SPINE-AREA PAIN IN MILITARY PERSONNEL: A REVIEW OF EPIDEMIOLOGY, ETIOLOGY, DIAGNOSIS, AND TREATMENT
 
   

Spine-area Pain in Military Personnel:
A Review of Epidemiology, Etiology,
Diagnosis, and Treatment

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:
   Frankp@chiro.org
 
   

FROM:   Spine J. 2012 (Sep);   12 (9):   833-842 ~ FULL TEXT

Steven P. Cohen, MD, Rollin M. Gallagher, MD, MPH, Shelton A. Davis, MD,
Scott R. Griffith, MD, Eugene J. Carragee, MD

Pain Management Division, Department of Anesthesiology & Critical Care Medicine,
Johns Hopkins School of Medicine,
Baltimore, MD 21205, USA.
scohen40@jhmi.edu



BACKGROUND CONTEXT:   non-battle illnesses and injuries are the major causes of unit attrition in modern warfare. Spine-area pain is a common disabling injury in service members associated with a very low return-to-duty (RTD) rate.

PURPOSE:   To provide an overview of the current understanding of epidemiology, possible causes, and relative prognosis of spine-area pain syndromes in military personnel, including a discussion of various treatment options available in theaters of operation.

STUDY DESIGN:   Literature review.

METHODS:   Search focusing on epidemiology, etiology and associative factors, and treatment of spinal pain using electronic databases, textbooks, bibliographic references, and personal accounts.

RESULTS:   Spine-area pain is the most common injury or complaint "in garrison" and appears to increase during training and combat deployments. Approximately three-quarters involve low back pain, followed by cervical and midback pain syndromes. Some predictive factors associated with spine-area pain are similar to those observed in civilian cohorts, such as psychosocial distress, heavy physical activity, and more sedentary lifestyle. Risk factors specific to military personnel include concomitant psychological trauma, g-force exposure in pilots and airmen, extreme shock and vibration exposure, heavy combat load requirements, and falls incurred during airborne, air assault, and urban dismounted ground operations. Effective forward-deployed treatment has been difficult to implement, but newer strategies may improve RTD rates.

CONCLUSIONS:   Spine-area pain syndromes comprise a major source of unit attrition and are often the result of duty-related burdens incurred during combat operations. Current strategies in theaters of operation that may improve the low RTD rates include individual and unit level psychological support, early resumption of at least some forward-area duties, multimodal treatments, and ergonomic modifications.

Keywords:   Back pain; Neck pain; non-battle injury; Soldier; War



From the FULL TEXT Article:

Epidemiology of war injuries

There is a common misconception regarding the physical risks of war. Since accurate statistics have been kept, the leading cause of hospitalization and medical evacuation has not been direct combat but rather disease and non-battle injuries. In World War I, World War II, and the Korean conflict, respiratory and infectious illnesses were the number one cause of hospitalization. By Vietnam, non-battle injuries had surpassed all other disease categories as the leading cause of service member attrition and has remained so ever since. [1]

In addition to changes in the patterns of injury, battle injury survival rates have changed in parallel. In World War I, the wounded-in-action:killed-in-action ratio was about 2:1. Over the course of the next century, this increased incrementally to around 8:1 in the Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). [2] This decreasing mortality rate has led to an increased emphasis on returning injured service members to their predeployment physical and psychological conditions.

      Burden of spinal pain

The administrative designation "spinal pain" has previously been used in evacuation databases to describe pain syndromes in the back and neck, although it must be emphasized that this is an unvalidated diagnosis that reflects only one of several potential anatomical sources of pain. For the purposes of this article, the term "spinal pain" refers to the location of pain (ie, neck, midback, or low back) rather than structural pathology.

Figure 1

In Operation Desert Storm (Gulf War), Operation Joint Endeavor (Bosnia), OIF, and OEF, the number one reason for hospitalization and medical evacuation was musculoskeletal conditions, representing between one-fourth and one-third of all injuries. [3–5] Spinal pain accounts for about one-quarter of these injuries. Between 2004 and 2007, 2,445 service members were medically evacuated out of theater from OIF and OEF with a primary designation of "spine pain," comprising 7.2% of all evacuees. [5] In deployed non-service members, spinal pain accounted for a slightly lower proportion of evacuated personnel (4.5%); however, this discrepancy may be attributable to differences in treatment paradigms. [6] Low back pain (LBP) syndromes are the primary complaint in approximately three-quarters of personnel with spinal pain (Figure).

Studies that focus only on evacuees likely underrepresent the burden of spinal pain. Although the precise incidence of service members who seek medical attention for spinal pain at forward-area treatment points is unknown, it is estimated that a large majority (80%) do not require medical evacuation.

