Bulgarian military neurosurgery: from Warsaw Pact to the North Atlantic Treaty Organization

Abstract

After 45 years as a closest ally of the Soviet Union in the Warsaw Pact, founded mainly against the US and the Western Europe countries, and 15 years of democratic changes, since 2004 Bulgaria has been a full member of NATO and an equal and trusted partner of its former enemies. The unprecedented transformation has affected all aspects of the Bulgarian society. As a function of the Bulgarian Armed Forces, Bulgarian military medicine and in particular Bulgarian military neurosurgery is indivisibly connected with their development. The history of Bulgarian military neurosurgery is the history of the transition from the Union of Soviet Socialist Republics military system and military medicine to NATO standards in every aspect. The career of the military neurosurgeon in Bulgaria is in many ways similar to that of the civilian neurosurgeon, but there are also many peculiarities. The purpose of this study was to outline the background and the history of Bulgarian military neurosurgery as well as its future trends in the conditions of world globalization.

Full text

Neurosurg Focus / Volume 28 / May 2010
Neurosurg Focus 28 (5):E15, 2010
1
Bu l g a r i a is a middle-range southeastern Europe-
an country with a territory of 111,000 km2 and a
population of 7.5 million. The history of Bulgar-
ian military neurosurgery is hard to understand without
the knowledge of signicant historical facts concerning
the political state and the military forces in Bulgaria dur-
ing the communist regime and the ensuing democratic
changes up to the present.
Bulgaria in the Communist Era
After Bulgaria was proclaimed a People’s Republic
in 1946, the military rapidly adopted the Soviet military
doctrine and organization. The country received large
amounts of Soviet weaponry, and established a powerful
domestic military production.
Traditionally Bulgaria had more troops in uniform per
capita than the other Warsaw Pact countries. At one time,
it had almost as many soldiers as Romania, a country with
a population three times as large as Bulgaria’s. By the year
1988, the Bulgarian People’s Army numbered 152,000
men, serving in four different branches; Land Forces,
Navy, Air and Air Defense Forces, and Missile Forces.
At that time the Bulgarian People’s Army operated
with an impressive amount of equipment for the country’s
size; 3000 tanks, 2000 armored vehicles, 2500 large-cal-
iber artillery systems, more than 300 combat aircraft, and
33 combat vessels, as well as 67 SCUD missile launch-
ers, 24 SS-23 launchers, and dozens of FROG-7 artillery
rocket launchers.
Being geographically isolated from the strategically
more important northern-tier countries of the alliance,
Bulgaria participated in only a few joint exercises of the
Warsaw Pact along the central front opposite the NATO
forces in the German Democratic Republic (East Ger-
many) and Czechoslovakia. Participation on that front
usually was limited to small contingents. Shield-82, the
rst major Warsaw Pact exercise in Bulgaria, was con-
ducted in 1982 and involved 60,000 allied troops from
the northern-tier Warsaw Pact countries for the rst time.
The Warsaw Pact conducted the major command and the
staff exercise for its Southwestern Theater of Military
Operations in Bulgaria in 1984.
Contemporary Postcommunist
Democratic Bulgaria
Bulgaria’s transition to democracy was relatively
smooth. The Bulgarian communist leader Todor Zhivkov
was ousted the day after the Berlin Wall fell, and his de-
parture gave impetus to the country’s prodemocracy move-
ment. The Communist Party voluntarily gave up its abso-
lute hold on power in February 1990, and the country’s
rst free elections since 1946 were held 4 months later.
Bulgarian military neurosurgery: from Warsaw Pact to the
North Atlantic Treaty Organization
Ya v o r En c h E v , M.D., Ph.D.,1 a n D Ti h o M i r Ef T i M o v , M.D., Ph.D., LTc, Bu L g a r i a n ar M Y 2
1Department of Neurosurgery, Medical University-Soa; and 2Clinic of Neurosurgery,
Military Medical Academy-Soa, Bulgaria
After 45 years as a closest ally of the Soviet Union in the Warsaw Pact, founded mainly against the US and the
Western Europe countries, and 15 years of democratic changes, since 2004 Bulgaria has been a full member of NATO
and an equal and trusted partner of its former enemies. The unprecedented transformation has affected all aspects of
the Bulgarian society. As a function of the Bulgarian Armed Forces, Bulgarian military medicine and in particular
Bulgarian military neurosurgery is indivisibly connected with their development. The history of Bulgarian military
neurosurgery is the history of the transition from the Union of Soviet Socialist Republics military system and military
medicine to NATO standards in every aspect. The career of the military neurosurgeon in Bulgaria is in many ways
similar to that of the civilian neurosurgeon, but there are also many peculiarities. The purpose of this study was to
outline the background and the history of Bulgarian military neurosurgery as well as its future trends in the conditions
of world globalization. (DOI: 10.3171/2010.3.FOCUS109)
KE Y Wo r D s • neurosurgery • military neurosurgery •
battleeld neurosurgery • Bulgarian military neurosurgery
1
Abbreviations used in this paper: BA = Bulgarian Army; BMMC
= Balkan Military Medical Committee; NATO = North Atlantic
Treaty Organization.
