Article

Characterization of spinal injuries sustained by American service members killed in Iraq and Afghanistan

and Statistical Consulting Laboratory (J.O.B.), University of Texas at El Paso, El Paso, Texas.
The journal of trauma and acute care surgery 04/2013; 74(4):1112-8. DOI: 10.1097/TA.0b013e31828273be
Source: PubMed
ABSTRACT
This study sought to characterize spine injuries among soldiers killed in Iraq or Afghanistan whose autopsy results were stored by the Armed Forces Medical Examiner System.
The Armed Forces Medical Examiner System data set was queried to identify American military personnel who sustained a spine injury in conjunction with wounds that resulted in death during deployment in Iraq or Afghanistan from 2003 to 2011. Demographic and injury-specific characteristics were abstracted for each individual identified. The raw incidence of spinal injuries was calculated and correlations were drawn between the presence of spinal trauma and military specialty, mechanism and manner of injury, and wounds in other body regions. Significant associations were also sought for specific injury patterns, including spinal cord injury, atlantooccipital injury, low lumbar vertebral fractures, and lumbosacral dissociation. Statistical calculations were performed using χ statistic, z test, t test with Satterthwaite correction, and multivariate logistic regression.
Among 5,424 deceased service members, 2,089 (38.5%) were found to have sustained at least one spinal injury. Sixty-seven percent of all fatalities with spinal injury were caused by explosion, while 15% occurred by gunshot. Spinal fracture was the most common type of injury (n = 2,328), while spinal dislocations occurred in 378, and vertebral column transection occurred in 223. Fifty-two percent sustained at least one cervical spine injury, and spinal cord injury occurred in 40%. Spinal cord injuries were more likely to occur as a result of gunshot (p < 0.001), while atlantooccipital injuries (p < 0.001) and low lumbar fractures (p = 0.01) were significantly higher among combat specialty soldiers. No significant association was identified between spinal injury risk and the periods 2003 to 2007 and 2008 to 2011, although atlantooccipital injuries and spinal cord injury were significantly reduced beginning in 2008 (p < 0.001).
The results of this study indicate that the incidence of spinal trauma in modern warfare seems to be higher than previously reported.
Epidemiologic study, level III.

Full-text

Available from: Brian R Waterman
Characterization of spinal injuries sustained by American
service members killed in Iraq and Afghanistan: A study
of 2,089 instances of spine trauma
Andrew J. Schoenfeld, MD, Ronald L. Newcomb, DO, Mark P. Pallis, DO, Andrew W. Cleveland, III, MD,
Jose A. Serrano, MD, Julia O. Bader, PhD, Brian R. Waterman, MD,
and Philip J. Belmont, Jr., MD, El Paso, Texas
BACKGROUND: This study sought to characterize spine injuries among soldiers killed in Iraq or Afghanistan whose autopsy results were stored
by the Armed Forces Medical Examiner System.
METHODS: The Armed Forces Medical Examiner System data set was queried to identify American military personnel who sustained a
spine injury in conjunction with wounds that resulted in death during deployment in Iraq or Afghanistan from 2003 to 2011.
Demographic and injury-specific characteristics were abstracted for each individual identified. The raw incidence of spinal
injuries was calculated and correlations were drawn between the presence of spinal trauma and military specialty, mechanism
and manner of injury, and wounds in other body regions. Significant associations were also sought for specific injury patterns,
including spinal cord injury, atlantooccipital injury, low lumbar vertebral fractures, and lumbosacral dissociation. Statistical
calculations were performed using W
2
statistic, z test, t test with Satterthwaite correction, and multivariate logistic regression.
RESULTS: Among 5,424 deceased service members, 2,089 (38.5%) were found to have sustained at least one spinal injury. Sixty-seven
percent of all fatalities with spinal injury were caused by explosion, while 15% occurred by gunshot. Spinal fracture was the
most common type of injury (n = 2,328), while spinal dislocations occurred in 378, and vertebral column transection occurred
in 223. Fifty-two percent sustained at least one cervical spine injury, and spinal cord injury occurred in 40%. Spinal cord in-
juries were more likely to occur as a result of gunshot ( p G 0.001), while atlantooccipital injuries ( p G 0.001) and low lumbar
fractures ( p = 0.01) were significantly higher among combat specialty soldiers. No significant association was identified be-
tween spinal injury risk and the periods 2003 to 2007 and 2008 to 2011, although atlantooccipital injuries and spinal cord
injury were significantly reduced beginning in 2008 ( p G 0.001).
