Neurosurgery in Afghanistan During “Operation Enduring Freedom”: a 24-Month Experience

Neurosurg Focus 28 (5):E8, 2010

Neurosurgery in Afghanistan during “Operation Enduring Freedom”: a 24-month experience

Br i a n T. Ra g e l , M.D.,1 Pa u l Kl i m o Jr., M.D., M.P.H.,2 Ro b e r t J. Ko w a l s k i , M.D.,3 Ra n d a l l R. McCa f f e r t y , M.D.,3 Je a n n e tt e M. Li u, M.D.,4 De r e k A. Ta g g a r d , M.D.,4 Da v i d Ga r r e tt Jr., M.D.,3 a n d Si d n e y B. Br e v a r d , M.D., M.P.H.5 1Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; 2Wright Patterson Air Force Base, Ohio; 3Department of Neurosurgery, Wilford Hall Medical Center, Lackland Air Force Base, Texas; 4Department of Neurosurgery, David Grant Medical Center, Travis Air Force Base, California; and 5Department of Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland

Object. “Operation Enduring Freedom” is the US war effort in Afghanistan in its global war on terror. One US military neurosurgeon is deployed in support of Operation Enduring Freedom to provide care for both battlefield injuries and humanitarian work. Here, the authors analyze a 24-month neurosurgical caseload experience in Afghanistan. Methods. Operative logs were analyzed between October 2007 and September 2009. Operative cases were divided into minor procedures (for example, placement of an intracranial pressure monitor) and major procedures (for example, craniotomy) for both battle injuries and humanitarian work. Battle injuries were defined as injuries sustained by soldiers while in the line of duty or injuries to Afghan civilians from weapons of war. Humanitarian work consisted of providing medical care to Afghans. Results. Six neurosurgeons covering a 24-month period performed 115 minor procedures and 210 major surgical procedures cases. Operations for battlefield injuries included 106 craniotomies, 25 spine surgeries, and 18 miscellaneous surgeries. Humanitarian work included 32 craniotomies (23 for trauma, 3 for tumor, 6 for other reasons, such as cyst fenestration), 27 spine surgeries (12 for degenerative conditions, 9 for trauma, 4 for myelomeningocele closure, and 2 for the treatment of infection), and 2 miscellaneous surgeries. Conclusions. Military neurosurgeons have provided surgical care at rates of 71% (149/210) for battlefield injuries and 29% (61/210) for humanitarian work. Of the operations for battle trauma, 50% (106/210) were cranial and 11% (25/210) spinal surgeries. Fifteen percent (32/210) and 13% (27/210) of operations were for humanitarian cranial and spine procedures, respectively. Overall, military neurosurgeons in Afghanistan are performing life-saving cranial and spine stabilization procedures for battlefield trauma and acting as general neurosurgeons for the Afghan community. (DOI: 10.3171/2010.3.FOCUS09324)

Ke y Wo r d s • Afghanistan • neurosurgery • Operation Enduring Freedom

p e r a t i o n Enduring Freedom is the US-led war mission is to “preserve the fighting force” by caring for effort in Afghanistan in its global war on terror. injured coalition soldiers (NATO and Afghan military The International Security and Assistance Force and security forces [AMSF]), as well as to provide care Ois NATO’s operation to rebuild Afghanistan and pro- for war-injured enemy combatants and Afghan civil- vide security. United States military neurosurgeons are ians.2,3,7,8,18,21,29,36 A secondary humanitarian mission is to a part of the International Security and Assistance Force, provide care for the local community.3,18,29 commanded by the acting US general in Afghanistan. In September 2007, a decision was made to provide The CJTH at Bagram Airfield, Afghanistan, is the mili- continuous neurosurgical coverage to Bagram Airfield tary’s primary trauma center for the entire country; its by sending a single Air Force neurosurgeon for a 4- to 6-month deployment in support of the dual missions/ roles. Surgical and personal experiences and lessons Abbreviations used in this paper: AMSF = Afghan military and learned are dependent on the role being fulfilled. The security forces; CJTH = Heathe N. Craig Joint Theater Hospital; GSW = gunshot wound; ICP = intracranial pressure; IED = impro- types of combat-related injuries to coalition forces and vised explosive device; MVC = motor vehicle collision; NATO = the management of those injuries are similar to those 3,11,14,16,19,21,24– North Atlantic Treaty Organization; RPG = rocket-propelled gre- previously reported in Afghanistan and Iraq. nade; VB = vertebral body. 26,28–30,32–34,36 However, it is in the context of a secondary