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Y. Enchev and T. Eftimov
2 Neurosurg Focus / Volume 28 / May 2010
Armed Forces Overview
As a new member of NATO since 2004, Bulgaria’s
chief military goal in the mid-2000s has been conformity
with the equipment and practices of its NATO allies, in-
cluding military medicine. This goal is to be attained in
a gradual modernization plan extending through 2015.
In 2009 Bulgaria had approximately 39,000 active-duty
military personnel, with the eventual goal of 30,000 ac-
tive-duty personnel. The process of gradual demilitariza-
tion has also affected many military doctors, including
military neurosurgeons.
Foreign Military Relations
In 1994 Bulgaria became a member of NATO’s Part-
nership for Peace, participating in joint military exercises
and generally supporting the NATO missions in the for-
mer Yugoslavia. Since 2004, the dominant aspect of for-
eign military relations has been activity in NATO.
External Threat
In 2009 Bulgaria faced no threat of conventional
armed attack.
Military Service
Bulgarian men were eligible for a basic 2-year mili-
tary conscription, which was reduced gradually to 9
months, and to 6 months for university graduates. Nowa-
days, the BA is completely professional, without any con-
scription.
Foreign Military Forces
In 2009 no foreign troops were stationed in Bulgaria.
However, as part of its NATO membership, Bulgaria has
negotiated the terms for joint training with a small con-
tingent of US troops at four Bulgarian bases.
Military Forces Abroad
In 2005 Bulgaria withdrew all 466 troops that had
supported Operation Iraqi Freedom, but it sent a 150-mem-
ber humanitarian group to Iraq in early 2006. Elsewhere,
in 2005 Bulgaria had 250 troops with the International
Security Assistance Force in Afghanistan; approximately
500 troops with the United Nations Kosovo Peacekeeping
Force in Serbia; and observers with the United Nations
forces in Burundi, the Democratic Republic of Congo, In-
dia and Pakistan, and the Middle East.
History and Present State of
Bulgarian Military Neurosurgery
The Central Military Hospital-Soa was founded in
1951, following the Soviet model, as a training and re-
search center in the military aspects of the medical sci-
ences, to upgrade the training of military physicians, and
to provide medical services for the armed forces.
The rst Bulgarian military neurosurgical ward was
established during the same year at the Central Military
Hospital-Soa. The founder of Bulgarian battleeld neu-
rosurgery, Major Dr. Gancho Savov, who had trained for
2 years in Leningrad, in the former Soviet Union, was ap-
pointed as its head.2 In 1961 the neurosurgical ward, with
a staff of 25 doctors, became a neurosurgical clinic, and
along with the clinics of Neurology, Psychiatry, and Max-
illofacial Surgery, was integrated into the Department of
War-Field Traumatology of the Nervous System at the
Higher Military Medical Institute-Soa. From its founda-
tion until 1986, the neurosurgical clinic and the Depart-
ment of War-Field Traumatology of the Nervous System
had been commanded by Professor Gancho Savov (Fig.
1), who by then had attained the rank of Major General.
Professor Savov’s scientic interest, work, and numer-
ous publications were focused mainly on the problems of
traumatic brain injuries, traumatic subdural hematomas,
and neurooncological and vascular neurosurgery. He was
a skillful neurosurgeon and a devoted teacher of the next
generations of Bulgarian military neurosurgeons.
Fig. 1. Portrait of Major-General Professor Gancho Savov.
Fig. 2. Photograph of the building of the Military Medical Academy-
Soa, currently the biggest hospital in the Balkans. The Clinic of Neuro-
surgery is located on the 10th oor.
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Neurosurg Focus / Volume 28 / May 2010
Bulgarian military neurosurgery
3
Throughout the communist era, many Bulgarian
military neurosurgeons, as representatives of a Warsaw
Pact country, gained signicant wartime experience in
the numerous world and regional military conicts and
missions in the countries of Latin America, Africa, and
Asia.
