A Joint Trauma System Clinical Practice Guideline: Traumatic Brain Injury Management and Basic Neurosurgery in the Deployed Environment.

Management of the patient with moderate to severe brain injury in any environment can be time consuming and resource intensive. These challenges are magnified while forward deployed in austere or hostile environments. This Joint Trauma System Clinical Practice Guideline provides recommendations for the treatment and medical management of casualties with moderate to severe head injuries in an environment where personnel, resources, and follow-on care are limited. These guidelines have been developed by acknowledging commonly recognized recommendations for neurosurgical and neuro-critical care patients and augmenting those evaluations and interventions based on the experience of neurosurgeons, trauma surgeons, and intensivists who have delivered care during recent coalition conflicts.

Assessment of Surgical Complications Strengthen the Relationship Between Spine Surgery Procedure Intensity and Chronic Opioid use After Surgery.

STUDY DESIGN: Prospective cohort using routinely-collected health data. OBJECTIVE: To compare opioid use based on surgery intensity (low or high). SUMMARY OF BACKGROUND DATA: Many factors influence an individual's experience of pain. The extent to which post-surgical opioid use is influenced by the severity of spine surgery is unknown. METHODS: The participants were individuals undergoing spine surgery in a large military hospital. Procedures were categorized as low-intensity (e.g., microdiscectomy and laminectomy) and high-intensity (e.g., fusion and arthroplasty). The Surgical Scheduling System and Military Health System Data Repository were queried for healthcare utilization the 1 year before and after surgery. We compared opioid use after surgery between groups, adjusting for prior opioid use and surgical complications. RESULTS: 342 individuals met the inclusion criteria, mean age 45.4 years (SD 10.9), 33.0% female. Of these, 221(64.6%) underwent a low-intensity procedure and 121(35.4%) underwent a high-intensity procedure. Mean postoperative opioid prescription fills were greater in the high- versus low-intensity group (9.0 vs. 5.7;P<0.001), as were the mean total days' supply (158.9 vs. 81.8;P<0.001). Median morphine milligram equivalents were not significantly different (MME; 40.2 vs. 42.7;P=0.287). 26.3% of the cohort were chronic opioid users after surgery. Adjusted rates of long-term opioid use were not different between groups when only accounting for prior opioid use, but significantly higher for the high-intensity group when adjusting for surgical complications (OR=2.08;95CI 1.09,3.97). 52.5% of the entire cohort was still filling opioid prescriptions after six months. CONCLUSION: Higher-intensity procedures were associated with greater postoperative opioid use than lower-intensity procedures. Chronic opioid use was not significantly different between surgical intensity groups when considering only prior opioid use. Chronic opioid use was significantly higher among higher intensity procedures when accounting for surgical complications. The prresence of surgical complications is a stronger predictor of post-surgical long-term opioid use in high intensity surgeries than history of opioid use alone.

Does Engaging Patients with Relevant Education About Long-Term Opioid Use Before Spine Surgery Affect Long-term Opioid Use? A Randomized Controlled Trial.

STUDY DESIGN: Parallel-arm randomized controlled trial. OBJECTIVE: To assess the effectiveness of an enhanced video education session highlighting risks of opioid utilization on longterm opioid utilization after spine surgery. SUMMARY OF BACKGROUND DATA: Long-term opioid use occurs in more than half of patients undergoing spine surgery and strategies to reduce this use are needed. METHODS: Patients undergoing spine surgery at Brooke Army Medical Center between July 2015 and February 2017 were recruited at their preoperative appointment, receiving the singlesession interactive video education or control at that same appointment. Opioid utilization was tracked for the full year after surgery from the Pharmacy Data Transaction Service of the Military Health System Data Repository. Self-reported pain also collected weekly for 1 and at 6months. RESULTS: A total of 120 participants (40 women, 33.3%) with a mean age of 45.9 ±â€Š10.6 years were randomized 1:1 to the enhanced education and usual care control (60 per group). In the year following surgery the cohort had a mean 5.1 (standard deviation [SD] 5.9) unique prescription fills, mean total days' supply was 88.3 (SD 134.9), and mean cumulative morphine milligrams equivalents per participant was 4193.0 (SD 12,187.9) within the year after surgery, with no significant differences in any opioid use measures between groups. Twelve individuals in the standard care group and 13 in the enhanced education group were classified with having long-term opioid utilization. CONCLUSION: The video education session did not influence opioid use after spine surgery compared to the usual care control. There was no significant difference in individuals classified as long-term opioid users after surgery based on the intervention group. Prior opioid use was a strong predictor of future opioid use in this cohort. Strategies to improve education engagement, understanding, and decision- making continue to be of high importance for mitigating risk of long-term opioid use after spine surgery.Level of Evidence: 1.