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sions. Minor procedures included placement of an ICP monitor, ventriculostomy, cervical spine clearance by active flexion-extension under fluoroscopy, lumbar drainage or puncture, halo orthosis placement, and placement of Gardner-Wells tongs for cervical traction. Major neurosurgical procedures were defined as taking place in the operating room under general anesthesia (for example, craniotomy, placement of spinal instrumentation). Battlefield injuries were defined as injuries sustained by soldiers while in the line of duty or civilian casualties. Civilian battlefield injuries were injuries caused by weapons of war (for example, GSW, IEDs). Humanitarian work consisted of routine civilian trauma cases and elec- Fig. 1. Line graph depicting number of war and humanitarian neu- tive procedures. Routine trauma was defined as injuries rosurgical operative cases performed per month in Afghanistan during sustained by local Afghan civilians while performing Operation Enduring Freedom between October 2007 and September normal daily activities (for example, MVC or fall from 2009. Note: The capacity for neurosurgical caseload at CJTH was ap- height). Humanitarian elective cases were non–trauma- proximately 8 cases per week. Thus, as wartime operations increased, the ability to accommodate humanitarian cases decreased. related neurosurgical cases (for example, myelomeningocele closure, discectomy). role that neurosurgeons have encountered unique challenges and experiences. Results Afghanistan has been at war for the last 30 years, Two-hundred and ten neurosurgical operations were from the occupation by the former Soviet Union in the performed in 185 patients at CJTH between October 1, late 1970s, through fighting between various warlords af- 2007, and September 30, 2009, by 6 neurosurgeons (Fig. ter the withdrawal of Soviet forces, to the current conflict 1). Neurosurgeons performed an average of 8.7 operations over the past 8 years. Noncombatant Afghans have been per month (range 4−14 cases). On average, the number of injured as a result of collateral damage from active fight- neurosurgical procedures performed for battlefield inju- ing, millions of past and present land mines, and ongoing 3,5,6,18,29 ries and humanitarian work were 6.2 (range 1–11) and 2.5 placement of IEDs. The Afghan health care sys- (range 1–8) per month, respectively (Fig. 1). tem is woefully inadequate and rudimentary at best, and 15,18,20 One hundred and forty-nine neurosurgical opera- few Afghans can afford medical care. Widespread tions for battlefield injuries were performed in 128 pa- lack of both running water and waste disposal contrib- tients, including 26 operations in 25 NATO soldiers, 71 ute to the high rate of malaria, intestinal tapeworms, and operations in 61 AMSF soldiers, 10 operations in 10 ene- tuberculosis. Malnourishment abounds, which has direct my combatants, and 42 operations in 32 Afghan civilians impact on immediate surgical factors such as prolonged who sustained injuries from weapons of war (Table 1). coagulation studies (for example, prothrombin times) and 12 Neurosurgical humanitarian cases accounted for 34 pro- long wound-healing times after surgery. cedures in 31 patients for routine trauma and 27 elective In this manuscript, we report the types of cases per- operations in 26 patients (Table 1). Overall, 71% (149) formed by US Air Force neurosurgeons in Afghanistan of the 210 surgical procedures performed by military between October 2007 and September 2009 and detail neurosurgeons in Afghanistan were for the treatment of the lessons learned. war-related injuries and 29% (61) were considered humanitarian work (Table 1). Methods Operations for Wartime Trauma War Records Twenty-five NATO soldiers required 26 neurosurgical At the onset of the neurosurgical mission in Bagram, interventions for trauma, including 20 cranial procedures neurosurgeons kept track of their personal surgical case (13 craniotomies, 6 decompressive hemicraniectomies for war records. Data collected included: diagnosis, mecha- uncontrolled ICP, and 1 decompressive hemicraniectomy nism of injury if applicable, operation performed, and for hemispheric stroke secondary to penetrating cervical complications, as well as the patient’s sex, age, and country intracranial artery injury). Two soldiers required spine of origin. Mechanism of injury was classified as gunshot procedures (1 for a penetrating injury and 1 for blunt wound (GSW), IED, rocket-propelled grenade (RPG), land trauma). Two soldiers underwent nerve graft repairs (1 for mine, motor vehicle collision (MVC), or fall from height. segmental median nerve loss and 1 for a transected per- For mechanism of injury analysis, IEDs, RPGs, and land oneal nerve). One soldier required closure of a complex mines were combined into one category called “explosive scalp wound. One soldier with neurofibromatosis Type 1 devices.” Country-of-origin was classified as NATO (US, underwent elective surgery for removal of subcutaneous Canada, and United Kingdom) or non-NATO (AMSF, en- scalp neurofibromas. All NATO soldiers undergoing neu- emy combatant, and local Afghan civilians). rosurgical operations for trauma at CJTH were medically Neurosurgical procedures were categorized as major evacuated to a US military hospital in Germany (Land- or minor and as battlefield injuries or humanitarian mis- stuhl Regional Medical Center) when medically stable

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TABLE 1: Neurosurgical procedures performed by US military neurosurgeons in Afghanistan in support of Operation Enduring Freedom*