CONCLUSION: The results of this study indicate that the incidence of spinal trauma in modern warfare seems to be higher than previously
reported. (J Trauma Acute Care Surg. 2013;74: 1112Y1118. Copyright * 2013 by Lippincott Williams & Wilkins)
LEVEL OF EVIDENCE: Epidemiologic study, level III.
KEY WORDS: Spinal injury; battle injury; combat; epidemiology.
I
n 1865, at the end of the American Civil War, Surgeon General
Joseph Barnes charged a member of his staff, Assistant Sur-
geon George Otis, with the task of cataloguing the extent of
combat-related trauma sustained by soldiers during the course of
the conflict.
1
Appreciating that as much, if not more, regarding
war trauma could be gleaned from service members who did
not survive their combat-related injuries, Otis compendium,
The Medical and Surgical History of the War of the Rebellion
2
and its companion piece, Surgical Cases Treated in the Army
of the United States from 1865Y1871,
3
included the results
of autopsies performed on deceased soldiers whenever possible.
Unfortunately, for a number of reasons including casualty vol-
ume, no study similar to that conducted by Otis following the
Civil War was published for either of the World Wars, Korea,
or Vietnam.
1,4Y7
At present, the 11 years of continuous conflict in the com-
bined battlefronts of Iraq and Afghanistan represent the longest
military engagement in the history of the United States.
4,8Y10
As of this writing, 56,351 casualties have been sustained by
the American military in Iraq and Afghanistan, with more than
3,500 hostile deaths incurred in Iraq alone.
11
During the last de-
cade, numerous initiativ es hav e facilitated the most comprehen-
siv e study of combat casualties in the history of American
military medicine.
1,4,8Y10,12Y21
Nonetheless, substantial questions
remain concerning the scope and nature of combat-rela ted spinal
injuries. A combination of the enem y’s extensi v e use of explosiv e
ORIGINAL ARTICLE
J Trauma Acute Care Surg
Volume 74, Number 4
1112
Submitted: September 21, 2012, Revised: October 29, 2012, Accepted: October
31, 2012.
From the Department of Orthopaedic Surgery (A.J.S., R.L.N., M.P.P., A.W.C.,
J.A.S., B.R.W., P.J.B.), William Beaumont Army Medical Center, Texas Tech
University Health Sciences Center; and Statistical Consulting Laboratory
(J.O.B.), University of Texas at El Paso, El Paso, Texas.
Some authors are employees of the US Federal Government and the United States
Army. The opinions or assertions contained herein are the private views of the
authors and are not to be construed as official or reflecting the views of William
Beaumont Army Medical Center, the Department of Defense, or United States
government. Data presented in this investigation are derived from the AFMES.
The AFMES is not responsible for any claims arising from works based on the
original data.
Address for reprints: Andrew J. Schoenfeld, MD, Department of Orthopaedic Sur-
gery, William Beaumont Army Medical Center, Texas Tech University Health
Sciences Center, 5005 N. Piedras St, El Paso, TX 79920; email: ajschoen@
neomed.edu.
DOI: 10.1097/TA.0b013e31828273be
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Page 1
dev ices against armored vehic les and enhanced surviv ability
among combat injured have culminated in a higher incidence
of spinal trauma compared with previous wars,
4,13Y15,20,21
as well as novel wounding patterns such as low lumbar burst
fractures
17
and lumbosacral dissociations.
16
Indeed, the only prospective longitudinal cohort focusing
on combat-related spinal trauma in Iraq maintained an inci-
dence of 7.4%,
20
the highest such statistics reported for the
American military in the modern period.
21
In another study,
Blair et al.
13
documented the rate of combat-related spine trauma
to approximate 5.5%. However, as Blair et al. and other authors
have recognized, major limitations to such works rest in the ab-
sence of autopsy data characterizing the prevalence and extent of
spine trauma among soldiers who succumb to their wounds.
