Combat related spine and spinal cord injuries: a systematic literature review and meta-analysis

Objective. To study the epidemiology and clinical features of spinal injuries and wounds in combat situations.

Material and Methods. A systematic literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using PubMed and Cochrane Library databases. Statistical analysis of the data was performed using the R statistical programming language in the RStudio integrated development environment. The meta and metafor libraries were used for meta-analysis. The Knapp-Hartung correction was used to calculate the confidence intervals of the pooled effects.

Results. Of the 30 full-text articles, 11 met the required criteria and were included in this review with STROBE assessment. The mean age of the injured was 26.58 years (95 % CI: 25.8–27.4 years; I² = 0 %; p = 0.65), males accounted for 98 % (95 % CI: 98–99; I² = 37 %; p = 0.1), closed spinal cord injury was diagnosed in 47.11 % of cases (95 % CI: 28.83–66.19 %; I² = 99 %; p < 0,01), and gunshot wounds – in 43.64 % (95 % CI: 23.94–65.59 %; I² = 99 %; p < 0.01). Cervical injures were recorded in 32.13 % of cases (95 % CI: 17.75–50.94 %; I²  = 95.1 %; p < 0.01), thoracic injuries – in 34.28 % (95 % CI: 22.58–48.27 %; I² = 88 %; p < 0.01), lumbar injuries – in 57.16 % (95 % CI: 44.52–68.92 %; I² = 97.5 %; p < 0.01), and sacral – in 21.23 % of cases (95 % CI: 16.99–26.21 %; I² = 76 %; p < 0.01).

Conclusion. The results emphasize the peculiarities of the modern epidemiology of combat related spine and spinal cord injuries and wounds. Conflicts of the 21st century are characterized by the predominance of mine and explosive action; as a rule, young people suffer, the overwhelming majority of them are men; at least 30 % of wounded with gunshot injuries to the spine require surgical treatment. The vast majority of authors choose isolated posterior fixation. The most common complications include thromboembolic complications, urinary tract infections, pneumonia and bedsores.

1. Possley DR, Blair JA, Schoenfeld AJ, Lehman RA, Hsu JR. Complications associated with military spine injuries. Spine J. 2012;12:756–761. DOI: 10.1016/j.spinee.2011.10.002

2. Reister FA. Battle Casualties and Medical Statistics: U.S. Army Experience in the Korean War. Washington, DC: Surgeon General, Dept. of the Army, 1973.

3. Schoenfeld AJ, Goodman GP, Belmont PJ Jr. Characterization of combat-related spinal injuries sustained by a US Army Brigade Combat Team during Operation Iraqi Freedom. Spine J. 2012;12:771–776. DOI: 10.1016/j.spinee.2010.05.004

4. Smirnov EI. Experience of Soviet Medicine in the Great Patriotic War of 1941–1945. Encyclopedia in 35 volumes. Vol. 11: Gunshot Wounds and Injuries to the Spine and Spinal Cord. Moscow: Medgiz, 1952.

5. Antonov GI, Manukovskiy VA, Chmutin GE, Ivanov II, Timonin SYu, Kelin AO. Analysis of treatment outcomes in patients with combat spinal column and spinal cord injuries. Bulletin of Neurology, Psychiatry and Neurosurgery. 2023;(11):912–921. DOI:10.33920/med-01-2311-06

6. Szuflita NS, Neal CJ, Rosner MK, Frankowski RF, Grossman RG. Spine injuries sustained by U.S. military personnel in combat are different from non-combat spine injuries. Mil Med. 2016;181:1314–1323. DOI: 10.7205/MILMED-D-15-00332

7. Blair JA, Patzkowski JC, Schoenfeld AJ, Cross Rivera JD, Grenier ES, Lehman RA, Hsu JR. Are spine injuries sustained in battle truly different? Spine J. 2012;12:824–829. DOI: 10.1016/j.spinee.2011.09.012

8. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6:e1000097. DOI: 10.1371/journal.pmed.1000097

9. Vandenbroucke JP, von Elm E, Altman DG, Gøtzsche PC, Mulrow CD, Pocock SJ, Poole C, Schlesselman JJ, Egger M. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. PLoS Med. 2007;4:e297. DOI: 10.1371/journal.pmed.0040297

10. Viechtbauer W. Bias and efficiency of meta-analytic variance estimators in the random-effects model. J Educ Behav Stat. 2005;30:261–293. DOI: 10.3102/10769986030003261

11. Knapp G, Hartung J. Improved tests for a random effects meta‐regression with a single covariate. Stat Med. 2003;22:2693–2710. DOI: 10.1002/sim.1482

12. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557–560. DOI: 10.1136/bmj.327.7414.557

13. Formby PM, Wagner SC, Kang DG, Van Blarcum GS, Pisano AJ, Lehman RA Jr. Reoperation after in-theater combat spine surgery. Spine J. 2016;16:329–334. DOI: 10.1016/j.spinee.2015.11.027

14. Ravindra VM, Wallace SA, Vaidya R, Fox WC, Klugh AR 3rd, Puskas D, Park MS. Spinal stabilization using orthopedic extremity instrumentation sets during Operation Enduring Freedom–Afghanistan. World Neurosurg. 2016;86:503–509. DOI: 10.1016/j.wneu.2015.09.018

15. Schoenfeld AJ, Mok JM, Cameron B, Jackson KL, Serrano JA, Freedman BA. Evaluation of immediate postoperative complications and outcomes among military personnel treated for spinal trauma in Afghanistan: a cohort-control study of 50 cases. J Spinal Disord Tech. 2014;27:376–381. DOI: 10.1097/BSD.0b013e3182a355c6

16. Schoenfeld AJ, Laughlin MD, McCriskin BJ, Bader JO, Waterman BR, Belmont PJ Jr. Spinal injuries in United States military personnel deployed to Iraq and Afghanistan: an epidemiological investigation involving 7877 combat casualties from 2005 to 2009. Spine. 2013;38:1770–1778. DOI: 10.1097/BRS.0b013e31829ef226

17. Schoenfeld AJ, Newcomb RL, Pallis MP, Cleveland AW 3rd, Serrano JA, Bader JO, Waterman BR, Belmont PJ Jr. Characterization of spinal injuries sustained by American service members killed in Iraq and Afghanistan: a study of 2,089 instances of spine trauma. J Trauma Acute Care Surg. 2013;74:1112–1118. DOI: 10.1097/TA.0b013e31828273be

18. Blair JA, Patzkowski JC, Schoenfeld AJ, Cross Rivera JD, Grenier ES, Lehman RA Jr, Hsu JR. Spinal column injuries among Americans in the global war on terrorism. J Bone Joint Surg Am. 2012;94: e135(1-9). DOI: 10.2106/JBJS.K.00502

19. Galvin JW, Freedman BA, Schoenfeld AJ, Cap AP, Mok JM. Morbidity of early spine surgery in the multiply injured patient. Arch Orthop Trauma Surg. 2014;134:1211–1217. DOI: 10.1007/s00402-014-2068-7

20. Baker SP, O’Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14:187–196.

21. Furlan JC, Fehlings MG, Tator CH, Davis AM. Motor and sensory assessment of patients in clinical trials for pharmacological therapy of acute spinal cord injury: psychometric properties of the ASIA Standards. J Neurotrauma. 2008;25:1273–1301. DOI: 10.1089/neu.2008.0617

22. Furlan JC, Gulasingam S, Craven BC. Epidemiology of war-related spinal cord injury among combatants: a systematic review. Global Spine J. 2019;9:545–558. DOI: 10.1177/2192568218776914