No. of Cranial Procedures No. of Spinal Procedures Category No. of Pts No. of Cases Craniotomy DHC Other Stabilization Other No. of Misc Cases war trauma 128 149 76 30 0 19 6 18 NATO 25 26 13 7 0 1 1 4 AMSF 61 71 36 16 0 13 3 3 EC 10 10 6 1 0 1 0 2 AL 32 42 21 6 0 4 2 9 humanitarian† 57 61 20 6 6 12 15 2 trauma 31 34 17 6 0 9 0 2 elective 26 27 3 0 6 3 15 0 total 185 210 96 36 6 31 21 20

* Between October 2007 and September 2009, 210 operations were performed in 185 patients for war-related injuries and humanitarian work by 6 neurosurgeons. Abbreviations: AL = Afghan local; DHC = decompressive hemicraniectomy; EC = enemy combatant; Misc = Miscellaneous; Pts = Patients. † Surgical procedures involving treatment of local Afghan civilians.

(usually 12–24 hours after surgery). The US soldiers were 11% (7/61). In Afghan civilians, the mechanism of injury subsequently transported back to the US 3–4 days after was GSW in 23% (15/63), explosive device in 27% (17/63), injury. 2,21 and accident in 49% (31/63) (Table 2). Sixty-one Afghan soldiers required 71 neurosurgical operations, including 52 cranial procedures, 16 spine Minor Procedures procedures (13 spine stabilizations, 1 dural repair after One-hundred and fifteen minor procedures were penetrating injury, and 2 partial sacrectomies), and 3 mis- performed over the time studied. These consisted of 85 cellaneous operations (2 incision and drainage of scalp procedures for battlefield injuries and 30 procedures for wounds and 1 incision and drainage of lumbar wound). humanitarian cases. Minor procedures for wartime cases Ten enemy combatants required 7 cranial surgeries, 1 included 51 ICP monitor placements, 15 ventriculosto- spinal stabilization, and 2 complex scalp wound closures. mies, 10 lumbar punctures or drain placements, 8 cervical Forty-two operations were performed in 32 local Afghan spine clearances by flexion-extension under fluoroscopy, citizens, including 27 cranial surgeries, 6 spine surgeries and 1 halo orthosis placement. Minor procedures for hu- (4 spine stabilizations and 2 dural repairs after penetrat- manitarian cases included 15 ICP monitor placements, ing injury), and 9 miscellaneous surgeries (5 closures of 5 ventriculostomies, 6 instances of lumbar puncture or complex scalp lacerations, 3 peripheral nerve repairs, and placement of lumbar drain, 3 flexion-extension studies of 1 neck exploration). the cervical spine under fluoroscopy, and 1 placement of Gardner-Wells tongs for cervical traction. Operations for Humanitarian Work Neurosurgical humanitarian work consisted of rou- Complications tine trauma and elective cases. Thirty-one Afghan pa- No surgery-related complications were noted in tients had 34 neurosurgical operations for trauma sus- NATO forces prior to transfer to Germany. However, these tained during normal daily activities. This included 23 patients were transferred within 1–2 days of surgery and craniotomies, 9 spine stabilization surgeries, and 2 com- were lost to follow-up to the authors. The authors report plex scalp closures. One patient sustained a non–com- only their personal war records, which did not include pa- bat-related indirect GSW to the head while attending a tient identifiers. Additionally, the US Armed Forces do wedding celebration. Twenty-six Afghans underwent 27 not track medical outcomes on non-US NATO soldiers. elective surgeries, including 3 craniotomies for tumor, 6 However, the following complications were noted in non- miscellaneous cranial procedures (4 ventriculoperitoneal NATO patients: 2 deaths during craniotomy for trauma shunt placements, 2 arachnoid cyst fenestration), and 18 from pulmonary embolus and uncontrollable bleeding spine procedures (12 basic spine surgeries, 4 myelom- from the sagittal sinus, 1 postoperative death from sep- eningocele closures, and 2 spine operations for tubercu- sis after delayed closure of open myelomeningocele, 1 lous spondylitis). wound revision 5 days after craniotomy for penetrating head injury with debridement of necrotic brain, 2 bone Mechanism of Injury flap expansions after decompressive hemicraniectomy to For injuries sustained by NATO soldiers, the mecha- prevent herniation of brain over bone edges, 1 case of in- nism of injury was GSW in 38% of cases (9/24), explo- creased paraparesis after thoracic anterior vertebral body sive device in 54% (13/24), and accident in 8% (2/24). In reconstruction for tuberculous spondylitis, 4 cases in AMSF, the mechanism of injury was GSW in 33% (20/61) which incision and drainage of previously closed complex of cases, explosive device in 56% (34/61), and accident in scalp wounds was required, and 2 wound revisions.

