Return to Duty Rates in Active Duty Service Members After Elective Surgery of the Lumbar Spine.

OBJECTIVES: The aim of this study is to define the percentage of military service members returned to active duty following elective lumbar spine surgery. METHODS: We reviewed 331 elective lumbar spine procedures performed on active duty service members over a 5-year period. All patients underwent a decompressive lumbar procedure with or without fusion. Return to duty (RTD) was our primary outcome, defined as no referral to a Medical Evaluation Board by the 12-month postoperative follow-up visit. All subject's final disposition was recorded as a binomial distribution and stratified by demographic parameters. Subgroup analysis comparing the return rates for specific procedures was performed. RESULTS: 232 patients met our study inclusion criteria. 136 underwent isolated decompressive procedures and 96 patients underwent fusion procedures. The overall RTD rate following elective lumbar spine surgery was 64% (n = 149) (95% confidence interval, CI [58, 70]). The RTD rate for isolated decompressive procedures was 63% (n = 86) (95% CI [55, 71]), and 66% (n = 63) (95% CI [56, 75]) after decompression with lumbar fusion. CONCLUSIONS: The RTD rate following elective lumbar spine surgery is 64%. When stratified by procedure type, isolated decompression procedures (63% RTD rate) and fusion procedures (66% RTD rate) displayed similar results.

Spine-related disability following combat injury.

Spine-related disability for military personnel injured in combat is not known. The goal of this study was to characterize spine-related disability in a cohort of soldiers wounded in recent military operations. The authors reviewed the U.S. Army Physical Evaluation Board database medical discharge records of 450 wounded soldiers for long-term disability causing a medical discharge from active duty service. Fourteen percent of the cohort had at least one spine-related disability resulting in medical discharge from the military. For the 54 unfitting conditions attributed to back pain, 33% had no precipitating injury. Eighteen soldiers had a spinal cord injury, 10 of which were complete. The average percent disability for back pain was 11%, and the average disability for a spinal cord injury was 77%. Twenty-one percent of the soldiers with spine-related disability also had disability attributed to psychological conditions. Spine-related disability is common after combat injury, though not all spine disability is directly related to an actual injury. Spinal cord injury with persistent neurological dysfunction results in higher permanent disability.

The reliability of the ball-tipped probe for detecting pedicle screw tract violations prior to instrumenting the thoracic and lumbar spine.

STUDY DESIGN: Cadaveric. OBJECTIVE: To determine the confidence with which surgeons should rely on a flexible ball-tipped probe to detect pedicle breeches in the thoracic and lumbar spine. SUMMARY OF BACKGROUND DATA: The reliability of a ball-tipped probe for detecting cortical violations of the pedicle tract has not been studied among fellowship-trained surgeons. METHODS: A total of 134 pedicles were randomized to have pedicle screw tracts with one of six possible options: no violation, anterior, superior, inferior, medial, or lateral violations. Five fellowship-trained spine surgeons examined each pedicle, using a standard flexible ball-tipped probe on three nonsequential occasions. The percentage of correctly identified violations, sensitivity, specificity, positive predictive value, and negative predictive value were calculated for the surgeons as a group and individually. The Cohen kappa coefficient was used to assess the accuracy of the observers and the interobserver and intraobserver agreement. Finally, we analyzed our results by spinal region to see whether this impacted the surgeons' ability to detect a pedicle violation. RESULTS: The surgeons were able to correctly identify 81% of intact pedicles, 39% of superior, 68% of medial, 74% of lateral, 62% of anterior, and 50% of inferior violations. The sensitivity varied considerably by breech location and surgeon with a range of 18% to 85%. Positive predictive value for each breech location ranged from 12% to 20%. The specificity was 81% and negative predictive value 98% overall. The intraobserver reliability was moderate and interobserver reliability was low in this series. The ability to detect a pedicle violation was significantly better in the lower thoracic region (T6-T12) than in other areas of the spine. CONCLUSION: The standard ball-tipped probe was much less reliable than expected. This technique can be used to confirm an intact pedicle but has an unacceptably high false-positive rate and should be used with caution. Our study suggests that overconfidence in pedicle probing might be dangerous.

Simulation training for a mass casualty incident: two-year experience at the Army Trauma Training Center.

BACKGROUND: Civilian and military mass casualty incidents (MCI) are an unfortunate reality in the 21st century, but there are few situational training exercises (STX) to prepare for them. To fill this gap, we developed a MCI STX for U.S. Army Forward Surgical Teams (FST) in conjunction with the U.S. Army Trauma Training Center. METHODS: After a standardized briefing, each FST has 60 minutes to unpack, setup, and organize a standard equipment cache into an emergency room, operating room, and intensive care unit. In an adjacent room, five anesthetized swine are prepared with standardized, combat-relevant injuries. The number and acuity of the total casualties are unknown to the FST and arrive in waves and without warning. A realistic combat environment is simulated by creating resource limitations, power outages, security breaches, and other stressors. The STX concludes when all casualties have died or are successfully treated. FSTs complete a teamwork self-assessment card, while staff and FST surgeons evaluate organization, resource allocation, communication, treatment, and overall performance. Feedback from each FST can be incorporated into an updated design for the next STX. RESULTS: From 2003-2005, 16 FSTs have completed the STX. All FSTs have had collapses in situational triage, primary/ secondary surveys, and/or ATLS principles (basic ABCs), resulting in approximately 20% preventable deaths. CONCLUSIONS: We concluded (1) a MCI can overwhelm even combat- experienced FSTs; (2) adherence to basic principles of emergency trauma care by all FST members is essential to effectively and efficiently respond to this MCI; (3) by prospectively identifying deficiencies, future military or civilian performance during an actual MCI may be improved; and (4) this MCI STX could provide a template for similar programs to develop, train, and evaluate civilian surgical disaster response teams.