weapons used, and increased survivability among American and coalition forces wounded in battle [2–7]. Recent literature has demonstrated that spine injuries are among the most disabling conditions affecting wounded servicemembers [6]. Some observations suggest that battle-incurred spinal injuries are more severe than those typically encountered in civilian trauma; however, no direct comparison has previously been made. Comparisons with civilian cohorts of spine injuries may introduce demographic differences that would confound results, such as patient age, pretrauma activity level, and mechanism of injury (MOI) [7–12]. A case-control analysis between groups of similar demographic and health status would allow a more refined determination of the influence of combat-related spinal trauma on outcome. Specifically, differences between soldiers who sustain spine injuries outside combat and those with war-related spinal trauma may have a substantial impact on future directions for warrior protection, tactics, treatment, and research. The purpose of this study is to compare the severity and prognosis of spinal injuries sustained by American military personnel during battle and in a nonbattle environment.
Classification of Diseases, Ninth Revision codes that were searched can be found in the Table. All patient medical records were individually abstracted by four reviewers (JAB, JCP, JDC, and ESG) for relevant data. Patients were excluded if medical records describing an injury to the spinal column or spinal cord could not be verified or if adequate documentation was not obtainable. Battle and nonbattle injuries were identified based on documentation in the patient’s medical records using the US Armed Forces Atlas of Injuries [13] definition of ‘‘battle injury:’’ any casualty incurred as the direct result of hostile action sustained in combat or sustained going to or from a combat mission. Included are persons killed or wounded accidentally by friendly fire directed at a hostile force or what was thought to be a hostile force. Anyone within this group was deemed a battle spine injury (BSI). The comparison group included individuals injured while in the theater of operations but not fitting into the criteria for ‘‘battle injury.’’ As per the US Armed Forces Atlas of Injuries [13], the following injuries are not battle casualties: self-inflicted wounds (except in unusual cases) and wounds or death inflicted by a friendly force while the soldier is absent without leave, dropped from the rolls, or is a voluntary absentee from his or her place of duty. Anyone within this group was deemed a nonbattle spine injury (NBSI). Injuries were classified and compared according to anatomic location, reported MOI, actual direct MOI, and concomitant injuries. Neurologic involvement was graded according to the criteria of the American Spinal Injury Association (ASIA) [14] whenever possible. Focused Table Joint Theater Trauma Registry ICD-9 search terms ICD-9 codes used for patient search
Methods After approval from the institutional investigational review board, the Joint Theater Trauma Registry (JTTR) [7] was queried via International Statistical Classification of Diseases, Ninth Revision codes for all US servicemembers serving in OIF or OEF sustaining injuries to the back, spinal cord, and spinal column from October 2001 to December 2009. The specific International Statistical
192, 225 336 721–724 805 806 839 876 952
ICD-9 interpretation Cauda equina syndrome Unspecified disease of spine Other spinal disorders and intervertebral disc disorders Spine fracture Spine fracture with cord injury Spine dislocation Open wound of back Spinal cord injury
ICD-9, International Statistical Classification of Diseases, Ninth Revision.
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comparisons were made for data points related to the severity of the injury and the prognosis between the BSIs and NBSIs groups. All data were securely stored in the Skeletal Trauma Research Consortium Spine Database using Microsoft Access Database 2007 (Microsoft Corporation, Seattle, WA, USA). A Student t test was used to detect significant differences between groups, with a p value of .05 identified as the threshold for significance.
