Low morbidity among returning Iraq War soldiers treated for spine injury

Walter Reed Medical Center study shows high associated injury rate, low neurological deterioration and low steroid use.

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CHICAGO — Military researchers in Washington found a low mortality rate and high associated injury rate with their current evacuation system for treating Iraq War soldiers with spinal cord and spinal column injuries.

Col. Timothy R. Kuklo, MD, of Walter Reed Army Medical Center (WRAMC), presented the results of the retrospective study here at the American Academy of Orthopaedic Surgeons 73rd Annual Meeting.

"The current data is statistically very good," he said. "We have less than 1% deterioration neurologically. Steroids have not been used in these injuries for the most part. ... The results of some of these soldiers wearing a flak vest are good. Of course, we've seen a statistical [rise] in the penetrating trauma in multi-level injuries that need surgery."

Evacuation system

WRAMC has received the most casualties from Iraq in the United States: over 6300 inpatients, including 1000 primary orthopedic inpatients and 250 neurosurgery patients, Kuklo said. At a three-year follow-up, he and his colleagues looked at the first 112 of 169 spinal cord and spinal column injuries, including 109 men and three women.

Patients were an average 28 years old (range, 20 to 59 years). And, on average, they arrived to WRAMC 8.3 days ± 5.5 days (range, two to 33 days) after injury.

Most patients were evacuated from the Landstuhl Regional Medical Center (LRMC), a U.S. military hospital in Germany. At the LRMC, physicians treat patients for trauma by bracing the spinal cord if necessary, and then immediately evacuate the patients to the continental United States (CONUS).

The researchers concentrated on their treatment algorithms, neurologic change prediction and ultimate outcomes to evaluate if patients lost function during the evacuation process, Kuklo said.

Patient statistics

Forty-five (40%) of the injuries were secondary to penetrating spinal injury (PSI), Kuklo said. Overall, injuries included 40 cervical (19 PSI), 25 thoracic (eight PSI), 37 lumbar (12 PSI) and 10 sacral (six PSI). Sixty-one were multi-level injuries and 11 were noncontiguous. Spinal cord injuries were found in 31 patients, 18 of which were complete injuries.

"Interestingly enough, there is a high incidence of multi-level injuries," Kuklo said. "These are very significant numbers and also about an equal amount of procedures at our institution."

Looking at injury mechanisms, the researchers found high numbers of motor vehicle injuries, Kuklo said. They also found a high incidence of head injuries, open thorax or abdominal injuries and laparotomy, as related to spine injuries. In addition, about 90% of the patients had significant upper and lower extremity injuries, amputations and open extremity injuries.

Results at follow-up

At the three-year follow-up, researchers found that 12 patients with spinal cord injury improved at least one Frankel grade. One patient with partial spinal cord injury deteriorated during medical evacuation, Kuklo said, adding, "most likely would continue to become a complete spinal cord injury."

The researchers found high-dose steroid use in only seven patients, which they attributed to timing and availability, Kuklo said.

Physicians treated 78 patients surgically and 52 required stabilization procedures. "Seven of 24 high-incidence patients that were surgically operated on ... in Germany prior to coming to the [United States] had to be returned to the operating room for instrumentation revision or infection," Kuklo said.

Researchers also found five infections, despite the concomitant bacterial colonization for extremity injuries. "Our postop infection rate is not great, but acceptable, especially in this high injury population," Kuklo said.

For more information:

Kuklo T, Groth A, Neal C, et al. Wartime management of spinal cord and spinal column injuries from Iraq. #192. Presented at the American Academy of Orthopaedic Surgeons 73rd Annual Meeting. March 22-26, 2006. Chicago.