Following Professor Savov’s tenure, the head of the
neurosurgical clinic at the Military Medical Academy
had been Colonel Professor Todor Stoianchev and Colo-
nel Associate Professor Dimitar Krastev for 4 and 3 years,
respectively.
During the period 1993–2004, the head of the neuro-
surgical clinic was Colonel Associate Professor Alexan-
dar Petkov. In 2004 Petkov retired as a colonel, but up to
date has been the head of the Clinic of Neurosurgery and
a head of the Department of Neurology and Neurosur-
gery at the Division of Military Surgery, Military Medi-
cal Academy-Soa (Fig. 2).
In 1995, in the Military Medical Academy, the Clinic
of Emergency Neurosurgery was established under the
leadership of Professor Manol Vanev and subsequently
Associate Professor Nedelcho Gergelchev. At that time
the clinic had 20 beds, 7 doctors, and 10 nurses. The pri-
ority of the clinic was the patients with neurotraumas,
but there was a permanent trend toward increase in the
number of patients with neurovascular, neurooncological,
and spinal diseases. Due to the reforms in the BA and
the processes of demilitarization and restructuring of the
Military Medical Academy, however, the Clinic of Emer-
gency Neurosurgery was closed in 2000.
Following the actual membership of Bulgaria in
NATO in 2004, the manner of organization of the Mili-
tary Medical Academy-Soa and in particular of the neu-
rosurgical clinic has been brought into line with NATO
standards.
Nowadays, the neurosurgical clinic has 2 operating
rooms, 30 beds, 7 senior neurosurgeons, 4 neurosurgical
residents, 10 ward nurses, and 3 scrub nurses. The clinical
structure includes 3 wards—general and functional neu-
rosurgery, spinal neurosurgery, and neurooncology. The
neurosurgical clinic is supplied with such contemporary
high-tech devices as 2 neuronavigation systems (infra-
red- and ultrasound-based); an ultrasonic aspirator; mod-
ern microscopes; neuroendoscopes; many complete sets
of microneurosurgical instruments; a digital C-arm; sets
of instruments for the anterior cervical approach and for
various types of transpedicular screw xation; a device
for intracranial pressure monitoring by intraventricular,
Fig . 3. Intraoperative application of light-emitting diode–based neuronavigation in a 49-year-old patient with 3 metastatic
tumors (outlined in green, orange, and yellow). The mirrorlike occipital tumors were removed simultaneously in 1 proce-
dure. A: Sitting position of the patient. B: Following a bi-occipital skin incision, 2 neuronavigationally outlined occipital
craniotomies were performed. C: In both metastatic tumors, catheters were inserted neuronavigationally as guides for the
localization of the lesions. D: Intraoperative screenshot visualizing the localization of the right occipital metastasis.
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Y. Enchev and T. Eftimov
4 Neurosurg Focus / Volume 28 / May 2010
intraparenchymal, and subdural transducers; and so forth.
Available for neurosurgical purposes are a modern 1-T
MR imaging device, a helical CT scanner, and a digital
angiograph.
The Clinic of Neurosurgery at the Military Medi-
cal Academy-Soa ensures neurosurgical treatment not
only to military personnel and their relatives, but also to
all health-insured Bulgarian people and to all emergency
neurosurgical patients. The neurosurgical clinic at the
Military Medical Academy-Soa is one of the leading
neurosurgical centers in Bulgaria, especially in the eld
of neurotrauma (cranial, spinal, and peripheral nerves)
caused by gunshots, missiles, and so on. The complicated
criminal situation during the time of transition to democ-
racy has been benecial for achieving signicant experi-
ence with civilian gunshot injuries.
In neurooncology, the surgical activity of the clinic
includes microsurgery of glial tumors, metastases (Fig.
3), meningiomas, vestibular schwannomas, craniopharyn-
giomas, and pituitary adenomas (via a transcranial and/or
transnasal-transsphenoidal approach); intraventricular tu-
mors (via a craniotomy or neuroendoscopy); pineal lesions,
orbital tumors, brainstem tumors, craniobasal carcinomas,
craniospinal chordomas, spinal tumors, and so forth.
Neurovascular pathological entities such as cerebral
aneurysms, arteriovenous malformations, cavernomas,
carotid–cavernous stulas, and so on are treated using
open neurosurgical procedures or endovascular tech-
niques. In less than 3 years, a rich and unique (for Bulgar-
ia) experience with endovascular embolization of brain
and spinal vascular malformations and aneurysms (Fig.
4), as well as with endovascular stenting procedures, has
been gained.