The Military Injuries: Understanding Post-Traumatic Epilepsy Study: Understanding Relationships among Lifetime Traumatic Brain Injury History, Epilepsy, and Quality of Life.

Understanding risk for epilepsy among persons who sustain a mild (mTBI) traumatic brain injury (TBI) is crucial for effective intervention and prevention. However, mTBI is frequently undocumented or poorly documented in health records. Further, health records are non-continuous, such as when persons move through health systems (e.g., from Department of Defense to Veterans Affairs [VA] or between jobs in the civilian sector), making population-based assessments of this relationship challenging. Here, we introduce the MINUTE (Military INjuries-Understanding post-Traumatic Epilepsy) study, which integrates data from the Veterans Health Administration with self-report survey data for post-9/11 veterans (n = 2603) with histories of TBI, epilepsy and controls without a history of TBI or epilepsy. This article describes the MINUTE study design, implementation, hypotheses, and initial results across four groups of interest for neurotrauma: 1) control; 2) epilepsy; 3) TBI; and 4) post-traumatic epilepsy (PTE). Using combined survey and health record data, we test hypotheses examining lifetime history of TBI and the differential impacts of TBI, epilepsy, and PTE on quality of life. The MINUTE study revealed high rates of undocumented lifetime TBIs among veterans with epilepsy who had no evidence of TBI in VA medical records. Further, worse physical functioning and health-related quality of life were found for persons with epilepsy + TBI compared to those with either epilepsy or TBI alone. This effect was not fully explained by TBI severity. These insights provide valuable opportunities to optimize the resilience, delivery of health services, and community reintegration of veterans with TBI and complex comorbidity.

Are Exercise and Physical Therapy Common Forms of Conservative Management in the Year Before Lumbar Spine Surgery?

OBJECTIVE: To quantify and compare utilization of opioids, exercise therapy, and physical therapy in the year before spine surgery. DESIGN: A retrospective cohort of surgical and claims data. SETTING: Beneficiaries of the Military Health System seen at Brooke Army Medical Center PARTICIPANTS: Patients (N=411) undergoing surgery between January 1, 2014, and December 31, 2015, identified retrospectively through the Surgical Scheduling System (S3) based on procedure type (fusion, laminectomy, arthroplasty, vertebroplasty, and diskectomy). INTERVENTIONS: Elective lumbar spine surgery. MAIN OUTCOME MEASURES: Health care utilization variables present during the full 12 months before surgery, which included physical therapy services and visits for exercise therapy or manual therapy procedures and opioid prescriptions. RESULTS: The mean age of participants was 44.8±11.7 years and 32.4% were female. In the year before surgery, 143 (34.8%) patients had a physical therapy plan of care, 140 (34.1%) had at least 1 visit that included exercise therapy, and only 60 (14.6%) had a minimum of 6 exercise therapy visits. However, 347 (84.4%) patients received at least 1 opioid prescription fill (mean of 6.1 unique fills). CONCLUSIONS: Before elective lumbar spine surgery, opioid prescriptions were common but physical therapy services and exercise therapy utilization occurred infrequently.

The Prehospital Evaluation and Care of Moderate/Severe TBI in the Austere Environment.

