Military Neurosurgery Research Articles

113 The Effect of Civilian Purchased Care on Military Neurosurgery Wartime Readiness

INTRODUCTION: The current landscape of military neurosurgery reflects the relative peacetime for the US-World relationship - a problem of intrinsically low case volume compounded by patients being deferred away from Military Treatment Facilities (MTFs). TRICARE is the healthcare program of the US Department of Defense Military Health Care System, in which ‘Purchased Care’ or civilian based health care, is used to supplement healthcare needs when services are not readily available to TRICARE beneficiaries. Within military neurosurgery, case volume and complexity continue to be diverted via purchased case pathways, greatly affecting wartime readiness. Neurosurgery wartime readiness can be measured through the Knowledge, Skills and Abilities (KSA) metric based on case complexity and volume. METHODS: We analyzed case counts and KSA values of active-duty military neurosurgery capable MTFs and purchased care counterparts using the CarePoint Access portal. Residents, civilian contractors, and retirees were excluded. RESULTS: In 2022, the KSA total for 16 MTFs was 139005, a result of 2286 cases and 47 surgeons. The average KSA/surgeon/month was 393.8, extrapolating to 4725.5/surgeon/year - 59% of the KSA goal of 8000/surgeon/year. The purchased care KSA of 10 MTFs totaled 301535 in 2022 from 7324 cases. Purchased care out-performed MTF case volume by over 300%. Recovering full purchased care volume would increase the individual MTF neurosurgeon KSA by 135%. CONCLUSIONS: The military neurosurgical community cannot maintain wartime readiness as defined by the KSA metric with current trends in military neurosurgery case volume and high incidence of purchased care. The solution lies in either recovering purchased care patients or expanding military-civilian partnerships to base military neurosurgeons at local academic hospitals and trauma centers.

Letter: Answering Our Nation's Call: A Solution for Military Neurosurgery Wartime Readiness Through Civilian Collaboration.

Letter: Answering Our Nation's Call: A Solution for Military Neurosurgery Wartime Readiness Through Civilian Collaboration.

In Reply: Answering Our Nation's Call: A Solution for Military Neurosurgery Wartime Readiness Through Civilian Collaboration.

In Reply: Answering Our Nation's Call: A Solution for Military Neurosurgery Wartime Readiness Through Civilian Collaboration.

French Military Neurosurgery: At Home and Abroad.

The origins of military neurosurgery are closely linked to those of neurosurgery in France and more particularly in Paris. The history of the field starts with its origins by 2 men, Thierry de Martel and Clovis Vincent. The first note about the creation of military neurosurgery was in 1942, when Marcel David was reassigned from the Sainte Anne Hospital to practice at the Val-de-Grâce Military Hospital. David trained the first military neurosurgeon. The field of military neurosurgery was subsequently developed at the Val-de-Grâce Military Hospital, at Sainte Anne Military Teaching Hospital in Toulon in 1990 and then at Percy Military Teaching Hospital in 1996. Over 29 military neurosurgeons were trained in these institutions. Since 2000, French military neurosurgeons have been deployed from France in the Mobile Neurosurgical Unit. This Mobile Neurosurgical Unit represents 12% of all medical evacuation of casualties categorized as the high dependency level. Neurosurgeons were able to adapt to asymmetrical wars, such as in the Afghanistan campaign where they were deployed in the Role 3 medical treatment facility, and more recently in sub-Saharan conflicts where they were deployed in forward surgical roles. To manage the increasing craniocerebral war casualties in the forward surgical team, the French Military Health Service Academy established a training course referred to as the "Advanced Course for Deployment Surgery" providing neurosurgical damage control skills to general surgeons. Finally, military neurosurgery is reinventing itself to adapt to future conflicts through the enhancement of surgical practices via the addition of head, face, and neck surgeons.

Commentary: French Military Neurosurgery: At Home and Abroad.

Commentary: French Military Neurosurgery: At Home and Abroad.

Answering Our Nation's Call: A Solution for Military Neurosurgery Wartime Readiness Through Civilian Collaboration.

