Neurosurg Focus
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Comparative Study
Cranioplasty complications following wartime decompressive craniectomy.
In support of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom-Afghanistan (OEF-A), military neurosurgeons in the combat theater are faced with the daunting task of stabilizing patients in such a way as to prevent irreversible neurological injury from cerebral edema while simultaneously allowing for prolonged transport stateside (5000-7000 miles). It is in this setting that decompressive craniectomy has become a mainstay of far-forward neurosurgical management of traumatic brain injury (TBI). As such, institutional experience with cranioplasty at the Walter Reed Army Medical Center (WRAMC) and the National Naval Medical Center (NNMC) has expanded concomitantly. Battlefield blast explosions create cavitary injury zones that often extend beyond the border of the exposed surface wound, and this situation has created unique reconstruction challenges not often seen in civilian TBI. The loss of both soft-tissue and skull base support along with the need for cranial vault reconstruction requires a multidisciplinary approach involving neurosurgery, plastics, oral-maxillofacial surgery, and ophthalmology. With this situation in mind, the authors of this paper endeavored to review the cranial reconstruction complications encountered in these combat-related injuries. ⋯ This study represents the largest to date in which cranioplasty and its complications have been evaluated in a trauma population that underwent decompressive craniectomy. The overall complication rate of 24% is consistent with rates reported in the literature (16-34%); however, the perioperative infection rate of 12% is higher than the rates reported in other studies. This difference is likely related to aspects of the initial injury pattern-such as skull base injury, orbitofacial fractures, sinus injuries, persistent fluid collection, and CSF leakage-which can predispose these patients to infection.
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For many years, the experience of neurosurgeons from the German Armed Forces was limited to the peacetime care of patients in Germany. In 1995, German military neurosurgeons were deployed abroad for the first time. Since the beginning of the International Security Assistance Force mission, there has been a rapidly increasing number of opportunities for military neurosurgeons to broaden their experience during deployments abroad. ⋯ The majority of neurosurgical procedures were performed in Afghan patients who received acute and elective treatment whenever the necessary infrastructure was available in the field hospital. Fifteen patients from the Afghan National Army and Police and 115 local patients underwent neurosurgery. Sixty-two procedures were carried out under acute or urgent conditions, and 78 operations were elective.
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Historical Article
The development of military medical care for peripheral nerve injuries during World War I.
Although the clinical and electrical diagnoses and treatments of peripheral nerve injuries (PNIs) had been described prior to World War I, many reports were fragmented and incomplete. Individual physicians' experiences were not extensive, and in 1914 the patient with a PNI remained a subject of medical curiosity, and was hardly a focus of comprehensive care. World War I altered these conditions; casualties with septic wounds and PNIs swamped the general hospitals. ⋯ Records were lost, personnel transferred, and patients discharged from the system. The lack of a standardized grading system seriously impaired the ability to record clinical changes and compare outcomes. Nevertheless, specialized treatment of a large number of PNIs during World War I established a foundation for comprehensive care that influenced military medical services in the next world war.
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Case Reports
Neurosurgery in Afghanistan during "Operation Enduring Freedom": a 24-month experience.
"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. ⋯ 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.
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Historical Article
An historical context of modern principles in the management of intracranial injury from projectiles.
The contemporary management of projectile head injuries owes much to the lessons neurosurgeons have distilled from their experiences in war. Through early investigation and an increasingly detailed account of wartime clinical experience, neurosurgeons--including the field's early giants--began to gain a greater understanding not only of intracranial missile pathophysiology but also of appropriate management. In this paper, the authors trace the development of the principles of managing intracranial projectile injury from the Crimean War in the 19th century through the Vietnam War to provide a context that frames a summary of today's core management principles.