Several studies have sought to evaluate the peacetime prevalence rates for spinal pain in service members. Six-month observational cohort studies conducted in Finnish military conscripts (median age, 19 years) found a 33% prevalence rate for musculoskeletal disorders necessitating medical attention. [7] A plurality (20%) of injuries involved the low back, with thoracic and cervical spine pain accounting for another 6%. Approximately one-third were for recurrent injuries, with more than 80% occurring during training exercises (40%) or other physical activities.

An epidemiological study performed in 6,488 Norwegian conscripts found LBP to be the leading musculoskeletal complaint during basic training (19% of all complaints), with an occurrence rate of 4.3% of conscripts. [8] In a prospective study evaluating the incidence of LBP in 3,555 British military recruits, Stowbridge [9] reported an LBP occurrence rate of 6.1 per 1,000 soldiers per month for male service members and 14.0 for female service members. Military duty can also increase the frequency of back pain episodes in individuals with a pre-existing history. A study comparing pre- and post-enlistment injury in 245 male service members with a history of chronic LBP found a 2.4–fold increase in the frequency of injuries requiring medical consultation after conscription. [10]

A systematic review examining the prevalence of thoracic spine pain in various cohorts reported 1–year prevalence rates in service members ranging between 4.3% and 32%, with the highest prevalence rate in fighter pilots. [11] Previous studies also found the prevalence rates of neck pain in fighter pilots (19%) to be higher than the general population. [12]

More recent work suggests that back pain in service members engaged in heavy physical training may be more the "rule" than the "exception". [13] A 5–year prospective cohort study followed 154 US Army Special Operations reserve soldiers who reported no history of back pain over a 3–year period. Over the next 18 months, these service members were queried on a monthly basis regarding back pain and disability. The cumulative percentages of subjects reporting mild and moderate back pain over the study period were 84% and 64%, respectively.

There is evidence that deployment to a combat zone increases the risk of spinal pain. This appears to be a multifactorial effect secondary to increased psychosocial stressors, greater time spent wearing heavy equipment, and increased duty hours. In a retrospective study conducted in 68 deployed helicopter pilots, Nevin and Means [14] found a significant increase in myriad pain complaints after deployment. Among individuals who logged more flight hours compared with predeployment status, 37%, 30%, and 70% reported increased neck pain, midback pain, and LBP, respectively. In individuals whose work hours stayed relatively constant, these increases were 22%, 20%, and 39%, respectively (Figure).



Risk factors for spinal pain

      Physical factors

There are a number of physical factors that can lead to complaints of spine pain in service members. Many of these factors involve poor ergonomics. Research by Attwells et al. [15] suggests that biomechanically, the cervical and lumbar spine work in concert to counterbalance loads carried in a rucksack, and the muscle tension necessary to sustain these changes is associated with an increased risk of musculoskeletal injury. In an account of the Roman Army by Goldsworthy [16], the loads of legionnaires on the march were typically 60 pounds over a day’s march of 20 miles. A historical review by Knapik et al. [17] reported that load carriage has increased for the infantry soldier since the 18th century, when loads typically weighed no more than 15 kg. Although each individual item tends to be lighter and more compact, an increased number of "essential" items has resulted in a greater load burden.

Carrying weights 45 kg or greater is not uncommon with the use of body armor and a full combat load, which may be needed to sustain operations in hostile environments for several days. This added weight creates shearing forces that can impact the lumbar spine, and to a lesser extent, the neck and upper back. When a service member goes on missions with this added gear, he is often required to perform various operations that place him in positions that can further stress spinal structures. The adverse effects of load carriage can theoretically be minimized by reducing loads, improving load distribution, optimizing load-carriage equipment, and taking preventive actions. Whether these strategies (eg, reducing body armor) put the soldier at greater risk for combat injuries is mission dependent.

Similar to non-service members, occupational driving, especially under suboptimal circumstances, can increase the risk for neck and back pain. [18] Although most military vehicles are designed to minimize the impact of improvised explosive devices, they are often poorly suited to provide proper ergonomic and comfortable seating. Whole-body shock and vibration associated with all-terrain vehicle driving and rotary wing aircraft has been shown in most, but not all studies, to increase the risk for LBP, midback pain, and neck pain. [19–21]