Military-civilian partnerships have built the foundation for US neurosurgery as we see it today. Each conflict throughout history has led to expansion within the field of neurosurgery, benefiting civilian patients and those in uniform. Despite the field's growth during wartime, military neurosurgical case volume declines during peacetime, and as a result, important knowledge gained is at risk of being lost. The current landscape of military neurosurgery reflects the relative peacetime for the US-World relationship. Because of this peacetime, the surgical case volume and experience of the military neurosurgeon are declining rapidly. In addition to providing a history of military-civilian partnerships in neurosurgery, we have analyzed the declining case volume trends at a single military treatment facility with neurosurgical capabilities. We compared the case volume of a military neurosurgeon at a civilian partnered location with their previous volume at a military treatment facility and analyzed current trends in wartime readiness by Neurosurgery Knowledge, Skills and Abilities metrics. We believe that military civilian partnerships hold the key to scaffolding the experience to maintain the wartime readiness in the military neurosurgical community.

The Impact of Major Military War Campaigns on Neurosurgery: Informetric Data and Time-Trend Analysis

Given the neurotrauma that soldiers might face during wars, a byproduct of such devastating neurosurgical conditions can be novel data, which can act as a catalyst for potentially paradigm-shifting research. We aimed to identify the impact of major U.S. military campaigns on military neurosurgery literature across defined time periods. A comprehensive Elsevier's Scopus database search was performed to capture all published and indexed studies from 1915 to 2021 relevant to military neurosurgery. A discrete set of validated informetric metadata parameters were extracted and analyzed using productivity analysis, citation analysis, keyword analysis, text mining, content analysis, and collaboration network mapping. Our search yielded 2216 documents. Annual scientific production since 1915 grew at a compounded rate of 6.1% per year, with the most significant increases during U.S. military campaigns (coefficient=42.9, P < 0.001) and following the introduction of the Department of Defense Trauma Registry in 2007 (coefficient=114.5; P < 0.001). Each war had a direct influence on military neurosurgery literature growth (P < 0.05), with the most prominent following the Afghanistan war. The journals with the most publications on military neurosurgery were Military Medicine (n= 168) and Journal of Head Trauma. The topmost cited author was Hoge etal. (N= 2083), while the topmost cited country was the United States (N= 1098). Since World War II, the military has contributed significant historical developments to neurosurgery, the most prominent being after the Iraq and Afghanistan wars and the introduction of the Department of Defense Trauma Registry.

Management of injuries on the 16th-century battlefield: Ambroise Paré's contributions to neurosurgery and functional recovery.

During the 1536 siege of Turin in northern Italy, a young French barber-surgeon abandoned the conventional treatment of battle-inflicted wounds, launching a revolution in military medicine and surgical techniques. Ambroise Paré (1510-1590) was born into a working-class Huguenot family in Laval, France, during an era when surgery was not considered a respectable profession. He rose from humble origins as a barber-surgeon, a low-ranked occupation in the French medical hierarchy, to become a royal surgeon (chirurgien ordinaire du Roi) serving 4 consecutive French monarchs. His innovative ideas and surgical practice were a response to the environment created by new military technology on 16th-century European battlefields. Gunpowder weapons caused unfamiliar, complicated injuries that challenged Paré to develop new techniques and surgical instruments. Although Paré's contributions to the treatment of wounds and functional prosthetics are documented, a deeper appreciation of his role in military neurosurgery is needed. This paper examines archives, primary texts, and written accounts by Paré that reveal specific patient cases highlighting his innovative contributions to neurotrauma and neurosurgery during demanding and harrowing circumstances, on and off the battlefield, in 16th-century France. Notably, trepanation indications increased because of battlefield head injuries, and Paré frequently described this technique and improved the design of the trepan tool. His contribution to neurologically related topics is extensive; there are more chapters devoted to the nervous system than to any other organ system in his compendium, Oeuvres. Regarding anatomical knowledge as fundamentally important and admiring the contemporary contributions of Andreas Vesalius, Paré reproduced many images from Vesalius' works at his own great expense. The manner in which Paré's participation in military expeditions enabled collaboration with multidisciplinary artisans on devices, including surgical tools and prosthetics, to restore neurologically associated functionality is also discussed. Deeply religious, in a life filled with adventure, and serving in often horrendous conditions during a time when Galenic dogma still dominated medical practice, Paré developed a reputation for logic, empiricism, technology, and careful treatment. "I have [had] the opportunity to praise God, for what he called me to do in medical operation, which is commonly called surgery, which could not be bought with gold or silver, but by only virtue and great experimentation."