14,20
The study of Blair et al.
13
was limited to personnel who survived
their war injuries, while Schoenfeld et al.
20
included information
on only 8 of 27 service members killed in action.
The present study endeavored to characterize spine inju-
ries among service members who were killed in Iraq and
Afghanistan and whose autopsy data were stored by the Armed
Forces Medical Examiner System (AFMES). Since 2003, the re-
mains of nearly all American military personnel killed in a com-
bat theater have received a postmortem examination, the results
of which are stored by the AFMES.
10,22
Information from the
AFMES has been used in previous studies regarding war trau-
ma,
10,22
and similar initiativ es have been performed for the ci vil-
ian sector.
23Y26
Ho wev er, pre vious w orks ha v e neither addressed
the type of spine woun ds sustained by deceased service members
nor have any systematically examined the entire AFMES data
set to ev aluate any particular category of injury. Using the data
set from 2003 to 2011, this study intended to catalog the scope
of spine trauma sustained by deceased personnel and describe im-
portant associations that exist between the types of injuries
sustained, associated w ounds, injury mechanisms, and the year
and location of woundin g (e.g., Iraq or Afghanistan).
PATIENTS AND METHODS
This study received approval from our institution’s inves-
tigational review board and was also approved by separate ap-
plication to the AFMES before commencement. The AFMES
data set for the period from 2003 to 2011 was queried to iden-
tify all US military service members who sustained a spine in-
jury in conjunction with wounds that resulted in death during
deployment to Iraq or Afghanistan. Neither soldiers who were
killed in other areas of operations nor individuals who were
wounded in theater and subsequently died after they were
evacuated and treated in medical facilities outside of Iraq or
Afghanistan were included in this study. Civilians, enemy sol-
diers, and service members from allied nations were similarly
excluded, as were personnel with autopsy findings limited to
total body charring or total body fragmentation.
The raw data set of service members identified in the ini-
tial query were evaluated by a series of investigators (A.J.S.,
R.L.N., A.W.C., J.A.S., B.R.W.) to ensure the presence of spinal
injuries. Soldiers without documented spinal trauma in their au-
topsy results were subsequently excluded from further analysis.
Final results were reviewed by a panel of physicians with deploy-
ment experience in support of medical operations (A.J.S., M.P.P.,
P.J.B.) and previous service with combat units (M.P.P., J.A.S.) to
ensure plausibility and identify apparent discrepancies. Any in-
consistencies were resolved by review of autopsy records and
mutual agreement between investigators.
For each individual whose record was included in the fi-
nal data set, the following information was available: sex, age,
military rank, military specialty, manner of injury, injury mech-
anism, location and year of injury, Injury Severity Score (ISS),
type of spinal injury (e.g., fracture, dislocation, etc.) and level,
presence of spina l cord injury, and associated wounds. Military
rank was organized according to groups consisting of junior en-
listed (lowest four military ranks in any branch), senior enlisted
(noncommissioned officers of any branch), junior officers (low-
est three officer ranks in any branch), and senior officers (highest
six ranks in any branch). Military specialty was defined as com-
bat or noncombat, based on accepted military designations,
while manner of injury was classified as combat or accident,
based on similar military definitions.
4,5,8,12Y14,20
The location
of injury was categorized as either Iraq or Afghanistan.
Statistical Analysis
The raw incidence of spinal injuries was calculated by
comparing the number of service members identified as having
sustained spinal trauma to the entire AFMES cohort. Descriptive
associations were drawn between the presence of spinal trauma
and military specialty, mechanism and manner of injury, and
wounds in other body regions as described by Churchill.
5,8
The Churchill system classifies wounds by body region (e.g.,
the head and neck, thorax, extremities) and facilitates compari-
sons with other military studies.
4,5,8,12
Owing to a high prevalence in the cohort or publications
highlighting a predilection for such wounding patterns among
the combat injured,
16,17
the following specific injuries were se-
lected for further statistical consideration: spinal cord injury,
atlantooccipital injury, low lumbar vertebral fractures, and lum-
bosacral dissociation. Statistically significant correlations were
sought between these specific injuries and injury mechanism,
military specialty, manner of injury, location, and year of injury.