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TABLE 2: Mechanisms of injury in 210 neurosurgical procedures in an inpatient wartime hospital*

Mechanism of Injury (%) Patient Category No. of Patients GSW Explosive Devices† Accidents NATO 24‡ 38 54 8 AMSF 61 33 56 11 Afghan civilian 63§ 23 27 49

* Surgery performed by 6 neurosurgeons between October 2007 and September 2009 at CJTH. The 210 operations were performed in 185 patients for treatment of war-related injuries and as part of the humanitarian mission. † Includes IEDs, RPGs, and land mines. ‡ Excludes 1 soldier who underwent an elective procedure. § Includes all local Afghan civilians who were treated for either wartime trauma (32 patients) or non–war-related trauma (humanitarian work, 31 patients).

Case Illustrations retained metal fragment projecting through the right orbit and into the frontal lobe (Fig. 3). It took over 4 days Case 1—Decompressive Hemicraniectomy for Penetrating for him to reach the hospital from his village in western Head Injury Afghanistan. During this time, the boy was kept moder- ately sedated with intravenous medication. On arrival, he This 23-year-old male Afghan soldier sustained a was awake, alert, and had no focal signs of deficit except low-velocity GSW to the right parietal region (Fig. 2). for blindness in his left eye. A CT angiogram revealed His Glasgow Coma Scale score was 5T, and a head CT no evidence of vascular injury. The patient underwent a scan showed the bullet resting in the right parietal cor- bifrontal craniotomy to expose the distal end of the frag- tex with imploded bone fragments along the bullet path ment (part of a bomb casing), which was then removed (Fig. 2). The patient underwent a right decompressive in a controlled fashion. The frontal lobe was debrided, hemicraniectomy with wound debridement; the bone flap a duraplasty was performed, and the frontal fossa floor was stored in a freezer. Three months postoperatively, the patient was conversant and ambulatory on examina- was repaired with bone and titanium microplates. Oph- tion. Four months after the decompressive craniectomy, thalmologists then performed a formal enucleation. Post- the patient underwent successful autologous cranioplasty with a good cosmetic result. Case 2—IED Injury to the Eye This 14-year-old Afghan boy had been struck by a roadside IED and was brought to the CJTH with a large

Fig. 2. Illustrative Case 1. A: Axial CT image depicting GSW to the head in which the bullet entered the right parietal bone causing implo- sion of bone fragments inward along the bullet track. The low-velocity bullet penetrated approximately 3 cm before stopping in the right pa- Fig. 3. Illustrative Case 2. A and B: Lateral skull radiograph (A) rietal cerebral cortex. B: Axial CT after placement of left external and photograph (B) depicting metal pipe fragment from an IED that im- ventricular drain and right decompressive hemicraniectomy for debride- pacted the patient’s left eye. C: A CT coronal reconstruction showing ment of GSW. Note: Because of brain swelling, the bone flap was left off the blunt portion of the metal fragment located within the left orbit. D: and stored at 30°F until cranioplasty with autologous bone flap. Photograph of the metal pipe fragment after removal.

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Fig. 4. Illustrative Case 3. A: A CT sagittal reconstruction of tuberculous spondylitis eroding the T-11 and T-12 VBs with retropulsion of a caseating granuloma–bone fragment mass into the spinal canal. B and C: Axial CT images of the T-11 (B) and T-12 (C) VBs showing approximately 50% spinal canal narrowing. D: Photograph of left fibula exposure prior to harvesting for “double-barrel” autologous bone grafting for T11–12 anterior VB reconstruction. E and F: Lateral (E) and anterior-posterior (F) radiographs of the final anterior VB reconstruction with double-barrel fibular strut grafts and lateral VB pedicle screw and rod construct. operatively, the patient made an excellent recovery aside VB rods and screws.27 The patient was able to walk with from his unilateral blindness. assistance at the 2-month follow-up examination. Case 3—Tuberculous Spondylitis With Anterior VB Reconstruction Discussion This 60-year-old woman with known tuberculosis Military neurosurgeons in Afghanistan serve a dual presented with a 2-year history of worsening lower ex- role of providing care to soldiers and to the local Afghan tremity paraparesis. She had been wheelchair bound for community. 3,18,29 Interestingly, the surgical challenges of the past year. An examination showed a kyphotic defor- today’s conflicts are similar to those of previous wars, mity at the thoracolumbar junction and lower extremity with limited hospital beds, supplies, and personnel.38 strength of 3 out of 5 throughout (Fig. 4). A spine CT A war-zone medical facility must quickly transfer war- revealed severe erosion of T-11 and T-12 with 50% canal time injured soldiers out of the country (usually, NATO compromise (Fig. 4). The patient underwent a left thora- forces) or to local hospitals (typically, Afghan Army) in cotomy with removal of a caseating granuloma at T11– order to maintain the ability to treat the newly wounded. 12. Anterior VB reconstruction was accomplished with Thus, economic use of personnel and hospital resources double-barreled autologous fibular strut graft and lateral mandated prompt operative decision-making to balance