Evolution of spinal cord injury treatment in military neurosurgery.

During the mid-1900s, military medicine made historical advancements in the diagnosis, stabilization, and treatment of spinal cord injuries (SCIs). In particular, World War II was an inflection point for clinical practice related to SCIs because of the vast number of devastating injuries to soldiers seen during World War I (WWI). The unprecedented rate of SCI along with growth in the field served as a catalyst for surgical and interdisciplinary advancements through the increased exposure to this challenging pathology. Initially, a tragic fate was assumed for soldiers with SCIs in WWI resulting in a very conservative approach strategy given a multitude of factors. However, soldiers with similar injuries 20 years later saw improved outcomes with more aggressive management interventions by specialists in spine trauma, who applied measures such as spinal traction, arthrodesis, and internal fixation, and with the significant developments in the complex rehabilitation of these patients. This article describes the historical shift in the management of SCIs through the two world wars. These historical lessons of SCI and the fundamental advances in their neurosurgical intervention have molded not only military but also modern civilian treatment of SCI.

A history of neurosurgical capabilities in the United States Pacific Command: from World War II to present.

Neurosurgery has benefited from innovations as a result of military conflict. The volume and complexity of injuries sustained on the battlefield require medical teams to triage, innovate, and practice beyond their capabilities in order to treat wartime injuries. The neurosurgeons who practiced in the Pacific Command (PACOM) during World War II, the Korean War, and the War in Vietnam built upon field operating room knowledge and influenced the logistics of treating battle-injured patients in far-forward environments. Modern-day battles are held on new terrain, and the military neurosurgeon must adapt. War in the PACOM uniquely presented significant obstacles due to geographic isolation, ultimately accelerating the growth and adaptability of military neurosurgery and medical evacuation. The advancements in infrastructure and resource mobilization made during PACOM conflicts continue to inform modern-day practices and provide insight for future conflicts. In this historical article, the authors review the development and evolution of neurosurgical care, forward surgical teams, and mobile field hospitals with surgical capabilities through US conflicts in the PACOM.

The birth of modern military neurosurgery through the eyes of Harvey Cushing's war memoir From a Surgeon's Journal, 1915-1918.

Dr. Harvey Cushing is considered the father of modern neurological surgery, and his role and efforts in World War I continue to have a lasting effect on today's practice of neurosurgery. During World War I, he embodied the tenets of a neurosurgeon-scientist: he created and implemented novel antiseptic techniques to decrease infection rates after craniotomies, leading him often to be referred to as "originator of brain wound care." His contributions did not come without struggles, however. He faced criticism for numerous military censorship violations, and he developed a severe peripheral neuropathy during the war. However, he continued to stress the importance of patient care and his surgical prowess was evident. In this paper, the authors summarize Cushing's notes published in From a Surgeon's Journal, 1915-1918 and discuss the impact of his experiences on his own practice and the field of neurosurgery.

Arnold Max Meirowsky: champion of the American mobile neurosurgical unit during the Korean War.

Dr. Arnold Max Meirowsky (1910-1984) was enormously influential to military neurosurgery during the Korean War, introducing to the American military the concept of the mobile neurosurgical unit. After implementation of the neurosurgical detachment, meningocerebral infections saw a decrease from 41% to less than 1%, with similar improvements in mortality and complication rates. Additionally, Meirowsky developed many techniques and improvements in neurosurgery, specifically in the field of neurosurgical trauma, which he dedicated himself to even after reentering civilian practice. Furthermore, his mentorship of Korean surgeons and the influence of his mobile neurosurgical unit were major influences cited to be pivotal to the founding of neurosurgery as a specialty in South Korea. As he is underrecognized for these accomplishments in the neurosurgical literature, the authors seek to review his wartime and career contributions. They also specifically present details of his standardization of the mobile neurosurgical unit and showcase several of his other advancements in the treatment of neurosurgical trauma.