Results Between October 2001 and December 2009, 10,979 evacuated battle casualties were registered in the JTTR. Among these 10,979 individuals, 598 sustained spine injuries. Five hundred two servicemembers (84%) sustained 1,834 battle-related spine injuries (87% of all spine injuries), resulting in an average of 3.7 spine injuries per patient. The remaining 96 servicemembers (16%) sustained 267 nonbattle-related injuries (13% of all spine injuries), resulting in an average of 2.8 spine injuries per patient. The average age at the time of injury was 26.3 (range, 18–56) and 27.3 (range, 19–56) for the BSI and NBSI cohorts, respectively. Ninety-eight percent of the BSI cohort were males (n5496) and 90% (n5452) were enlisted, whereas 92% of the NBSI cohort were males (n588) and 92% were enlisted (n588). The mean rank for battle- and nonbattle-injured enlisted servicemembers was E-5 (Sergeant). The mean rank for battle-injured officers was O-3 (Captain), whereas it was O-4 (Major) for nonbattleinjured officers. Explosive mechanisms accounted for 336 of 598 (56%) of all spine injuries, of which 335 (99.7%) were sustained in battle (p!.0001). The single nonbattle explosion causing a spine injury was because of a tire explosion. A total of 175 servicemembers (29.2% of all spine-injured patients) sustained spine injuries caused by motor vehicle collisions. Of these, 123 (73.2% of servicemembers injured by motor vehicle collisions and 24.5% of all BSIs) were battle related and 52 were nonbattle related (31.1% of servicemembers injured by motor vehicle collisions [p!.0001] and 54% of all NBSIs). Gunshot wounds were responsible for spine injuries to 89 servicemembers (14.9% of all spine-injured servicemembers), and 94% (n584/89) of these were sustained in combat (p5.009), which accounts for 16.7% (n584/502) of all BSIs and 5.2% of all NBSIs (n55/96). Falls from height accounted for 44 (7.4%) spine injuries among all servicemembers with 34% (n515) of falls occurring in battle (3.0% of all BSIs) and 66% (n529, 30.2% of all NBSIs) of falls related to the nonbattle environment (p!.0001). The anatomic distribution of spine injuries was comparable between the battle and nonbattle cohorts, with an increasing incidence of injury from cephalad to caudad. Within the cervical spine, 82% (n5262) of injuries were
battle related and 18% (n557) were nonbattle related. This comprised 14% of all spine injuries in the BSI cohort and 21% of all spine injuries in the NBSI cohort (p5.003). Battle spine injury constituted 86% (n5511) of thoracic injuries compared with 14% (n580) of NBSI. Thoracic spine injuries were documented in 28% of BSI and 30% of NBSI (p5.53). Battle spine injurie represented 88% (n5758) of all lumbar spine fractures, whereas NBSI represented 12% (n599) of lumbar spine fractures (p5.015). There were 210 (11%) BSIs and 20 (7%) NBSIs to the sacrum (p5.048) (Fig. 1). Transverse process fractures were the most commonly documented injuries for BSI, identified in 223 battle servicemembers (44%) (Fig. 2), and the second most common nonbattle injury was found in 35 nonbattle servicemembers (36%) (Fig. 3). Twenty-four servicemembers (11% of servicemembers sustaining transverse process fractures) sustained transverse process fractures to the cervical spine with 20 considered BSIs and four considered NBSIs. Thoracic transverse process fractures were sustained by 64 servicemembers (29% of servicemembers sustaining transverse process fractures) with 89% considered BSIs (n557/ 64). Lumbar transverse process fractures were sustained by 205 servicemembers (92% of servicemembers sustaining transverse process fractures), of which 176 were BSIs and 29 were NBSIs. Of these 205 servicemembers sustaining lumbar transverse process fractures, 47 (23%) involved the L5 vertebral level (42 BSIs and 7 NBSIs). Compression fractures were the next most common injuries for BSI, whereas they were the most common injuries for NBSI (battle: 34% [n5171] and nonbattle: 41% [n536]). Burst fractures were the third most common injuries within both cohorts (battle: 26% [n5123] and nonbattle: 17% [n516]). One hundred sixty-three (32%, n5163/502) BSI servicemembers underwent an operative intervention for their
Fig. 1. Anatomic distribution of spine injuries sustained in Operation Iraqi Freedom and Operation Enduring Freedom.