Because previous works have linked the prevalence of spinal
trauma to the use of up-armored military vehicles in Iraq and
Afghanistan,
9,16Y18
comparisons regarding year of injury w ere
made betw een the periods 2003 and 2007 (before the introduction
of up-armored ve hicles)
27
and 2008 and 2011 (when up-armored
vehicles became standardized among American combat units).
27
While the enhanced protection afforded by up-armored vehicles
against explosiv e blasts ma y diminish the risk of lethal injury,
27
some authors ha v e theorized that the blas t mechanism ele v ates
the risk of lumbar fractures and spinopelvic trauma.
16Y18
Statistical determinations for categorical data were made
using the W
2
statistics or a z test, when appropriate. Analyses re-
garding location of injury were performed using a t test with
Satterthwaite correction. Multivariate analysis was subsequently
used to control for all factors present in the model. Statistical sig-
nificance was set, a priori, for all calculations at p G 0.05. Only
associations that maintained significance in univariate and mul-
tivariate analyseswere considered statistically important. All sta-
tistics were performed using SAS version 9.2 (SAS Institute,
Cary, NC).
J Trauma Acute Care Surg
Volume 74, Number 4 Schoenfeld et al.
* 2013 Lippincott Williams & Wilkins 1113
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Page 2
RESULTS
Demographic and Injury-Related Characteristics
In the period from 2003 to 2011, 5,424 American service
members killed in theater had their autopsy records document-
ed by the AFMES, representing 86% of all recorde d fatalities
(Fig. 1). Following panel review, 2,089 (38.5%) service member
fatalities with at least one spinal injury were identified. Among
these, 3,691 distinct vertebral column injuries were present. The
average age of the cohort was 26.6 years (range, 18Y59 years),
and 98% of the soldiers were male (Table 1). More than half of
the service members were junior enlisted. Eighty-percent of sol-
diers possessed a combat-related military specialty, and 87% of
all deaths were sustained in combat. The mean (SD) ISS of sol-
diers in the data set was 57.4 (19).
Sixty-three percent (n = 1,317) of all spine injuries occurred
in Iraq. The incidence of spinal trauma peaked in 2007, with 390
cases occurring during the course of that year (Fig. 2). The most
common mechanism of injury was an explosion (e.g., improvised
explosive de vice, rocket-propelled grenade, or mine), accounting
for 67% of deaths in the cohort (Table 1). Gunshot was the second
most common cause of injury, identified in 15%.
Characteristics of Spinal Injuries
Overall, fracture was the most common type of spinal in-
jury, with 2,328 instances identified in the cervical, thoracic,
or lumbar regions (Tables 2 and 3). In addition, there were
375 sacral fractures. Three hundred seventy-eight spinal dislo-
cations were documented , and spinal column transection occurred
in 223 soldiers. Injuries to the atlantooccipital joint were present in
18% (n = 386) of the cohort, with the vast majority of these de-
fined as frank atlantooccipital dislocations (n = 375). Fifty-two
percent (n = 1,095) of service member fatalities with a spinal
injury sustained at least one injury in the cervical region, with
the upper cervical spine most commonly involved. C1 injuries
were present in 686 soldiers (63%), while only 285 (26%)
Figure 1. Study population relative to the total number of
soldiers killed in theater* and autopsy records contained in the
AFMES data set. *Obtained from the publicly available casualty
reporting Web site, icasualties.org. Accessed October 24, 2012.
TABLE 1. Demographic Characteristics of Service Members
With Spinal Injuries
No. Service Members With
Spinal Injury, n (%)
Sex
Male 2,044 (98)
Female 45 (2)
Rank
Junior enlisted 1,112 (53)
Senior enlisted 731 (35)
Junior officers 195 (9)
Senior officers 47 (2)
Unknown 4 (0.2)
Age, y
G30 1,545 (74)
30Y39 417 (20)
Q40 127 (6)
Military specialty
Combat 1,679 (80)
Noncombat 408 (19.5)
Unknown 2 (0.1)
Theater of injury
Iraq 1,317 (63)
Afghanistan 772 (37)
Manner of injury
Combat 1,821 (87)
Accident 268 (13)
Mechanism of injury
Gunshot 312 (15)
Explosion 1,403 (67)
Aviation 234 (11)
Other 140 (7%)
Figure 2. The annual incidence of spinal injuries among service
members killed in Iraq or Afghanistan from 2003 to 2011.