Patriarch of military neurosurgery

January 19, 2021 marks the 75th anniversary of the birth of one of the leading Russian neurosurgeons, Academician of the Russian Academy of Sciences Boris Vsevolodovich Gaidar. Eight years at the head of the Department and Clinic of Neurosurgery at the Military Medical Academy and 7 years at the head of Military Medical Academy, when his talent as a teacher and leader was most clearly revealed. Academician B.V. Gaidar is one of the countrys leading scientists in the field of treatment of combat injuries of the central nervous system (craniocerebral trauma and mine-explosive wounds of the central nervous system), vascular neurosurgery, and neurooncology. He made a major contribution to solving the issues of organizing specialized neurosurgical care in the Armed Forces in peacetime and in wartime. He personally took part in providing medical assistance to the wounded during the armed conflict in the North Caucasus. B.V. Gaidar represented Russian science at international forums in Austria, Germany and the United States of America, in 2005 he led the organization of the World Congress on Military Medicine for the only time in our country. During the years of leadership of the S.M. Kirov Military Medical Academy B.V. Gaidar carried out a large-scale reconstruction and re-equipment of a number of leading surgical clinics, which contributed to the progressive development of the academys scientific schools. B.V. Gaidar created a scientific school of neurosurgeons, prepared a rich legacy of articles, textbooks and monographs, his merits were recognized by the scientific community and the state. Celebrating the anniversary, Boris Vsevolodovich continues to actively engage in scientific work, training, counseling critical patients, passionately defending the interests of the Military Medical Academy.

Analysis of Factors and Conditions Influencing Military Neurosurgery Recruitment and Retention.

The Defense Health Agency has shifted focus of military medicine to operational readiness. As such, neurosurgery remains a critical wartime specialty. We investigate the factors impacting recruitment and retention of military neurosurgeons. Survey of military neurosurgeons was performed via the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Committee of Military Neurosurgeons and the Council of State Neurosurgical Societies. Retention and recruitment were queried. 93/119 (78.2%) current or previously affiliated military neurosurgeons would recommend service as a military neurosurgeon to a colleague. Those who felt a sense of patriotism were 4.3 times more likely to recommend military service (P=0.027, CI 1.19-16.82). Those who developed a sense of camaraderie showed a trend to recommending military neurosurgery (P=0.058, CI 0.95-9.78). Those with a current military obligation were.28 times (P=0.02, CI 0.09-0.85) as likely to recommend service. Military physicians who felt a need for reform to increase salary were 2.5 times less likely to be retained. Service in the US military is a positive experience with camaraderie, patriotism, and unique military experiences predictive of recruitment. Meanwhile, focus on pay discrepancy can result in lost retention. These factors should be explored regarding recruitment and retention of military neurosurgeons.

The Evolving Concept of Damage Control in Neurotrauma: Application of Military Protocols in Civilian Settings with Limited Resources

The aim of the present review was to describe the evolution of the damage control concept in neurotrauma, including the surgical technique and medical postoperative care, from the lessons learned from civilian and military neurosurgeons who have applied the concept regularly in practice at military hospitals and civilian institutions in areas with limited resources. The present narrative review was based on the experience of a group of neurosurgeons who participated in the development of the concept from their practice working in military theaters and low-resources settings with an important burden of blunt and penetrating cranial neurotrauma. Damage control surgery in neurotrauma has been described as a sequential therapeutic strategy that supports physiological restoration before anatomical repair in patients with critical injuries. The application of the concept has evolved since the early definitions in 1998. Current strategies have been supported by military neurosurgery experience, and the concept has been applied in civilian settings with limited resources. Damage control in neurotrauma is a therapeutic option for severe traumatic brain injury management in austere environments. To apply the concept while using an appropriate approach, lessons must be learned from experienced neurosurgeons who use this technique regularly.

Introduction. Military neurosurgery.

Introduction. Military neurosurgery.

Direct enhancement of readiness for wartime critical specialties by civilian-military partnerships for neurosurgical care: residency training and beyond.

Military neurosurgery has played an integral role in the development and innovation of neurosurgery and neurocritical care in treating battlefield injuries. It is of paramount importance to continue to train and prepare the next generation of military neurosurgeons. For the Army, this is currently primarily achieved through the military neurosurgery residency at the National Capital Consortium and through full-time out-service positions at the Veterans Affairs-Department of Defense partnerships with the University of Florida, the University of Texas-San Antonio, and Baylor University. The authors describe the application process for military neurosurgery residency and highlight the training imparted to residents in a busy academic and level I trauma center at the University of Florida, with a focus on how case variety and volume at this particular civilian-partnered institution produces neurosurgeons who are prepared for the complexities of the battlefield. Further emphasis is also placed on collaboration for research as well as continuing education to maintain the skills of nondeployed neurosurgeons. With ongoing uncertainty regarding future conflict, it is critical to preserve and expand these civilian-military partnerships to maintain a standard level of readiness in order to face the unknown with the confidence befitting a military neurosurgeon.

