Spinal Injury Trends During Swords of Iron War

OBJECTIVES: To analyze the incidence, mechanisms, anatomical distribution, and clinical outcomes of combat-related spinal injuries during high-intensity modern warfare ("Swords of Iron War"). SUMMARY OF BACKGROUND DATA: Combat-related spinal trauma has seen a rising incidence in recent conflicts, primarily driven by high-energy mechanisms such as explosive devices. These injuries often result in severe neurological deficits and present as part of complex polytrauma, yet data regarding the specific trends in recent urban warfare remain limited. METHODS: A retrospective observational study was conducted in two stages using the Israel Defense Force (IDF) Trauma Registry and Electronic Medical Records between October 2023 and June 2025. Stage 1 analyzed 3,972 urgent pre-hospital casualties to determine incidence and systemic severity of spinal injuries. Stage 2 focused on 105 hospital-confirmed spinal injury cases to delineate specific anatomical patterns, injury mechanisms, and surgical management. RESULTS: The incidence of spinal injury was 2.2% among urgent casualties. Spinal trauma served as a significant marker for injury severity, with 45.0% of patients exhibiting an Injury Severity Score (ISS) ≥25, compared to 12.0% in the non-spinal group (P<0.001). Explosive mechanisms (including combined explosion and ballistic trauma) predominated, accounting for 47.6% of cases. While total injuries were relatively balanced across spinal regions, major fractures were disproportionately concentrated in the lower segments, with the lumbar and sacral regions accounting for 35% and 26% of all major fractures, respectively. Neurological deficits were present in 42.9% of the cohort. Spinal fixation was the most frequent surgical intervention, primarily in the lumbar region, and 66.7% of all cases were managed non-operatively. CONCLUSIONS: Combat-related spinal injuries are uncommon but serve as a critical indicator of high-energy multisystem polytrauma. The distinct pattern of major fractures favoring the lower spinal segments, likely due to axial blast loading, necessitates specialized triage and care to optimize functional outcomes.