Increased resource constraints secondary to a smaller medical footprint, prolonged evacuation times, or overwhelming casualty volumes all increase the challenges of effective management of traumatic brain injury (TBI) in the austere environment. Prehospital providers are responsible for the battlefield recognition and initial management of TBI. As such, targeted education is critical to efficient injury recognition, promoting both provider readiness and improved patient outcomes. When austere conditions limit or prevent definitive treatment, a comprehensive understanding of TBI pathophysiology can help inform acute care and enhance prevention of secondary brain injury. Field deployable, noninvasive TBI assessment and monitoring devices are urgently needed and are currently undergoing clinical evaluation. Evidence shows that the assessment, monitoring, and treatment in the first few hours and days after injury should focus on the preservation of cerebral perfusion and oxygenation. For cases where medical management is inadequate (eg, evidence of an enlarging intracranial hematoma), guidelines have been developed for the performance of cranial surgery by nonneurosurgeons. TBI management in the austere environment will continue to be a challenge, but research focused on improving evidence-based monitoring and therapeutic interventions can help to mitigate some of these challenges and improve patient outcomes.

Association of time to craniectomy with survival in patients with severe combat-related brain injury.

OBJECTIVEIn combat and austere environments, evacuation to a location with neurosurgery capability is challenging. A planning target in terms of time to neurosurgery is paramount to inform prepositioning of neurosurgical and transport resources to support a population at risk. This study sought to examine the association of wait time to craniectomy with mortality in patients with severe combat-related brain injury who received decompressive craniectomy.METHODSPatients with combat-related brain injury sustained between 2005 and 2015 who underwent craniectomy at deployed surgical facilities were identified from the Department of Defense Trauma Registry and Joint Trauma System Role 2 Registry. Eligible patients survived transport to a hospital capable of diagnosing the need for craniectomy and performing surgery. Statistical analyses included unadjusted comparisons of postoperative mortality by elapsed time from injury to start of craniectomy, and Cox proportional hazards modeling adjusting for potential confounders. Time from injury to craniectomy was divided into quintiles, and explored in Cox models as a binary variable comparing early versus delayed craniectomy with cutoffs determined by the maximum value of each quintile (quintile 1 vs 2-5, quintiles 1-2 vs 3-5, etc.). Covariates included location of the facility at which the craniectomy was performed (limited-resource role 2 facility vs neurosurgically capable role 3 facility), use of head CT scan, US military status, age, head Abbreviated Injury Scale score, Injury Severity Score, and injury year. To reduce immortal time bias, time from injury to hospital arrival was included as a covariate, entry into the survival analysis cohort was defined as hospital arrival time, and early versus delayed craniectomy was modeled as a time-dependent covariate. Follow-up for survival ended at death, hospital discharge, or hospital day 16, whichever occurred first.RESULTSOf 486 patients identified as having undergone craniectomy, 213 (44%) had complete date/time values. Unadjusted postoperative mortality was 23% for quintile 1 (n = 43, time from injury to start of craniectomy 30-152 minutes); 7% for quintile 2 (n = 42, 154-210 minutes); 7% for quintile 3 (n = 43, 212-320 minutes); 19% for quintile 4 (n = 42, 325-639 minutes); and 14% for quintile 5 (n = 43, 665-3885 minutes). In Cox models adjusted for potential confounders and immortal time bias, postoperative mortality was significantly lower when time to craniectomy was within 5.33 hours of injury (quintiles 1-3) relative to longer delays (quintiles 4-5), with an adjusted hazard ratio of 0.28, 95% CI 0.10-0.76 (p = 0.012).CONCLUSIONSPostoperative mortality was significantly lower when craniectomy was initiated within 5.33 hours of injury. Further research to optimize craniectomy timing and mitigate delays is needed. Functional outcomes should also be evaluated.

Cervical and Thoracolumbar Spine Injury Evaluation, Transport, and Surgery in the Deployed Setting.