The applied functional neurosurgical procedures are
epileptic surgery, glycerol rhizolysis, microvascular de-
compression, and rhizotomy in cases of trigeminal neu-
ralgia, cancer pain surgery, and so on. All possible neu-
roendoscopic procedures, such as third ventriculostomy,
septopellucidotomy, aqueductoplasty, biopsy, and tumor
resection are performed in the clinic. Many procedures
are neuroendoscopically assisted, proting by the ability
of the endoscope “to look behind the corner.”
Spinal neurosurgery is highly developed, including
percutaneous vertebroplasty and kyphoplasty and most
of the contemporary methods and techniques of spinal
instrumentation of the degenerative and traumatically in-
jured spine (Fig. 5).
An experimental direction is the neurosurgical treat-
ment with brainstem cells and neurotrophic growth fac-
tors.The Clinic of Neurosurgery at the Military Medi-
cal Academy-Soa is a referent center for neurosurgical
residency not only for the military neurosurgeons. The
term of residency is 5 years, and terminates with a Board
Examination in Neurosurgery. The examination has three
steps. The rst part is practical; the resident performs a
neurosurgical procedure under the supervision of a se-
nior neurosurgeon. The residents who have passed the
rst step have a written exam in several neurosurgical ar-
eas. The ones who have passed the second then reach the
third part—an oral examination in front of the Govern-
ment Еxamination Сommission, which consists of three
professors in neurosurgery, and usually among them is
the Head of the Clinic of Neurosurgery at the Military
Medical Academy-Soa.
The Clinic of Neurosurgery at the Military Medi-
cal Academy-Soa is a regular participant in the annual
congresses of the BMMC, where actual problems and
achievements in the military medicine of the Balkan
countries are presented and discussed. The BMMC was
established in 1995 based on the idea and initiative of
Colonel Associate Professor Alexandar Petkov and with
Fig. 4. Endovascular treatment of cerebral brain aneurysm. A: Preembolization angiographic study. B: Postembolization
angiographic study.
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Neurosurg Focus / Volume 28 / May 2010
Bulgarian military neurosurgery
5
the participation of Bulgaria, Greece, Romania, and Tur-
key. Nowadays the BMMC is growing, with the associa-
tion and acceptance of new member countries—Macedo-
nia, Serbia, Croatia, and Montenegro. The participation
of Bulgarian military neurosurgeons in military NATO
missions is still limited.
Recruitment of Bulgarian
Military Neurosurgeons
A professional military career, including that of a
military doctor and in particular a military neurosurgeon,
has been considered relatively prestigious in Bulgaria, al-
though its prestige has begun to wane in the postcom-
munist era. Depending on whether nonmonetary benets
like housing and food were considered, an ofcer’s pay
was generally 25–50% higher than that offered in civil-
ian positions for neurosurgeons with comparable respon-
sibilities. Only in 1990 did the defense establishment
start to address problems familiar to military ofcers in
all countries, however. For example, spouses frequently
were unable to nd work in the vicinity of military posts.
In 1991 a special cash allowance to military families was
considered to cover these instances. Day-care and school
accommodations often were scarce, and adequate hous-
ing was unavailable.
Before becoming a full member of NATO in 2004,
the BA started a strict plan for reorganization in accor-
dance with NATO standards. The process of reduction of
the number of members in the BA by the gradual demo-
bilization of part of the ofcers’ staff has also affected
many military doctors, including military neurosurgeons.
Five military neurosurgeons lost their status as military
ofcers and became civilian neurosurgeons.
Training System for Bulgarian
Military Neurosurgeons
Military medical training in Bulgaria during the
communist regime followed the Soviet model. The medi-
cal students willing to become military medical doctors
were able to apply for a whole-studies-term military grant.
The candidates were subjected to a thorough political ex-
amination of their families by the relevant communist
organization. The selection was not based on results of
medical exams, but on the decision of the communist au-
thorities. The approved medical students signed contracts
for 10 years of service as military doctors in the BA with-
out an option to choose their place of work. The military
residents in neurosurgery received a substantial monthly
grant for the term of residency. In return, after gradua-
tion the military neurosurgeons were obliged to fulll
the preliminary contractual duration in military service
as medical ofcers. Following the democratic changes
in Bulgaria, the resources for the BA, military medicine,
and in particular for military neurosurgery have been sig-
nicantly reduced. The military neurosurgical residents
have lost their privileges, including their nancial support
by means of monthly grants and nonmonetary benets.
Since the beginning of Bulgaria’s membership in NATO,
the situation has improved gradually.