J Trauma Acute Care Surg
Volume 74, Number 4Schoenfeld et al.
1114 * 2013 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Page 3
had injuries confined to the subaxial region. A fracture was
the most frequently encountered cervical injury, recognized
in 704 individuals (64%) with cervical trauma. Cervical spine
transection occurred in 64 cases (6%).
Thoracic spinal injuries were documented in 924 in-
stances (44%). Fractures were present in 731 soldiers (79%),
and thoracic transection was reported in 107 soldiers (12%).
The thoracolumbar junction (T10YT12) was involved in 270
cases (30%). Lumbar spinal injuries occurred in 638 soldiers
(30.5%). Again, fractures were the injury most frequently en-
countered (n = 579, 91%), while there were 48 lumbar spinal
transections (7.5%). L1 was the most common level involved
(n = 316, 49.5%). Low lumbar vertebral body fractures were
identified in 165 cases (26%), and lumbosacral dissociation
in 14 instances (2%). Sacral injuries occurred in 405 individ-
uals (19%).
Injuries to the spinal cord were recorded in 834 soldiers
(40%). Injury to the cervical spinal cord was documented in
453 cases (54%), while injury was limited to the thoracic region
in 381 cases (46%). C1 was the most commonly identified level
of injury to the spinal cord (n = 113, 13.5%).
Associated Wounds by Churchill Region
The mean (SD) number of injuries sustained by each sol-
dier in the cohort was 20.6 (10.8). There was a high prevalence
of associated injuries in other Churchill regions (Fig. 3). Injuries
to the head and neck maintained the highest associated incidence
at 70%, while wounds in the abdomen and extremities had rates
exceeding 50%. Vascular injuries occurred in 49% of cases
(n = 1,023), and 188 (9%) had thermal burns.
Statistical Results
When examining the presence of spinal wounds by the-
ater and p erio d, a significantly great er number of spinal inju-
ries ( p G 0.001) occur red in Iraq (63%) as compared with
Afghanistan (37%). No significant association was identified
between the risk of spinal injury and the periods 2 003 to
2007 and 2008 to 2011 ( p = 0.2). When evaluating specific s pi-
nal injuries, spinal cord injuries were found to be m ore likely
to occur as a result of gunshot ( p G 0.001), to have transpired
in the Iraq theater ( p =0.002),andtohaveoccurredbetween
2003 and 2007 ( p G 0.001). Atlantooc cipi ta l injuri es were
significantly more frequent among soldiers with a combat spe-
cialty ( p G 0.001) and were also significantly associated with
theperiod2003to2007(p G 0.001, Table 4). Atlantooccipital
trauma was also significantly associated with explosion, avia-
tion, and other mechanisms of injury, when compared with
soldiers who did not sustain such wo unds ( p G 0.001). The in-
cidence of low lumbar vertebral body fractures was signifi-
cantly higher among combat specialty soldiers ( p =0.01),
and although the raw numbe rs for this condition were greater
among se rvi ce members from Iraq, proportionally, there was
a significantly increased risk for personnel from Afghanistan
( p = 0.04) to sustain such wounds. No significant associations
were encountered for lumbosacral dissociation. All significant
associations were maint ained in m ultivariate analysis.
DISCUSSION
For the better part of the first two hundred years of Amer-
ican military medicine, spinal injuries occurred infrequently
during war.
1,20,21
Less than 700 instances of vertebral column
injury were described during the Civil War,
2
with mortality
rates approaching 100% for any wound associa ted with spinal
cord injury.
1Y3
Owing to the circumstances of warfare and lim-
ited diagnostic capacity, the 1% incidence of combat-related
spine trauma reported for major conflicts in the mid-20th
century
4Y7,28
is almost certainly underestimated, especially
when one takes into account that these figures, generally, only
represent wounding patt erns among survivors.
In Iraq and Afghanistan, an enemy reliance on assaulting
vehicles with explosive devices, enhanced personnel protective
measures, medical advancements, and improved survivability
have led to an appreciable increase in the number of soldiers
presenting with complex spine wounds as a result of war.
