Spinal Injuries during Military Operations or under Limited Resources: What Must, What Can, and What Should Be Done and When?

Combat-related spinal injuries have risen from around 1% in the second half of the last century to 5%–8% in the 2000s. With an average disability rate of 60%, spinal disorders are the second-most common cause of disability among retired US veterans. The increase is attributed to changes in war tactics, such as asymmetric warfare in Iraq and Afghanistan, where improvised explosive devices were increasingly used, leading to changes in injury profiles. Moreover, the conflict in Ukraine shows a new high intensity of warfare, in which modern artillery, guided missiles, drones, and cluster bombs are used. These experiences call for a critical analysis of existing guidelines and consensus, which have so far been based on fixed role allocations among the various echelons. It may be necessary to rethink and make more flexible the health care chains currently used in military and austere environments. The purpose of this paper is to provide an overview of the state of the scientific literature and guidelines on the question of which surgical treatments of spinal injuries must, can, or should be performed during military operations or under limited resources. Publicly available guidelines on the timing of surgical treatment of spine injuries in the deployed setting and the medical literature on time of surgery in military and civilian settings published since early 2000 are summarized for this narrative review. This includes the results of a structured literature search using PubMed, Embase, and other sources. According to the existing guidelines of the US Army, it is recommended that surgical procedures that can be postponed without expected adverse effects for the patient should be performed in military hospitals providing a high standard of care. This usually requires the possibility of safe transportation, which can considerably delay surgery. It is also noted that in some cases, early surgery may be beneficial for the patient. These include patients with incomplete spinal cord injuries, open cerebrospinal fluid leaks, and cervical cord injuries, in which an urgent reduction may improve the degree of neurological impairment. The final decision lies with the medical team deployed. Reports on early surgery performed in-country during military operations show inconsistent results, indicating comparable or higher complication and revision rates and slightly better or similar neurological outcomes compared to postponed procedures. Decompression with or without stabilization is the most frequently performed spine surgery in this setting. The evidence from the studies is limited. Civil studies demonstrate that early surgery leads to fewer complications, shorter hospital and intensive care unit stays, and less ventilator support. Patients with incomplete spinal cord injuries, open cerebrospinal fluid leaks, or cervical cord injuries where rapid reduction can improve the degree of neurological impairment, as well as patients who cannot be transported in the foreseeable future, are candidates for early surgery during military operations. The potential benefits of early surgery, such as better neurological recovery and faster rehabilitation, must be weighed on a case-by-case basis by the medical team involved against the higher risk of complications and revision surgery in an austere environment. For patients who require early surgery, the best possible conditions must be created. The conflicts of recent decades have shown that it is time to rethink the health chain. Instead of fixed role assignments, it depends on the capacities that are currently available in the extreme forward surgical team. These need to be strengthened. Remote technologies such as teleradiology, artificial intelligence, and augmented reality can provide the necessary expertise to nonspecialized surgeons. Sterile and lightweight spinal instruments that can be delivered by drones are needed. Portable, energy-efficient medical devices with minimal electromagnetic footprints may mitigate the risk profiles of existing doctrine.