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Fig. 2. Battle spine injuries sustained in Operation Iraqi Freedom and Operation Enduring Freedom. Fx, fracture.
spinal injuries either at Landstuhl Regional Medical Center or in the United States, compared with only 19 (20%) of those NBSIs (p!.0001). One hundred seventeen (23%) BSI servicemembers received spinal instrumentation compared with 16 (17%) NBSI servicemembers (p!.0001). Arthrodesis was performed on 129 (26%) BSI servicemembers compared with 15 (16%) NBSI servicemembers (p!.0001). A spinal decompression was performed on 98 (20%) BSI servicemembers compared with 10 (10%) NBSI servicemembers (p!.0001). Forty-eight BSI and six NBSI servicemembers did not have documentation of their treatment. Spinal cord injuries (SCIs) were sustained by 13 (5%) NBSI servicemembers compared with 91 (5%) in the BSI group (p5.92). Of the 13 nonbattle SCIs, six were complete SCIs, whereas 41 of 91 (45%) of the SCIs sustained in battle were complete injuries. Initial ASIA grades were available for 77 battle spine–injured servicemembers and eight nonbattle spine–injured patients. At least one follow-up ASIA grade was available for 53 battle-injured servicemembers and six nonbattle-injured servicemembers. Of the 53 battle-injured servicemembers with follow-up ASIA
grades, 26 (49%) had an improved ASIA grade on followup with six of these servicemembers regaining full neurologic function below the level of injury (ASIA E). Nineteen of the 26 (73%) that demonstrated improved ASIA grade at follow-up had undergone a surgical intervention. There was a significantly higher rate of neurologic improvement for servicemembers undergoing a surgical intervention after a nonbattle injury (75%, n53/4) versus a surgical intervention after a battle injury (50%, n519/38) (p5.0068). There was no significant difference between the rates of neurologic improvement between battle (n57/12) and nonbattle (n51/2) groups treated nonoperatively (p5.12) Four of the six patients with a normal ASIA grade at follow-up had also received surgery. Four nonbattle-injured servicemembers had an improved ASIA grade at follow-up, and three of these had undergone a surgical intervention. Twenty-six (49%) BSI servicemembers and two NBSI servicemembers had no change in their ASIA grade over the course of follow-up. Only one servicemember (battle injured) was found to have a decline in neurologic status over the course of treatment.
Fig. 3. Nonbattle spine injuries sustained in Operation Iraqi Freedom and Operation Enduring Freedom. Fx, fracture.
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Discussion As participants in the Global War on Terrorism, US military personnel have been deployed to two separate theaters in Iraq and Afghanistan. The nature and epidemiology of battle wounds sustained during OIF and OEF have been described on both general [2,7,15] and unit-specific scales [5]. Although these reports have demonstrated the substantial incidence of musculoskeletal injuries and extensive musculoskeletal burden of disease [16], few studies have specifically addressed injuries to the spinal column [17,18]. Furthermore, to date, no study has examined prognostic differences between combat-related and nonbattle spinal trauma. The present investigation is the first to directly compare differences between spinal trauma sustained as a result of battle versus those occurring in the nonbattle environment. The findings in this report indicate that the overall incidence of spinal column and SCIs during OEF/OIF is 5.45%, 83% of which are the result of battle injuries, whereas 17% occurred outside battle. The vast majority of all spine injuries in both cohorts were fractures. As expected, most BSIs were sustained as a result of explosions, gunshot wounds, and motor vehicle collisions, whereas NBSIs occurred primarily as the result of motor vehicle collisions and falls from height. Surprisingly, whether injured in battle or not, the anatomic location of injuries was similar between groups. Moreover, no significant differences in the incidence of SCI as a whole, or the rate of complete SCI, were encountered between cohorts. Significantly higher rates of vertebral arthrodeses, spinal instrumentation, and decompression were noted in the BSI group. However, it seems plausible that the higher rate of surgical intervention and the use of internal fixation and arthrodesis is indicative of more substantial spinal injuries in the BSI group. Greater degrees of spinal instability and a high-energy MOI may also be responsible for the decreased rate of neurologic improvement after surgical intervention among those with SCI. The findings in this study are consistent with the reports of previous works. Schoenfeld et al. [17] reported a 7.4% incidence of spine injuries among soldiers in a US Army Brigade Combat Team, which closely approximates the overall incidence reported here. Belmont and Goodman [3] evaluated the same Brigade Combat Team for disease nonbattle injuries during the unit’s deployment and found a 10% incidence of spinal conditions. Lumbago was the most common complaint, followed by cervicalgia, thoracic pain, and degenerative disc conditions. Contrary to our study, there were no fractures or SCIs reported. The vast majority of these individuals returned to duty without medical evacuation and do not provide a meaningful comparison to our population, where every servicemember was evacuated for medical reasons. The large proportion of battle injuries because of explosive mechanisms is consistent with prior works describing injuries sustained in OIF and OEF [3,7,15,17–20].