4,8,
9,13,14,16,17,20,21
Although, previously, combat-related spine in-
jury rates rarely ever exceeded 1% to 2% of all trauma owing to
lower survivability,
4Y7,28,29
multiple studies have now docu-
mented a 5% to 8% incidence of spinal wounds during the Iraq
TABLE 2. Frequency of Distinct Vertebral Column Injuries
Identified Among Service Members Killed in Theater
Vertebral Column Injury, n (%)
Atlantooccipital injury 386 (10)
Fracture of the mobile spine 2,328 (63)
Sacral injury 405 (11)
Fracture/dislocation 245 (7)
Dislocation/subluxation 96 (3)
Spinal column transection 223 (6)
Other injuries 8 (0.02)
Total 3,691 (100)*
*Individual percentages do not add up to 100% owing to rounding off.
Figure 3. Incidence rates (%) of associated injuries among
service members with spinal trauma who were killed in Iraq or
Afghanistan. The raw number for each associated injury is
presented at the top of each bar with the percentage relative to
the entire cohort (n = 2,089) presented on the y axis.
J Trauma Acute Care Surg
Volume 74, Number 4 Schoenfeld et al.
* 2013 Lippincott Williams & Wilkins 1115
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Page 4
and Afghanistan conflicts.
13Y15,20
Previous works, however, are
limited by restrictive temporal focus,
15,19,20
sole consideration
of specific injuries,
16,17,19
or reliance on data from a single cen-
ter
15,19
or military unit.
20
Although the studies of Blair
et al.
13,14
entailed a more complete analysis through the use
of the Joint Theater Trauma Registry, the exclusion of woun-
ding patterns among soldiers killed in theater serves as a sub-
stantial limitation.
The present investigation explores an unexamined aspect
of the conflicts in Iraq and Afghanistan, specifically spinal in-
juries incur red by soldiers killed in theater. To the best of our
knowledge, no previous effort has systematically examined the
autopsy results of combat casualties to describe the nature, in-
cidence, and cumulative burden of war-related spine trauma.
Results of this work demonstrated that, between 2003 and
2011, 38.5% of fatalities in the AFMES data set sustained
one or more spine injuries. The most common mechanism of
injury was an explosion, cited in 67% of cases in the cohort.
Fractures of the mobile spine were overwhelmingly the most
frequent injury, but more severe wounds such as spinal dislo-
cations and trans ections were also present in substantial num-
bers. More than half of all service members sustained at least
one injury to the cervical region, and more injuries were en-
countered at the level of C1 (n = 686) than in the entirety of
the lumbar spine (n = 638).
In the general composition of our cohort; specifically
mean age, rank, mechanism of injury, and military specialties
of those involved, this work approximates most other s that have
been considered in military medical studies concerning Iraq
and Afghanis tan.
4,8,9,12Y14,20,22
Although the soldiers under
study here are markedly different from published works of ci-
vilian spinal trauma,
30
particularly in age, the types of injuries
sustained, and the extent of associated wounds, some similar-
ities are present when considering civilian autopsy studies.
23Y26
For example, the mean ISS for personnel in our work approx-
imates that of civilian gunshot victims with associated spinal
trauma.
25
In addition, while the high incidences of cervical
spine trauma, dislocation and vertebral transection reported
here are markedly different from military studies conducted
among survivors of combat injury,
13Y18,20
similar findings
are encountered in works examining wounding patterns result-
ing from both airline
23
and helicopter accidents.
26
Several novel findings include the prevalence of spine
trauma within our cohort, the high incidence of atlantooccipital
injuries, relatively diminished rates of low lumbar fractures and
TABLE 3. Frequency of Spinal Fractures Within the Mobile
Spine
Spinal Injury, n (%)
Fracture not otherwise specified 1,557 (67)
Burst fracture 42 (2)
Compression fracture 88 (4)
Transverse process fracture 394 (17)
Spinous process fracture 233 (10)
Lamina fracture 14 (0.6)
Fracture of the mobile spine (total) 2,328 (100)*
*Percentages do not add to a hundred owing to rounding off.