This Cervical and Thoracolumbar Spine Injury Evaluation, Transport, and Surgery Clinical Practice Guideline (CPG) is designed to provide guidance to the deployed provider when they are treating a combat casualty who has sustained a spine or spinal cord injury. The CPG objective for the treatment and the movement of these patients is to maintain spinal stability through transport, perform decompression when urgently needed, achieve definitive stabilization when appropriate, avoid secondary injury, and prevent deterioration of the patient's neurological condition. Thorough and accurate documentation of the patient's neurological examination is crucial to ensure appropriate management decisions are made as the patient transits through the evacuation system. The use of this CPG should be in conjunction with good clinical judgment.

Neurosurgery and Medical Management of Severe Head Injury.

Management of the patient with moderate to severe brain injury in any environment can be time consuming and resource intensive. In the austere or hostile environment, the challenges to deliver care to this patient population are magnified. These guidelines have been developed by acknowledging commonly recognized recommendations for neurosurgical and neuro-critical care patients and augmenting those evaluations and interventions based on the experience of neurosurgeons, trauma surgeons, and intensivists who have delivered care during recent coalition conflicts.

Severe Pediatric Head Injury During the Iraq and Afghanistan Conflicts.

BACKGROUND: Much has been written about injuries sustained by US and coalition soldiers during the Global War on Terrorism campaigns. However, injuries to civilians, including children, have been less well documented. OBJECTIVE: To describe the epidemiologic features and outcomes associated with isolated severe head injury in children during Operations Enduring Freedom and Iraqi Freedom (OEF and OIF). METHODS: A retrospective review of children (<18 years old) in the Joint Theater Trauma Registry with isolated head injury (defined as an Abbreviated Injury Score Severity Code >3) and treated at a US combat support hospital in Iraq or Afghanistan (2004-2012). The primary outcome was in-hospital mortality. RESULTS: We identified 647 children with severe isolated head injuries: 337 from OEF, 268 from OIF, and 42 nontheater specific. Most were boys (76%; median age = 8 years). Penetrating injuries were most common (60.6%). Overall, 330 (51%) children underwent a craniotomy/craniectomy; 156 (24.1%) succumbed to their injuries. Admission Glasgow Coma Score was predictive of survival among the entire cohort and each of the individual conflicts. Male sex also significantly increased the odds of survival for the entire group and OEF, but not for OIF. Closed-head injury improved the predictive ability of our model but did not reach statistical significance as an independent factor. CONCLUSION: This is the largest study of combat-related isolated head injuries in children. Admission Glasgow Coma Score and male sex were found to be predictive of survival. Assets to comprehensively care for the pediatric patient should be established early in future conflicts.

Thirty-Day Perioperative Outcomes in Spinal Fusion by Specialty Within the NSQIP Database.

STUDY DESIGN: Cross-sectional analysis of the American College of Surgeons' National Surgical Quality Improvement Program database between 2005 and 2011. OBJECTIVE: To determine whether differences exist in 30-day rate of return to the operating room, mortality, and other perioperative outcomes for spinal fusion by specialty. SUMMARY OF BACKGROUND DATA: Although both neurosurgeons and orthopedic surgeons perform spinal fusions, it is unclear whether surgeon specialty impacts perioperative outcomes. METHODS: Unadjusted bivariate analysis was performed to determine whether outcomes differed by surgeon specialty. A Bonferroni correction was applied to account for multiple comparisons. For outcomes with a statistically significant association, further multivariate analysis was performed. RESULTS: A total of 9719 patients receiving a spinal fusion were identified. Of them, 54.0% had their operation completed by a neurosurgeon. Orthopedic surgeons had practices with a greater percentage of lumbar spine cases (76.0% vs. 65.0%, P < 0.001). There was not a statistically significant difference in the number of levels fused or operative technique used between specialties. There was no difference in the majority of perioperative outcomes between orthopedic surgeons and neurosurgeons including death, rate of return to the operating room, and other complications associated with significant morbidity. On unadjusted analysis, it was found that neurosurgeons were associated with a decreased incidence of operations requiring blood transfusion relative to orthopedic surgeons (8.3% vs. 14.6%, P < 0.001). This trend persisted on multivariate analysis controlling for preoperative hematocrit, history of bleeding disorder, anatomical location of the operation, number of levels fused, operative technique, demographics, and comorbidities (odds ratio, 0.49; 95% confidence interval, 0.43-0.57). CONCLUSION: Spine surgeons, regardless of specialty, seem to achieve equivalent outcomes on measured metrics of mortality, 30-day readmission, and surgical site infection. Observed differences in blood transfusion rates by specialty were noted, but the cause of this difference is unclear and warrants further investigation to assess the impact of this difference, if any, on patient outcomes and cost. LEVEL OF EVIDENCE: 3.