With respect to the civilian literature, it is evident that active duty servicemembers sustaining NBSI in a hostile environment are not comparable to the standard spine-injured patient in a trauma setting. In Pirouzmand’s [8] analysis of more than 2,800 civilian trauma patients sustaining spine injuries, several differences are noted when compared with the present analysis. Foremost, patients were older than the average NBSI servicemember and the male:female injury ratio was markedly higher than the 8% reported in the current effort. Similar, however, was the high rate of motor vehicle collisions as the principal MOI and resultant rates of SCI. However, when one considers civilians sustaining spinal injuries in conjunction with polytrauma, similarities appear more readily. For example, in their analysis of patients with thoracolumbar spine injuries and injury severity scores greater than 15, Chipman et al. [21] reported an average patient age comparable to that documented in the present work. Similarly, they found the incidence of substantial neurologic improvement to be poor in their high injury severity score spine injury cohort. Likewise, the study of McLain and Benson [22], investigating outcomes among 27 individuals with spinal fractures and associated polytrauma, documented a 7% mortality and only fair neurologic improvement after surgery, ranging from 0.2 to 1.5 Frankel grades. Several limitations to this study should be noted. This study is dependent on data entered in the JTTR, a database that was only initiated at the beginning of the Global War on Terror. Therefore, many casualties that occurred early in OIF and OEF were not logged in the database. Similarly, as this is a registry study, the details of this work are entirely dependent on the quality of data entered in the JTTR. Servicemembers whose spinal injuries were not documented, or miscoded, may not be represented in this analysis. Furthermore, as information regarding combat wounds resulting in death is not recorded in the JTTR, the complete scope of combat-related spinal injuries is not represented in this investigation. Along these same lines, the current analysis excludes spinal conditions, such as herniated discs, radiculopathy, spondylolisthesis, or degenerative disease, that did not result in a servicemember’s evacuation from theater. Consequently, our assessment of the total burden of nonbattle-related spinal conditions is underestimated and represents a worst-case scenario. However, we chose to include only acute traumatic conditions to garner a more meaningful direct comparison with the cohort injured in combat. Although the results of this study emphasize the tremendous burden spine injuries incurred on the battlefield have on military personnel, nonbattle spine injuries also impact the fighting force during an armed conflict. Battle and nonbattle spine injuries impart substantial disability, with longterm ramifications for wounded servicemembers, their families, the military, and the Veterans’ Administration system [3,6]. The results presented in this analysis emphasize that battle and nonbattle spine injuries are clearly
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separate entities and should not be considered together in further research, although such injuries may arise in the same operational theater. Furthermore, battle and nonbattle spine injuries sustained during military conflicts, and the population in which they occur, are most comparable to severe spinal injuries sustained in conjunction with polytrauma among civilians [21,22]. As civilian research among such a select population is exceedingly difficult to conduct, further work among military patients with war-related spinal injuries may have important implications for future best practices in the civilian sector. Ultimately, more work of a prospective nature must be conducted on the epidemiology, management, and outcome of both battle and nonbattle spine