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Mechanism of Combat-Related Injuries in Soldiers and Civilians A difference in the proportion of surgeries for soldiers in comparison with Afghan citizens was observed. The proportion of GSW victims who required neurosurgery for their wounds was between 33 and 39% for soldiers and 47% for Afghan locals. We attribute this difference to the wide use of helmets and body armor by soldiers.3,29 The proportion of NATO soldiers requiring neurosurgery is higher than the overall injury rates previously reported in the literature.3,14,16,19,25,26,28–30,32,36,37 A recent report noted 6609 injuries in 1566 US soldiers during combat in Iraq and Afghanistan.26 In that study, the proportions of injuries caused by GSW and explosions were 18 and 78%, respectively. 26 The authors attribute differences in the data they present (38 and 54%, respectively, Table 2) to the dif- ferent preferences in enemy tactics in Afghanistan (use of direct- and indirect-fire weapons) and Iraq (use of IEDs). Also, our data reflect the caseload at an inpatient wartime hospital rather than overall wartime soldier injury patterns. Interestingly, military neurosurgeons are asked to provide forensic information to aid in the analysis of evolving enemy tactics. Lessons Learned in the Operative Management of Penetrating Head Injuries From IEDs The opposing fighters use IEDs to incapacitate or de- stroy personnel and equipment. These devices are usually constructed from conventional military high-explosive weapons (e.g., artillery shells) attached to a detonating mechanism.7,13,14,22,24 Such IED attacks in Afghanistan and Iraq are common, accounting for 48% (2560/5283) and 65% (23,650/36,222) of all US soldier deaths and injuries, respectively.1 Our experience with penetrating cranial injuries due to IED blast reveal cranial injuries from ball bearings, nails, metal fragments, and rocks (Cases 1 and 2; Figs. 2, 3, and 5). Fig. 5. Examples of penetrating head injuries from IEDs. A and Several issues were important in the management of B: Lateral (A) and anterior-posterior (B) CT scout images obtained in these patients. Patient hemodynamic stabilization was a a soldier attacked by roadside IED packed with nails and ball bear- priority in these cases, with treatment of life-threatening ings. C and D: Lateral (C) and anterior-posterior (D) CT scout im- bleeding attended to prior to or in conjunction with the ages obtained in a soldier attacked by IED with a metal fragment “hooked” into frontal sinus. E and F: Sagittal (E) and axial (F) head craniotomy. Without access to magnetic resonance (MR) CT images obtained in a soldier attacked by IED with rock impacting imaging equipment, CT angiograms proved valuable for the left frontal bone. evaluation of intra- and extracranial vascular injury due to a roughly 30% incidence of cerebrovascular injury.4 Ag- gressive surgical management was warranted in all cases not believed imminently fatal. Large craniotomies were performed in the event of need to convert to a decompres- patient outcome with rapid, safe transfer of patients. For sive hemicraniectomy. There was a low threshold to per- example, decompressive craniectomy evolved to be the form decompressive hemicraniectomies for those cases in treatment of choice for recalcitrant ICP elevation because which the neurosurgeons believed intracranial hyperten- it allowed for the safe transfer of patients on long medi- sion was highly likely, this is because of long transport cal flights, as well as to local hospitals lacking intensive flights where neurosurgical care and intracranial moni- care units. Humanitarian work was also limited by the toring were not available (Case 1).4 Particular attention local Afghan medical system’s ability to care for patients was paid to making the craniotomy as large as possible needing either high-end nursing care (for example, care of to diminish the risk of any postoperative ICP issues and quadriplegic patients) or advanced treatment modalities also to prevent herniating brain tissue from becoming (for example, chemotherapy). Therefore, neurosurgeons lacerated and ischemic at the cut bone edges. Intraparen- tended to focus humanitarian surgical efforts on disease chymal injuries were debrided without being overly ag- states that did not require advanced care or therapies. gressive with deep and small bone or foreign fragments,