Economic analysis of the military health professions scholarship program for neurosurgeons.

BACKGROUND: The 4-year military Health Professions Scholarship Program (HPSP) provides funds for medical school tuition, books, and a monthly stipend in exchange for a 4-year military commitment (to receive all physician bonuses, an additional 3 months must be served). OBJECTIVE: To analyze the economics of the HPSP for students with an interest in neurosurgery by comparing medical school debt and salaries of military, academic, and private practice neurosurgeons. METHODS: Salary and medical school debt values from the American Association of Medical Colleges, salary data from the Medical Group Management Association, and 2009 military pay tables were obtained. Annual cash flow diagrams were created to encompass 14.25 years that spanned 4 years (medical school), 6 years (neurosurgical residency), and the first 4.25 years of practice for military, academic, and private practice neurosurgeons. A present value economic model was applied. RESULTS: Mean medical school loan debt was $154,607. Mean military (adjusted for tax-free portions), academic, and private practice salaries were $160,318, $451,068, and $721,458, respectively. After 14.25 years, the cumulative present value cash flow for military, academic, and private practice neurosurgeons was $1 193 323, $2 372 582, and $3 639 276, respectively. After 14.25 years, surgeons with medical student loans still owed $208 761. CONCLUSION: The difference in cumulative annual present value cash flow between military and academic and between military and private practice neurosurgeons was $1,179,259 and $2,445,953, respectively. The military neurosurgeon will have little to no medical school debt, whereas the calculated medical school debt of a nonmilitary surgeon was approximately $208,000.

Pediatric neurosurgery during Operation Enduring Freedom.

OBJECT: Operation Enduring Freedom (OEF) is the current US military conflict against terrorist elements in Afghanistan. Deepening US involvement in this conflict and increasing coalition casualties prompted the establishment of continuous neurosurgical assets at Craig Joint Theater Hospital (CJTH) at Bagram Airfield, Afghanistan, in September 2007. As part of the military's medical mission, children with battlefield-related injuries and, on a selective case-by-case basis, non-war-related pathological conditions are treated at CJTH. METHODS: A prospectively maintained record was created in which all rotating neurosurgeons at CJTH recorded their personal procedures. From this record, the authors were able to extract all cases involving patients 18 years of age or younger. Variables recorded included: age, sex, and category of patient (for example, local national, enemy combatant), date, indication and description of the neurosurgical procedure, mechanism of injury, and in-hospital morbidity and mortality data. RESULTS: From September 2007 to October 2009, 296 neurosurgical procedures were performed at CJTH. Fifty-seven (19%) were performed in 43 pediatric patients (16 girls and 27 boys) with an average age of 7.5 years (range 11 days-18 years). Thirty-one of the 57 procedures (54%) were for battlefield-related trauma and 26 for humanitarian reasons (46%). The vast majority of cases were cranial (49/57, 86%) compared with spinal (7/54, 13%), with one peripheral nerve case. Craniotomies or craniectomies for penetrating brain injuries were the most common procedures. There were 5 complications (11.6%) and 4 in-hospital deaths (9.3%). CONCLUSIONS: As in previous military conflicts, children are the unfortunate victims of the current Afghanistan campaign. Extremely limited pediatric neurosurgical service and care is rendered under challenging conditions and Air Force neurosurgeons provide valuable, life-saving pediatric treatment for both war-related injuries and humanitarian needs. As the conflict in Afghanistan continues, military neurosurgeons will continue to care for injured children to the best of their abilities.

