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Neck Pain During Combat Operations: An Epidemiological Study Analyzing Clinical and Prognostic Factors

Cohen, Steven P. MD*†; Kapoor, Shruti G. MD, MPH*; Nguyen, Cuong MD; Anderson-Barnes, Victoria C. BA§; Brown, Charlie MD*; Schiffer, Dominique MD; Turabi, Ali MD; Plunkett, Anthony MD

doi: 10.1097/BRS.0b013e3181bb11a8

Study Design. Prospective observational study among soldiers medically evacuated out of theaters of combat operations for neck pain, with retrospective analysis of variables associated with return-to-duty.

Objectives. To provide an epidemiological overview of the burden of neck pain in deployed soldiers involved in combat operations and to identify factors associated with return-to-duty.

Summary of Background Data. Neck pain represents one of the leading causes of medical evacuation out of theaters of combat operations. Yet when compared to other diagnostic categories, treatment outcomes, militarily defined as returning a soldier to duty, remain appallingly low.

Methods. Demographic, military-specific, and outcome data were prospectively collected over a 2-week period at the Deployed Warrior Medical Management Center in Germany on 374 consecutive soldiers medically evacuated out of theaters of combat operations for a primary diagnosis pertaining to neck pain between 2004 and 2007. The 2-week period represents the maximal allowable time an evacuated soldier can spend in treatment before disposition (i.e., return to theater or evacuate to United States) is rendered. Electronic medical records were reviewed to examine the effect the following variables had on the categorical outcome measure, return-to-unit: age, gender, service-affiliation, rank and seniority, smoking history, coexisting psychiatric diagnosis, prior neck pain, mechanism of injury, whether or not the injury was combat-related, presence of headache, quality of symptoms, correlation with radiologic imaging, and referral to pain specialist.

Results. Only 14% of service members returned to their units. Significant correlations were found between female gender and non-army service affiliation, and a service member returning to their unit. Weak trends toward returning to duty were noted for nonsmokers, absence of prior neck pain, concomitant psychiatric diagnosis, corresponding complaints of headache, and referral to a pain specialist.

Conclusion. The treatment of service members medically evacuated for neck pain at the main receiving center, the level IV military treatment facility in Landstuhl, Germany, is associated with a low return-to-unit rate. Future studies should consider whether treating personnel predisposed towards a positive outcome with the limited resources available can improve return-to-duty rates.

This epidemiological study found a 14% return-to-unit rate among 374 soldiers medically evacuated out of Operations Iraqi and Enduring Freedom. Variables associated with a positive outcome were female gender, non-army service personnel, no concurrent psychiatric diagnosis, no prior history of neck pain, headache, and treatment by a pain specialist.

From the *Department of Anesthesiology, Johns Hopkins School of Medicine, Baltimore, MD; †Department of Surgery, Walter Reed Army Medical Center, Washington, DC; ‡Physical Medicine & Rehabilitation Service, Department of Surgery, Landstuhl Regional Medical Center, Landstuhl, Germany; §Department of Orthopedic Surgery and Rehabilitation, Walter Reed Army Medical Center, Washington, DC; and ¶Department of Anesthesiology, University of Colorado School of Medicine, Denver, CO.

Acknowledgment date: February 9, 2009. First revision date: May 17, 2009. Second revision date: July 18, 2009. Acceptance date: July 20, 2009.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Government funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Supported by a Congressional Grant from the John P. Murtha Neuroscience and Pain Institute, Johnstown, PA; the US Army; and the Army Regional Anesthesia & Pain Medicine Initiative, Washington, DC.

Presented in part at American Society of Regional Anesthesia and Pain Medicine 2008 Annual Meeting; November 20–23, 2008; Huntington Beach, CA (winner resident travel award).

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Dept of the Army or the Dept of Defense.

Address correspondence and reprint requests to Steven P. Cohen, MD, 550 North Broadway, Suite 301, Baltimore, MD 21029; E-mail:

© 2010 Lippincott Williams & Wilkins, Inc.