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The first surgery wounds from years of war, lack of adequate local health often represented “damage control” surgery with an em- care, malnourishment, long travel times for patients, and phasis on quick removal of mass lesions, homeostasis, lack of postoperative tertiary care (for example, tracheo- and quick decision on decompressive hemicraniectomy; stomy care).9,10,23,32,39 Overall, US military neurosurgeons deep imploded bone fragments and foreign bodies were performed a broad spectrum of general neurosurgical not chased.4 Second or third operations were sometimes procedures including myelomeningocele closures, micro necessary for further debridement of necrotic brain tis- discectomies, spine stabilization for tuberculous spon- sue, and it was found that deep imploded bone fragments dylitis, craniotomy for tumor, and general neurosurgical and foreign bodies would often deliver themselves to the trauma care for Afghans injured during normal daily surface at this time. activities.31 Several lessons were learned in treating mal- nourished patients, as well as patients with tuberculosis.17 Lessons Learned in Bone Flap Management The general nutritional health of the average Afghan Bone flap management for soldiers being transported civilian is poor because of a combination of inadequate on an 8-hour flight to Germany without subzero freez- nutritional intake and endemic intestinal parasites (for ers, as well as proper handling and storage of autologous example, ascarids). The 2 major surgical issues attributed bone flaps of Afghan patients without cryogenic freezers to malnourishment were prolonged coagulation studies presented unique challenges in cases requiring decom- and poor wound healing. Preoperative administration of vitamin K would usually correct mildly elevated co- pressive hemicraniectomy. Three scenarios of managing 12 decompressive bone flaps were encountered, depending agulation studies within 24 hours. Attempts to enhance wound healing were made by treating patients with an an- upon the patient’s country of origin. For US soldiers, bone tihelminthic medication (usually mebendazole) in hopes flaps were routinely discarded because of fear of infec- of increasing nutritional absorption in the short term. In tion and our excellent cosmetic results from 3D methyl- 21 addition, incision staples were left in for at least 14 days methacrylate prosthetic implants. For all patients from because earlier removal often resulted in wound dehis- other NATO forces, bone flaps were placed in a subcu- cence. Tuberculosis is also endemic in Afghanistan and taneous abdominal pocket, preferably on the left lower untreated patients were required to complete at least 2 quadrant to avoid contamination by feeding tube place- weeks of an antituberculosis regimen (typically rifampin ment and to decrease the chance of later confusion with and isoniazid) prior to being allowed into the hospital to an appendectomy scar. Finally, for injured Afghans, bone undergo elective surgery.17 flaps were washed with bacitracin irrigation, sterilely wrapped, and stored at 30°F (Case 1, Fig. 2). To date, no Lesson Learned in Case of Probable Early Fatal postoperative cranioplasty infections have been noted. Pulmonary Embolus After IED Attack One 4-year-old patient required cranioplasty revision with mesh and methylmethacrylate at 8 months postop- We would like to draw attention to one particular eratively because of autograft resorption. case of a soldier who died in the operating room of a presumed pulmonary embolus. This 25-year-old Afghan Lessons Learned in Humanitarian Work soldier was a passenger in a car attacked by an IED, and sustained a right open tibia–fibula fracture and depressed The Afghan health care system has been devastated 5 frontal sinus fracture with embedded bone fragment in due to the 3 decades of constant military conflict. Many the left frontal lobe. A CT angiogram showed no vascular medical professionals fled the country in the 1980s and injury. The patient was taken to the operating room for 1990s resulting in a halt in the training of new health simultaneous below-the-knee amputation and bifrontal care professionals. In the early 2000s Afghanistan had craniotomy for skull fracture elevation. Shortly after the 11 physicians and 18 nurses per 100,000 population, with leg was removed and the bifrontal craniotomy performed, 1 medical facility for every 27,000 people.5 Most of the the patient went into cardiac pulseless electrical activity current health care is provided by humanitarian aid, with and his oxygen saturation dropped to 40%. Cardiopulmo- roughly 25% of the population having no access to medi- nary resuscitation was instituted. Intraoperative maneu- cal care.5 Between 250 and 400 patients daily at an Egyp- vers included covering the sagittal sinus with wet packs, tian hospital at Bagram Airfield, with patients needing placement of bilateral chest tubes, aspiration of the right neurosurgical care referred to the CJTH. Patients were ventricle with a long central line, replacement of the bone often within driving distance, but some were known to flap, and closure of scalp wound. Epinephrine and blood walk for weeks before reaching the Egyptian hospital. products were administered. Upon return of his pulse, the The decision to treat neurosurgical disorders was com- patient was transferred to the intensive care unit where an plex and imperfect. Due to lack of ancillary services, the echocardiogram revealed a hypokinetic heart without ev- neurosurgeons were unable to treat any disease process idence of air embolus. The cardiac rhythm was again lost that would require prolonged hospitalization, or further and the patient died after bedside exploratory laparotomy high-end therapies (for example, chemotherapy). Treated and thoracotomy for open cardiac massage. An autopsy patients were cared for until well enough to transfer to the was not performed due to local Afghan customs requiring Egyptian inpatient service or home. the deceased to be buried within 24 hours. Neurosurgeons undertaking humanitarian work We believe blast injuries prime the vascular system in Afghanistan report observations similar to those re- for deep vein thrombosis and venous thromboembolism ported by other workers in war-torn countries: horrific by damaging vascular endothelium and upregulating pro-