Can surgery improve neurological function in penetrating spinal injury? A review of the military and civilian literature and treatment recommendations for military neurosurgeons.

OBJECT: Penetrating spinal injury (PSI), although an infrequent injury in the civilian population, is not an infrequent injury in military conflicts. Throughout military history, the role of surgery in the treatment of PSI has been controversial. The US is currently involved in 2 military campaigns, the hallmark of both being the widespread use of various explosive devices. The authors reviewed the evidence for or against the use of decompressive laminectomy to treat PSI to provide a triservice (US Army, Navy, and Air Force) consensus and treatment recommendations for military neurosurgeons and spine surgeons. METHODS: A US National Library of Medicine PubMed database search that identified all literature dealing with acute management of PSI from military conflicts and civilian urban trauma centers in the post-Vietnam War period was undertaken. RESULTS: Nineteen retrospective case series (11 military and 8 civilian) met the study criteria. Eleven military articles covered a 20-year time span that included 782 patients who suffered either gunshot or blast-related projectile wounds. Four papers included sufficient data that analyzed the effectiveness of surgery compared with nonoperative management, 6 papers concluded that surgery was of no benefit, 2 papers indicated that surgery did have a role, and 3 papers made no comment. Eight civilian articles covered a 9-year time span that included 653 patients with spinal gunshot wounds. Two articles lacked any comparative data because of treatment bias. Two papers concluded that decompressive laminectomy had a beneficial role, 1 paper favored the removal of intracanal bullets between T-12 and L-4, and 5 papers indicated that surgery was of no benefit. CONCLUSIONS: Based on the authors' military and civilian PubMed literature search, most of the evidence suggests that decompressive laminectomy does not improve neurological function in patients with PSI. However, there are serious methodological shortcomings in both literature groups. For this and other reasons, neurosurgeons from the US Air Force, Army, and Navy collectively believe that decompression should still be considered for any patient with an incomplete neurological injury and continued spinal canal compromise, ideally within 24-48 hours of injury; the patient should be stabilized concurrently if it is believed that the spinal injury is unstable. The authors recognize the highly controversial nature of this topic and hope that this literature review and the proposed treatment recommendations will be a valuable resource for deployed neurosurgeons. Ultimately, the deployed neurosurgeon must make the final treatment decision based on his or her opinion of the literature, individual abilities, and facility resources available.

Neurosurgery in Afghanistan during "Operation Enduring Freedom": a 24-month experience.

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.

Indirect gunshot wound to the head.

BACKGROUND: An Afghani man presented to a U.S. military facility in Afghanistan with a 3-month history of clear fluid from his left naris and frequent sinusitis. Eleven years earlier, he had been struck in the forehead by an object falling from the sky. MATERIALS AND METHODS: Neurologic examination revealed decreased sensation in V1 and V2 on the left side. Imaging revealed a large bullet lodged in the left maxillary sinus. FINDINGS: The bullet was removed via sublabial incision and opening of the anterior bony wall of the maxillary sinus. CONCLUSIONS: In Afghanistan, indirect gunshot wounds to the head are not uncommon because of the constant war conditions since the invasion by the former Soviet Union in 1979 and the tradition of firing rounds into the air during cultural celebrations.

Neural function preservation and early mobilization after resection of metastatic sacral tumors and lumbosacropelvic junction reconstruction. Report of three cases.

The management of tumors that metastasize to the sacrum remains controversial. Typically, resection of such tumors and reconstruction of the lumbopelvic junction requires sacrifice of neural elements resulting in neurological dysfunction and prolonged periods of bed rest. This severely affects the quality of life in patients in whom there is frequently a limited life expectancy. The authors describe three patients who underwent subtotal resection of metastatic sacral tumors. Postoperatively, good outcome was demonstrated in all patients. The authors present a technique for debulking and reconstruction that provides immediate spinopelvic junction stability and allows for early mobilization. Quality of life is significantly improved compared with that resulting from either medical treatment or traditional surgery.