Traumatic brain injury among female veterans: a review of sex differences in military neurosurgery.

The impact of traumatic brain injury (TBI) has been demonstrated in various studies with respect to prevalence, morbidity, and mortality data. Many of the patients burdened with long-term sequelae of TBI are veterans. Although fewer in number, female veterans with TBI have been suggested to suffer from unique physical, mental, and social challenges. However, there remains a significant knowledge gap in the sex differences in TBI. Increased female representation in the military heralds an increased risk of TBI for female soldiers, and medical professionals must be prepared to address the unique health challenges in the face of changing demographics among the veteran TBI population. In this review, the authors aimed to present the current understanding of sex differences in TBI in the veteran population and suggest directions for future investigations.

Military Neurosurgery Socioeconomic Data: Benefits, Challenges, and Opportunities.

Military conflict and neurosurgery date back to antiquity. Neurosurgery's development is intimately linked with Harvey Cushing's military experience. Previous papers highlighted unique opportunities and socioeconomic challenges facing military neurosurgeons. Here, we provide objective data from military neurosurgeons surrounding these issues.Internet survey responses were solicited from current, separated, and retired military neurosurgeons regarding workforce issues and their perception of military neurosurgery.A total of 80.9% (98/121) of respondents enjoyed their military experience, 63.6% (77/121) were very pleased with their service; 97.4% (114/117) enjoyed treating military patients, and 78.2% (93/119) would recommend military service. Positives included feelings of patriotism (87.4%), development of camaraderie (71.4%), and deployment experience (93.8%).However, 76.5% of respondents noted concerns regarding military and civilian pay disparity. 37.5% were overwhelmed with administrative responsibilities, and over 50% desired higher case volume.Multivariate analysis showed those who failed to develop a sense of camaraderie were more likely to be dissatisfied (P = .02). Those still currently serving trended towards dissatisfaction (P = .08), and current military neurosurgeons were only 0.29 times as likely to recommend military service to another neurosurgeon as compared to those who were retired or separated (P < .024).Service as a military neurosurgeon is an overwhelmingly positive experience but opportunities exist for mechanisms to increase operative case load, reduce administrative responsibilities, and reduce military-civilian income disparity. Addressing these issues is important as current military neurosurgeons were more likely to be dissatisfied with their military experience and less likely to recommend military service to another neurosurgeon.

Military neurosurgery in operation: experience in the French role-3 medical treatment facility of Kabul.

In 2009, during the war in Afghanistan, the increasing number of head injuries led to the deployment of a military neurosurgeon at the Kabul International Airport (KaIA) medical treatment facility, in March 2010. The main goal of this study was to depict the neurosurgical activity in this centre and to analyse its different aspects. A retrospective study of all the neurosurgical patients treated in KaIA from March 2010 to June 2013. Three hundred and seventy-three interventions performed by the neurosurgeon deployed were reported for 373 surgeries, in 335 patients, representing 10.6% of the overall surgical activity of the centre. Among the 69 interventions performed on soldiers, 57 surgeries were undertaken in emergency (82.6%), while 12 were elective procedures (17.4%). On the other hand, 289 surgeries were performed in civilian Afghans, with 126 emergency procedures in (43.6%), against 163 elective interventions (56.4%). Among the 44.5% (n = 149) of the traumatic casualties, cerebral lesions represented 28.7% (n = 96) and spinal lesions 12.4% (n = 42). Ninety patients had multiple injuries. Additionally, patients without trauma accounted for 55.5% (n = 186) of the overall population. Thus, 49% (n = 164) were operated on for non-traumatic lesion of the spine. These were mostly civilian Afghans treated under medical aid to the population (90.2%, n = 148/164). The military neurosurgeon had two roles in KaIA: both to support the armed forces and to manage medical aid to the civilian population. This study gives food for thought on the neurosurgical needs in modern warfare, and on the skills required for the military neurosurgeon.