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Unauthenticated | Downloaded 10/09/21 04:59 AM UTC B. T. Ragel et al. coagulation factors (such as thromboxane A2).7,13 This, 2. Bates M: Flying for life. Airman: Offical Magazine of the combined with extremity bone fractures, rapid infusion United States Air Force 42:4–9, 2008 of blood products, and possible activated factor VII ad- 3. Beekley AC, Watts DM: Combat trauma experience with the ministration, may increase the chance of early deep vein United States Army 102nd Forward Surgical Team in Af- 35 ghanistan. Am J Surg 187:652–654, 2004 thrombosis with subsequent fatal pulmonary embolus. 4. Bell RS, Vo AH, Neal CJ, Tigno J, Roberts R, Mossop C, et al: Although in this case fatal air embolus cannot be ex- Military traumatic brain and spinal column injury: a 5-year cluded, we believe primary embolus is more likely due study of the impact blast and other military grade weaponry to isolated reports of similar intraoperative deaths in Iraq on the central nervous system. J Trauma 66 (4 Suppl):S104– after attack by IED (personal communications) and the S111, 2009 negative echocardiogram. After this case, only life-saving 5. Bilukha OO, Brennan M, Anderson M: Injuries and deaths craniotomies were immediately performed on patients from landmines and unexploded ordnance in Afghanistan, 2002–2006. JAMA 298:516–518, 2007 sustaining polytrauma from IED attack. 6. Bilukha OO, Brennan M, Woodruff BA: Death and injury from landmines and unexploded ordnance in Afghanistan. Conclusions JAMA 290:650–653, 2003 7. Cernak I, Savic J, Ignjatovic D, Jevtic M: Blast injury from Military neurosurgeons in Afghanistan perform explosive munitions. J Trauma 47:96–104, 1999 life-saving cranial operations and spine stabilization 8. Doscher TJ: New joint theater hospital offers advanced care in Afghanistan, in American Forces Press Service: Depart- procedures for wartime injuries and act as general neu- ment of Defense, 2007 rosurgeons to the local Afghan community. The lessons 9. Ellegala DB: Neurosurgery in the bush. Congress Quarterly learned with regard to combat-related injuries are similar 9:17–19, 2008 to those learned in Iraq and other conflicts. Military neu- 10. Farrow GB, Rosenfeld JV, Crozier JA, Wheatley P, Warfe P: rosurgeons are also asked to provide forensic informa- Military surgery in Rwanda. Aust N Z J Surg 67:696–702, tion to aid in the continual assessment of evolving enemy 1997 tactics. We experienced unique issues when treating the 11. Foulkes GD: Orthopedic casualties in an activated National local Afghan population. As the neurosurgical mission Guard Mechanized Infantry Brigade during Operation Desert Shield. Mil Med 160:128–131, 1995 continues in Afghanistan, undoubtedly lessons will con- 12. Friedman PA: Vitamin K-dependent proteins. N Engl J Med tinue to be learned and measures implemented that will 310:1458–1460, 1984 hopefully further endeavors to provide the best care for 13. Garner MJ, Brett SJ: Mechanisms of injury by explosive de- all patients. vices. Anesthesiol Clin 25:147–160, 2007 14. Gondusky JS, Reiter MP: Protecting military convoys in Disclosure Iraq: an examination of battle injuries sustained by a mechanized battalion during Operation Iraqi Freedom II. Mil Med The authors report no conflict of interest concerning the mate- 170:546–549, 2005 rials or methods used in this study or the findings specified in this 15. Guidotti RJ, Kandasamy T, Betran AP, Merialdi M, Hakimi F, paper. Van Look P, et al: Monitoring perinatal outcomes in hospitals The opinions and assertions contained herein are the private in Kabul, Afghanistan: the first step of a quality assurance views of the authors and are not to be construed as official or reflect- process. J Matern Fetal Neonatal Med 22:285–292, 2009 ing the views of the US Air Force, the Department of Defense, or the 16. Helmkamp JC: United States military casualty comparison Department of Veterans Affairs. during the Persian Gulf War. J Occup Med 36:609–615, Author contributions to the study and manuscript prepara- 1994 tion include the following. Conception and design: Ragel, Klimo, 17. Khan K, Muennig P, Behta M, Zivin JG: Global drug-resis- Kowalski, McCafferty, Liu, Taggard, Garrett, Brevard. Acquisition tance patterns and the management of latent tuberculosis in- of data: Ragel, Klimo, Kowalski, McCafferty, Liu, Taggard, fection in immigrants to the United States. N Engl J Med Garrett, Brevard. Analysis and interpretation of data: Ragel, Klimo, 347:1850–1859, 2002 Kowalski, McCafferty, Liu, Taggard, Garrett, Brevard. Drafting the 18. Klimo PK, Ragel B: Military neurosurgery in support of Op- article: Ragel, Klimo, Kowalski, McCafferty, Liu, Taggard, Garrett, eration Enduring Freedom (OEF). AANS Young Neurosur- Brevard. Critically revising the article: Ragel, Klimo, Kowalski, geons Committee Newsletter:2–7, 2009 McCafferty, Liu, Taggard, Garrett, Brevard. Reviewed final version 19. Leedham CS, Blood CG, Newland C: A descriptive analysis of of the manuscript and approved it for submission: Ragel, Klimo, wounds among U.S. Marines treated at second-echelon facili- Kowalski, McCafferty, Liu, Taggard, Garrett, Brevard. ties in the Kuwaiti theater of operations. Mil Med 158:508– 512, 1993 Acknowledgments 20. Lejars M: [Health system in Afghanistan: problems and insti- tutional perspectives.] Med Trop (Mars) 68:463–467, 2008 The authors thank Kristin Kraus and Shirley McCartney, Ph.D. (Fr) for editorial assistance. 21. Moores L: Neurosurgery in U.S. Military. Congress Quar- terly 9:31–36, 2008 References 22. Morrison JJ, Mahoney PF, Hodgetts T: Shaped charges and explosively formed penetrators: background for clinicians. J 1. Anonymous: DoD Personnel & Procurement Statistics: R Army Med Corps 153:184–187, 2007 Global War on Terrorism Casualty Summary by Reason, 23. Muraszko K, Boulis NM: Project Shunt: University of Michi- October 7, 2001 through December 5, 2009. DoD, De- gan goes to Guatemala. Congress Quarterly 9:1–15, 2008 fense Manpower Data Center, Personnel & Procurement Re- 24. NiNicolo G: Reducing the threat. Military Officer 6:92–97, ports and Data Files (http://siadapp.dmdc.osd.mil/personnel/ 2008 CASUALTY/gwot_reason.pdf) [Accessed December 22, 25. Owens BD, Kragh JF Jr, Macaitis J, Svoboda SJ, Wenke JC: 2009] Characterization of extremity wounds in Operation Iraqi