TABLE 4. Association of Specific Spinal Injuries With Military Specialty, Manner of Injury, Year of Injury, and Theater as Compared With Individuals Who Did Not Sustain
Such Injuries
AO Injury,
n (%)
No AO Injury,
n (%) p for AO Injury
Low
Lumbar VF,
n (%)
No Low
Lumbar VF,
n (%)
p for Low
Lumbar VF
LSD,
n (%)
No LSD,
n (%) p for LSD
SCI,
n (%)
No SCI,
n (%) p for SCI
Military specialty 0.2 0.01 0.2 0.99
Combat 302 (78) 1,377 (81) 145 (88) 1,534 (80) 13 (93) 1,666 (80) 670 (80) 1,009 (80)
Noncombat 84 (22) 324 (19) 20 (12) 388 (20) 1 (7) 407 (20) 163 (20) 245 (20)
Manner of
injury
G0.001 0.8 0.8 1.0
Combat 307 (80) 1,514 (89) 143 (87) 1,678 (87) 12 (86) 1,809 (87) 727 (87) 1,094 (87)
Accident 79 (20) 189 (11) 22 (13) 246 (13) 2 (14) 266 (13) 107 (13) 161 (13)
Year of injury G0.001 0.3 0.6 G0.001
2003Y2007 211 (55) 1,132 (66) 100 (61) 1,243 (65) 10 (71) 1,333 (64) 578 (69) 765 (61)
2008Y2011 175 (45) 571 (34) 65 (39) 681 (35) 4 (29) 742 (36) 256 (31) 490 (39)
Theater of
injury
0.06 0.04 0.5 0.002
Iraq 227 (59) 1,090 (64) 92 (56) 1,225 (64) 10 (71) 1,307 (63) 559 (67) 758 (60)
Afghanistan 159 (41) 613 (36) 73 (44) 699 (36) 4 (29) 768 (37) 275 (33) 497 (40)
AO, atlantooccipital; LSD, lumbosacral dissociation; SCI, spinal cord injury; VF, vertebral fracture.
J Trauma Acute Care Surg
Volume 74, Number 4Schoenfeld et al.
1116 * 2013 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Page 5
lumbosacral dissociation, and some of the temporal associations
that were identified. By far, the 38.5% incidence rate of spinal
injuries documented within the AFMES exceeds any previously
reported rate of spine trauma for this
13Y15,20
or any other
4Y7,28,29
military conflict. If the data from this work are combined with
previous estimates of combat-related spine injuries among sur-
vivors,
13,14
the incidence of spinal wounds sustained in theater
rests at an astonishing 12%. These findings point to the need
for vigilance on the part of first responders administering care
to combat wounded and careful scrutiny for spine-related inju-
ries. In addition, while some have maintained that the increased
incidence of spinal wounds results from the military’s use of up-
armored vehicles,
16Y18
such conclusions were not borne out in
our analysis. The standardization of up-armored vehicles among
American military units, beginning in 2008,
27
was not associat-
ed with a statistically significant increase in spinal trauma among
fatalities, while statistical reductions in atlantooccipital trauma
and spinal cord injury were appreciated.
Although low lumbar vertebral fractures and lumbosa-
cral dissociations have been heralded in previous works as in-
juries characteristic of the current military engagements,
16,17
their presence in our cohort was lower than expected (8%
and 0.7% of the entire study set, respectively). Such findings
may be influenced by the fact that most spinal fractures were
not described with sufficient detail to enable definitive charac-
terization, a limitation that has been recognized in other works
as well.
8,13,14,22
Other limitations to this effort include reliance
on a study database and dependence on patholo gists’determina-
tions when categorizing the manner , and extent, of spinal tra uma.
Errors in classification or data entry on the part of the AFMES
w ould go unrecognized, could not be controlled, and defy quan-
titation in this analysis.
Despite these limitations, however, no previous study has
systematically examined the extent of combat wounds among
casualties killed in theater, making ours a novel effort that can-
not be meaningfully qualified through comparisons to other lit-
erature. The data presented here bespeak the devastating nature
of combat-related spine trauma, with a high prevalence of as-
sociated injuries and elevated rates of expectant wounds such
as atlantooccipital dislocation and spinal column transection.
