Even as war has resulted in millions of spinal cord injuries, the doctors who have tended to them on the field have contributed to vastly improved care for all people with SCI.
By Tom Scott
The mortality rate of U.S. soldiers serving in Iraq and Afghanistan is significantly lower compared to previous wars. During World War II, 30% of US soldiers died from wounds received in combat and 24% of US soldiers died in Vietnam. In Iraq and Afghanistan mortality has dropped to approximately 10%. Advancements in field medicine have saved thousands of lives. Stronger body armor and the utilization of heavily reinforced armored military vehicles has led to more soldiers surviving small arms fire, land mines, rocket-propelled grenade (RPG) attacks, and new threats such as improvised explosive devices (IEDs).
This positive development, however, has its dark side: it has resulted in thousands of soldiers- approaching 100,000 as of the fall of 2006—with lifetime disabilities, such as spinal cord injury (SCI). The proper and efficient treatment of SCIs on the battlefield, therefore, is of great importance.
War and SCI—A Historical Perspective
The experiences of military surgeons during major conflicts in the middle to late 19th century, such as the American Civil War (1861-1865), helped advance the field of neurology and the clinical and surgical treatment of SCI. During World War I (WWI), more sophisticated treatments-including the integration of civil surgeons to care for the wounded, surgical intervention, more efficient evacuation procedures, improved medical facilities capable of treating SCI, and improved urological and skin care treatment methods—had a positive impact on patient outcomes and long-term care on and off the battlefield.
Before the innovations in SCI medicine introduced in WWI, treatment for SCI was rudimentary, usually limited to closed reduction (setting a fractured bone by manipulation without incision into the skin) and bed rest. Due to limited research and understanding, many doctors showed little interest in SCI, especially since most methods to treat it at the time had negative outcomes. This, however, soon changed.
“Innovations in basic and clinical neuroscience resulted in significant changes in the treatment of patients with SCIs,” W. Hanigan and C. Sloffer write in a history of 19th and early 20th century battlefield medicine in the journal Neurosurgery Focus (January 2004). “Anatomists and neurophysiologists outlined nerve tracts and reflex arcs, demonstrating that the spinal cord showed distinctive reflex activity following disease and injury. New instruments, such as the esthesiometer, and techniques, such as the lumbar puncture, added measurable data to the clinical examination as well as to the cache of scientific apparatuses and techniques by the bedside.”
In an article written for the Postgraduate Medical Journal titled “History of the Treatment of Spinal Injuries,” Dr. J.R. Silver explains that WWI served as a catalyst for the modern management and treatment of SCI. As casualties mounted during the war, the United Kingdom, Germany, and France established SCI units staffed by multidisciplinary teams of surgeons, urologists, and neurologists. Many patients still developed complications such as pressure sores and sepsis (local or generalized invasion of the body by pathogenic micro-organisms or their toxins), but knowledge in the field broadened. Nursing care, physiotherapy (i.e., exercise therapy), and the importance of a collaborative effort in treating and researching SCI were now paramount.
American Pioneers
After WWI, the knowledge base in SCI treatment began to shift to the US. This was led by the American pioneer of neurosurgery Dr. Charles Harrison Frazier (1880-1936). Frazier’s experiences in treating peripheral nerve injuries during WWI were well-documented, as was his detailed statistical analysis of French and German papers on results of surgery, prognosis, life expectancy, and discharge of soldiers with SCI.
Dr. Donald Munro (1889-1973) was another famous American pioneer in the field of SCI. Munro, who served as Dr. Frazier’s assistant in 1916 during his surgical internship at the Augustana Hospital in Chicago, also worked in the U.S. Medical Department in France during WWI. Munro’s studies on traumatic brain and spinal cord injuries profoundly influenced the treatment of US soldiers during WWII and the establishment of a series of veterans hospitals that focused on SCI, including the Long Beach, California VA, founded by Ernest Bors. Munro’s research also had an impact on other pioneers, such as Ludwig Guttmann (1899-1980), the German neurologist who founded the Paralympics and is considered a founding father of organized physical activities for people with disabilities and the modern treatment of SCI.
Medical Support on the Frontlines
Since the Gulf War, there have been even more dramatic improvements to the U.S. military medical system, most involving evacuation procedures. In Vietnam, statistics showed that only 2.6% of the wounded soldiers transported to surgical field hospitals died, meaning that despite helicopter evacuation, a majority of deaths occurred before the injured made it to surgical care. This demonstrated that a majority of seriously injured soldiers had died on the battlefield and did not have a chance to receive life-saving medical intervention, prompting the U.S. military to re-evaluate and improve the speed of care for wounded soldiers.
The result has been “leaner, faster” military units that have enabled surgical teams to get closer to the frontlines. These highly mobilized units are referred to as forward surgical teams (FSTs), which typically consist of 20 personnel: three general surgeons, one orthopedic surgeon, two nurse anesthetists, three nurses, and a number of medics and other support staff. FSTs are divided into four functional areas: triage-trauma management, surgery, recovery, and administration/operations.
According to the U.S. Army, approximately 10% to 15% of wounded in action require surgical intervention to control hemorrhage and provide stabilization for evacuation. FSTs provide this intervention in minutes instead of hours. They can also provide up to six hours of postoperative intensive care for a maximum of eight patients. FSTs are equipped with enough supplies to evaluate and perform surgery on 30 wounded soldiers and treat major chest and abdominal wounds, crush and closed head wounds, amputations, major organ fractures, and SCI. Many FST units are attached to area combat support hospitals (CSH), where the wounded are transferred after emergency treatment is performed in the field. CSHs stabilize seriously injured patients (approximately 3-5 days), transport them to military hospitals in the US or elsewhere, and then to Veterans Hospitals (VAs), where a majority of soldiers with SCI are rehabilitated. Additional medical support comes from Combat Life Savors (CLSs), which are soldiers who have received rudimentary training in advanced first aid skills. CLSs usually represent the first line of treatment for wounded soldiers and are knowledgeable in intubation and advanced airway management. They are exclusively used in combat situations.
The improved emergency evacuation procedures and the utilization of FSTs and CLSs have prevented neurologic deterioration of a majority of spinal cord injured soldiers in Iraq and Afghanistan. “On the battlefield, minutes, even seconds, can mean the difference between life and death, the length of recovery and the patient’s future quality of life. Field medicine is a constantly evolving science, with each generation of practitioners building on the work of their predecessors. Today, the chances of surviving a critical battlefield injury are greater than they have ever been,” said Leonard Selfon, United Spinal Association’s National Service director. “However, it is important to remember that the wounded service person’s troubles are not over once he or she has been treated and discharged from the military. The residuals of such an injury can last a lifetime and often increase in severity as the person ages. That is why it is vital that our government ensures that the military and the Department of Veterans Affairs have the resources necessary to care for and compensate those who have borne the battle.”
Modern SCI treatment strategies, whether on the battlefield or on the home front, are a culmination of civil and military medical techniques that have developed over many years. SCI research and case studies documented by the United Kingdom, Germany, and France during WWI provided American pioneers in SCI medicine a solid foundation to build upon, leading to dramatic advancements in treatment standards, surgical techniques, and rehabilitation that have been utilized in the current conflicts in Iraq and Afghanistan.
Tom Scott is staff editor.