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Freedom and Operation Enduring Freedom. J Orthop Trau- 35. Spinella PC, Perkins JG, McLaughlin DF, Niles SE, Grathwohl ma 21:254–257, 2007 KW, Beekley AC, et al: The effect of recombinant activated 26. Owens BD, Kragh JF Jr, Wenke JC, Macaitis J, Wade CE, factor VII on mortality in combat-related casualties with se- Holcomb JB: Combat wounds in operation Iraqi Freedom and vere trauma and massive transfusion. J Trauma 64:286–294, operation Enduring Freedom. J Trauma 64:295–299, 2008 2008 27. Ozdemir HM, Us AK, Oğün T: The role of anterior spinal 36. Tai N, Hill P, Kay A, Parker P: Forward trauma surgery in instrumentation and allograft fibula for the treatment of pott Afghanistan: lessons learnt on the modern asymmetric battle- disease. Spine 28:474–479, 2003 field. J R Army Med Corps 154:14–18, 2008 28. Parker PJ, Adams SA, Williams D, Shepherd A: Forward sur- 37. Travis MT, Cosio MQ: A retrospective review of orthopedic gery on Operation Telic—Iraq 2003. J R Army Med Corps patients returning from Operations Desert Shield and Desert 151:186–191, 2005 Storm to an Army Medical Center. Mil Med 158:348–351, 29. Peoples GE, Gerlinger T, Craig R, Burlingame B: Combat ca- 1993 sualties in Afghanistan cared for by a single Forward Surgical 38. Trunkey D: Lessons learned. Arch Surg 128:261–264, 1993 Team during the initial phases of Operation Enduring Free- 39. Warf BC: Hydrocephalus in Uganda: the predominance of dom. Mil Med 170:462–468, 2005 infectious origin and primary management with endoscopic 30. Pratt JW, Rush RM Jr: The military surgeon and the war on third ventriculostomy. J Neurosurg 102 (1 Suppl):1–15, terrorism: a Zollinger legacy. Am J Surg 186:292–295, 2003 2005 31. Ragel BT, McCafferty RR: Indirect gunshot wound to the head. Acta Neurochir (Wien) 150:1311–1312, 2008 32. Rosenfeld JV: A neurosurgeon in Iraq: a personal perspective. J Clin Neurosci 13:986–990, 2006 Manuscript submitted December 30, 2009. 33. Souka HM: Management of Gulf War casualties. Br J Surg Accepted March 8, 2010. 79:1307–1308, 1992 Address correspondence to: Brian T. Ragel, M.D., Department of 34. Spalding TJ, Stewart MP, Tulloch DN, Stephens KM: Pen- Neurological Surgery, Oregon Health & Science University, Mail etrating missile injuries in the Gulf War 1991. Br J Surg Code CH8N, 3303 SW Bond Avenue, Portland, Oregon 97239. 78:1102–1104, 1991 email: [email protected].

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