In addition, when evaluating this study in its context and in
conjunction with comparable investigations, the incidence of
spinal trauma as a result of modern warfare seems to be higher
than previously reported and continues to maintain the highest
statistic within the history of American military medicine.
AUTHORSHIP
A.J.S., R.L.N., B.R.W., and P.J.B. contributed in the study design. A.J.S.,
R.L.N., and P.J.B. performed the literature search. A.J.S., R.L.N., A.W.C.,
J.A.S., and B.R.W. performed the data collection. A.J.S., J.O.B., and P.J.B.
performed the statistical analysis. A.J.S., M.P.P., J.O.B., B.R.W., and P.J.B.
performed the data interpretation. A.J.S., R.L.N., A.W.C., J.A.S., J.O.B. wrote
the article. A.J.S., M.P.P., J.O.B., B.R.W., and P.J.B. provided critical revision.
ACKNOWLEDGMENT
We thank CDR Sean Swiatkowski, Tamara Zubko, and Lynne Oetjen-
Gerdes of the AFMES for their assistance in accessing the AFMES autopsy
data set. We also acknowledge those service members who selflessly de-
cided to serve in the all-volunteer force and made the ultimate sacrifice in
defense of the nation.
DISCLOSURE
The authors declare no conflicts of interest.
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  • [Show abstract] [Hide abstract] ABSTRACT: Previous studies regarding combat wounding have a limited translational capacity due to inclusion of soldiers from all military branches and occupational specialties as well as a lack of information regarding soldiers who died in theater. A search was performed of the Department of Defense Trauma Registry and Armed Forces Medical Examiner data set for the years 2003 to 2011 to identify all injured personnel with the military specialty 19D (cavalry scout). A manual search was conducted for each record identified, and age, rank, location and manner of injury, mechanism of injury, Injury Severity Score (ISS), and extent of wounding were abstracted. The incidence of injuries by body region and rates for specific types of wounds were determined. Statistically significant associations between rank, location of injury, manner of injury, body region involved, and injury mechanism were assessed using χ analysis. Associations between ISS, rank, manner of injury, and survival were evaluated by t test with Satterthwaite correction. A total of 701 casualties were identified with 3,189 distinct injuries. Mean (SD) age of injured personnel was 25.9 (6.0) years. Thirty-five percent of the cohort was composed of soldiers who died in theater. Explosions were the most common mechanism of injury (70%), while 18% of wounds occurred owing to gunshot. Extremity wounds and injuries to the head and neck represented 34% of casualty burden. Thoracic trauma occurred in 16%, and abdominal injuries occurred in 17%. Wounds with a frequency exceeding 5% included skin, extremity, facial, brain, and gastrointestinal injuries. Vascular injury occurred in 4%. Gunshot wounds were a greater cause of injury in Afghanistan (p = 0.001) and resulted in a higher percentage of thoracic injuries (p < 0.001). The nature and extent of trauma sustained by combat-specific personnel seems to be different from that experienced by all soldiers deployed to a war zone. Epidemiologic/prognostic study, level III.
    No preview · Article · Aug 2013
  • [Show abstract] [Hide abstract] ABSTRACT: 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. 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. 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. 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.
    No preview · Article · Aug 2013 · Injury
  • [Show abstract] [Hide abstract] ABSTRACT: Study Design: Retrospective analysis of a prospective dataset.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 2005-2009. 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 employed to identify statistically significant factors associated with spinal injury.Results: In the years 2005-2009, 872 (11.1%) casualties with spine injuries were identified among a total of 7,877 combat wounded. The mean age of spine casualties was 26.6. 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, while that of spine fractures was 4.0 per 10,000. Spinal cord injuries occurred at a rate of 4.0 per 100,000. Spinal injuries were most likely to occur in Afghanistan [Incident rate ratio (IRR) 1.96, 95% CI 1.68, 2.28], among Army personnel (IRR 16.85, 95% CI 8.39, 33.84), and in the year 2007 (IRR 1.90, 95% CI 1.55, 2.32). Spinal injuries from gunshot were significantly more likely to occur in Iraq (17%) as compared to 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.
    No preview · Article · Sep 2013 · Spine
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