Advantages and Disadvantages of a Career as a
Military Neurosurgeon in Bulgaria
Nowadays, the salary of Bulgarian military neurosur-
geons is equal to or relatively higher compared with that
of Bulgarian civilian neurosurgeons, in contrast to the
situation with the US military neurosurgeons.1 Bulgarian
military neurosurgeons receive payment from the BA on
Fig. 5. Neuronavigationally guided insertion of a pedicle screw as part of a spinal stabilization procedure. A: Intraoperative
screenshot visualizing the positioning of a pedicle screw by using the “autopilot” function of neuronavigation. B: Postoperative
anterior-posterior radiography study showing the spinal instrumentation in position. C: Postoperative lateral radiography study
showing the spinal instrumentation in position.
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Y. Enchev and T. Eftimov
6 Neurosurg Focus / Volume 28 / May 2010
the one hand as military ofcers, and from the National
Health Insurance Fund on the other hand as medical doc-
tors supplying services to the health-insured citizen. The
age of retirement, however, although comparable to that
of US military neurosurgeons,1 is lower by several years
compared to that of civilian neurosurgeons. Other advan-
tages are the multiple possibilities for sponsored training
and continuing medical education. The patient population
is not limited to military personnel and their dependents,
but to all health-insured Bulgarian citizens, and even to
uninsured emergency patients. In this way, the high case
volume of various neurosurgical pathological entities is
benecial for the professional qualication and mainte-
nance of competence. The excellent technical equipment
of the military neurosurgical clinic due to NATO’s mem-
bership nancial support is also very attractive. The most
appealing aspect of military neurosurgical practice, how-
ever, is the opportunity to serve as an ofcer of the BA
and in this way to serve one’s country.
The drawbacks of military service are mainly out-
lined in the signed contract, and include a permanent
readiness to be deployed in risk-lled points of military
conict or humanitarian crisis, an impossibility of chang-
ing one’s workplace of one’s own free will, and last (but
not least) the prohibition against private neurosurgical
practice. The current disadvantages of the career of mili-
tary neurosurgeon in Bulgaria do not differ signicantly
from those of US military neurosurgeons.1
Future Trends in Bulgarian
Military Neurosurgery
The number of the Bulgarian military neurosurgeons
will probably increase with the growing number of peace-
keeping missions of the BA outside the country. Recently
the Military Medical Academy-Soa became equipped
with a modern mobile battleeld hospital, which, al-
though it has not got specic equipment allowing the per-
formance of all kinds of neurosurgical procedures, still
includes a mobile CT scanner for neurodiagnosis and is
perfectly suitable for wartime neurotrauma cases. The
beginning of NATO missions abroad for the Bulgarian
military neurosurgeons connected with this hospital are
only a matter of a short time. In this way, the currently
limited battleeld experience of these neurosurgeons will
be augmented in real-time, dangerous situations.
Conclusions
Bulgarian military neurosurgery has a short but very
eventful history, reecting the changes in the political
philosophy and military organization of Bulgaria. Dur-
ing the communist era, military neurosurgery was fo-
cused mainly on battleeld neurosurgical pathological
conditions such as traumatic brain injury, traumatic sub-
dural hematoma, and so forth, which were expected to be
caused by the military forces of the Warsaw Pact’s enemy
countries in NATO. Almost 2 decades after the demo-
cratic changes in our country, Bulgaria is a NATO mem-
ber, and Bulgarian military neurosurgery covers every
neurosurgical disease. The prestige of Bulgarian military
neurosurgeons has remained consistently high, regard-
less of the described reforms. The only limitation on the
increasе of their number is due to the lack of vacancies.
Disclosure
The authors report no conflict of interest concerning the mate-
rials or methods used in this study or the findings specified in this
paper.
Author contributions to the study and manuscript preparation
include the following. Conception and design: Y Enchev. Analysis
and interpretation of data: Y Enchev. Critically revising the article:
T Eftimov.
References
1. Moquin RR, Ecklund JM: Socioeconomic issues of United
States military neurosurgery. Neurosurg Focus 12(4):e6, 2002
2. Petkov A: History and development of Clinic of Neurosur-
gery at Militar y Medical Academy—Soa. Bulg Neurosurg
11:30–31, 2006
Manuscript submitted January 15, 2010.
Accepted March 1, 2010.
Address correspondence to: Yavor Enchev, M.D., Ph.D.,
De partment of Neurosurgery, Medical University-Sofia, University
Hospital “Sv. Ivan Rilsky,” 15, Boulevard “Acad. Ivan Geshov,”
1431 Sofia, Bulgaria. email: dr.y.enchev@gmail.com.
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