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Spinal Injuries in United States Military Personnel Deployed to Iraq and Afghanistan: An Epidemiological Investigation Involving 7877 Combat Casualties From 2005 to 2009

Schoenfeld, Andrew J., MD*; Laughlin, Matthew D., DO*; McCriskin, Brendan J., MD*; Bader, Julia O., PhD; Waterman, Brian R., MD*; Belmont, Philip J. Jr, MD*

doi: 10.1097/BRS.0b013e31829ef226

Study Design. Retrospective analysis of a prospective data set.

Objective. Determine the incidence and epidemiology of combat-related spinal injuries for the wars in Afghanistan and Iraq.

Summary of Background Data. Recent studies have identified a marked increase in the rate of combat-related spine trauma among casualties in Afghanistan and Iraq. Limitations in these previous works, however, limit their capacity for generalization.

Methods. A manual search of casualty records stored in the Department of Defense Trauma Registry was performed for the years 2005 to 2009. Demographic information, nature of spinal wounding, injury mechanism, concomitant injuries, year, and location of injury were recorded for all soldiers identified as having sustained combat-related spine trauma. Incidence rates were constructed by comparing the frequencies of spine casualties against defense manpower deployment data. Multivariate Poisson regression was used to identify statistically significant factors associated with spinal injury.

Results. In the years 2005 to 2009, 872 (11.1%) casualties with spine injuries were identified among a total of 7877 combat wounded. The mean age of spine casualties was 26.6 years. Spine fractures were the most common injury morphology, comprising 83% of all spinal wounds. The incidence of combat-related spinal trauma was 4.4 per 10,000, whereas that of spine fractures was 4.0 per 10,000. Spinal cord injuries occurred at a rate of 4.0 per 100,000. Spinal cord injuries were most likely to occur in Afghanistan (incident rate ratio: 1.96; 95% confidence interval: 1.68–2.28), among Army personnel (incident rate ratio: 16.85; 95% confidence interval: 8.39–33.84), and in the year 2007 (incident rate ratio: 1.90; 95% confidence interval: 1.55–2.32). Spinal injuries from gunshot were significantly more likely to occur in Iraq (17%) than in Afghanistan (10%, P = 0.02).

Conclusion. The incidence of spine trauma in modern warfare exceeds reported rates from earlier conflicts. The study design and population size may enhance the capacity for generalization of our findings.

Level of Evidence: 3

Data from the Department of Defense Trauma Registry was used to describe the incidence and epidemiology of combat-related spine trauma resulting from the wars in Afghanistan and Iraq. The incidence of spine trauma in these conflicts exceeds reported rates from previous engagements.

*Department of Orthopaedic Surgery, William Beaumont Army Medical Center, Texas Tech University Health Sciences Center, El Paso, TX; and

Statistical Consulting Laboratory, University of Texas at El Paso, El Paso, TX.

Address correspondence and reprint requests to Philip J. Belmont, Jr, MD, William Beaumont Army Medical Center, 5005 N. Piedras St, El Paso, TX 79920; E-mail:

Acknowledgment date: March 1, 2013. First revision date: May 2, 2013. Second revision date: May 28, 2013. Acceptance date: May 31, 2013.

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

No funds were received in support of this work.

Relevant financial activities outside the submitted work: fees for participation in review activities such as data monitoring boards, statistical analysis, end point committees, and the like and royalties.

© 2013 by Lippincott Williams & Wilkins