injuries before more definitive recommendations, or treatment algorithms, can be devised. References [1] Directorate for Information Operations and Reports. Department of Defense. Available at: http://siadapp.dmdc.osd.mil/personnel/CASUALTY/ castop.htm. Accessed March 27, 2011. [2] Covey DC. From the frontlines to the home front: the crucial role of military orthopaedic surgeons. J Bone Joint Surg Am 2009;91: 998–1006. [3] Belmont PJ Jr, Goodman GP. The combat environment and epidemiology of musculoskeletal combat casualties. In: Owens BD, Belmont PJ, eds. Combat orthopaedic surgery: lessons learned in Iraq and Afghanistan. Thorofare, NJ: Slack Incorporated; 2011:13–22. [4] Bell RS, Vo AH, Neal CJ, et al. Military traumatic brain and spinal column injury: a 5-year study of the impact blast and other military grade weaponry on the central nervous system. J Trauma 2009;66: S104–11. [5] Belmont PJ, Thomas D, Goodman GP, et al. Combat musculoskeletal wounds in a US Army Brigade Combat Team during Operation Iraqi Freedom. J Trauma 2011;71:E1–7. [6] Cross JD, Ficke JR, Hsu JR, et al. Battlefield orthopaedic injuries cause the majority of long term disabilities. J Am Acad Orthop Surg 2011;19:S1–7. [7] Owens BD, Kragh JF Jr, Wenke JC, et al. Battle wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 2008;64: 295–9.
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[8] Pirouzmand F. Epidemiological trends of spine and spinal cord injuries in the largest Canadian adult trauma center from 1986 to 2006. J Neurosurg Spine 2010;12:131–40. [9] Prasad VS, Schwartz A, Bhutani R, et al. Characteristics of injuries to the cervical spine and spinal cord in polytrauma patient population: experience from a regional trauma unit. Spinal Cord 1999;37:560–8. [10] Kattail D, Furlan JC, Fehlings MG. Epidemiology and clinical outcomes of acute spine trauma and spinal cord injury: experience from a specialized spine trauma center in Canada in comparison with a large national registry. J Trauma 2009;67:936–43. [11] Dodwell ERR, Kwon BK, Hughes B, et al. Spinal column and spinal cord injuries in mountain bikers: a 13-year review. Am J Sports Med 2010;38:1647–52. [12] Belmont PJ Jr, Goodman GP, Waterman B, et al. Disease and nonbattle injuries sustained by a U.S. Army Brigade Combat Team during Operation Iraqi Freedom. Mil Med 2010;175:469–76. [13] Atlas of injuries in the U.S. Armed Forces. Mil Med 1999;164 (8 Suppl):S1–89. [14] American Spinal Injury Association/International Medical Society of Paraplegia. International standards for neurological classification of spinal cord injury. Chicago, IL: American Spinal Injury Association; 2002. [15] Owens BD, Kragh JF Jr, Macaitis J, et al. Characterization of extremity wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma 2007;21:254–7. [16] Masini BD, Waterman SM, Wenke JC, et al. Resource utilization and disability outcome assessment of combat casualties from Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma 2009;23:261–6. [17] Schoenfeld AJ, Goodman GP, Belmont PJ. Characterization of combat-related spinal injuries sustained by a US Army Brigade Combat Team during Operation Iraqi Freedom. Spine J 2012;12:771–6. [18] Ragel BT, Allred CD, Brevard S, et al. Fractures of the thoracolumbar spine sustained by soldiers in vehicles attacked by improvised explosive devices. Spine 2009;34:2400–5. [19] Ramasamy A, Midwinter M, Mahoney P, Clasper J. Learning the lessons from conflict: pre-hospital cervical spine stabilisation following ballistic neck trauma. Injury 2009;40:1342–5. [20] Helgeson MD, Lehman RA Jr, Cooper P, et al. Retrospective review of lumbosacral dissociation injuries in blast injuries. Spine 2011;36: E469–75. [21] Chipman JG, Deuser WE, Beilman GJ. Early surgery for thoracolumbar spine injuries decreases complications. J Trauma 2004;56:52–7. [22] McLain RF, Benson DR. Urgent surgical stabilization of spinal fractures in polytrauma patients. Spine 1999;24:1646–54.