      Psychosocial

Studies conducted in a wide array of non-military cohorts have found psychosocial factors to be major predictors of persistence of pain after injury. A study of 7–year outcomes of 567 patients seen in emergency rooms with severe limb trauma showed that predictors of poor outcomes included premorbid alcohol abuse, low "self-efficacy," and a host of postmorbid (at 3 months) factors, such as acute pain intensity, anxiety, depression, and sleep disturbance. [22] These are similar to the risk factors for poor return-to-work outcomes in prospective studies conducted in civilian populations with spine injuries. [23–25] These factors, and others, such as somatization, catastrophization, and poor coping skills, also appear to influence the effectiveness of treatments for spine pain. [26–29] Evidence-based lessons regarding early intervention to maintain psychosocial integrity for acute back pain in the civilian sector are reflected in military’s strategy for early intervention after combat injury in the present conflict in the Middle East. [30] The goals of this approach include reducing immediate stress and pain associated with physical and psychological trauma, maintaining injured troops close to the field with their units, and restoring role functioning as soon as possible. [31]

The high rates of psychiatric comorbidity complicating combat exposure, such as mood and anxiety disorders, including post-traumatic stress disorder (PTSD), and neuropsychiatric complications of blast injuries, demand sensitive screening for these conditions in troops with spine pain. A large-scale cross-sectional study among Gulf War Veterans with PTSD found that more than 95% continued to experience persistent musculoskeletal complaints. [32] A prospective study by Shaw et al. [33] found that coexisting diagnoses of generalized anxiety, PTSD, and major depression were associated with 2.5–, 3.2–, and 5.0–fold increases in risk for transitioning from new onset to chronic back pain, respectively. Among service members evacuated from OIF and OEF for back and neck pain, the presence of a concurrent psychiatric illness decreased the likelihood of returning to duty 31% and 56%, respectively. [34, 35] These statistics strongly augur for the identification and prompt treatment of comorbid psychiatric conditions as a means to reduce the burden of spine pain in service members.



Etiology

      Neck pain

A substantial body of literature has examined neck pain in fighter pilots. In a study by De Loose et al. [12], the authors found that pilots with neck pain were more likely to sit for longer periods of time, frequently held their neck in a forward bent posture, and were more physically and emotionally fatigued than non-pilots and pilots without neck pain. Studies have also demonstrated electromyographic differences and increased levels of myoelectric activity in pilots with cervical symptoms compared with asymptomatic pilots and non-pilots. [36, 37]

Cohen et al. [35] performed an epidemiological study analyzing clinical and prognostic factors in 374 service members medically evacuated out of OIF and OEF with a primary complaint of neck pain. Among the 35.3% who could identify an inciting event, the most common etiologies were

prolonged driving   (10%),
falls   (9%),
lifting   (9%), and
wearing Kevlar   (5%).

      Thoracic pain

Few studies have sought to determine the causes of mid-back pain in military cohorts. Hamalainen [38] found a strong association between the number of GZ flight hours and the incidence of midback pain and LBP among fighter pilots. Similar to civilian cohorts, a retrospective review by Morken et al. [39] conducted in 2,265 Norwegian naval personnel determined that low levels of physical activity were moderately correlated with cervical, thoracic, and lumbar spine pain.

      Low back pain

A service member’s job can be linked to sources of LBP. A literature review by Pelham et al. [40] found that whole-body vibration and in-flight sitting posture may be associated with the development of LBP in rotary wing pilots but are not clearly causative. In a Finnish study that followed 245 male conscripts, the authors found that the same inciting events that precipitated LBP before enlistment, namely lifting and carrying, were most likely to incite back pain during military service. Among various military activities, combat training (11%) and marching (10%) were the two events most likely to result in injury. [10] Rohrer et al. [41] reported that prolonged standing, twisting, vibration, and heavy work were associated with chronic LBP in 1,398 Swiss conscripts. A large prospective study (n = 53,555) conducted in British service members found that military exercises, regular work, off-duty activities, and sports were the most common etiologies. [9] The observation that LBP episodes surge during military training is supported by work by Carragee and Cohen [13], who reported an approximately 10% increase in the monthly incidence of moderate LBP, and a three-fold to four-fold increase in disability, during heavy training. In an epidemiological study evaluating back pain evacuees from OIF and OEF, the three leading reported precipitating events were lifting (18%), falls (11%), and pain incurred during driving (8%). [34]



Workup

The workup of spinal pain in forward-deployed areas is different than in civilian settings. Equipment and personnel resources are limited in war zones, and magnetic resonance images are generally not available. Computed tomographic scans are available at combat support hospitals (CSHs) and are approximately 90% sensitive and 70% specific in detecting disc pathology with magnetic resonance imaging as the reference standard. [42] In view of the poor correlation between advanced imaging pathology and symptoms at all spinal levels [43, 44], the failure to demonstrate that radiological studies improve outcomes [45], and the fact that epidural injectates spread to multiple spinal levels, imaging is not essential when selecting patients for lumbar epidural steroid injection (ESI). For safety reasons, performing thoracic or cervical ESI without viewing computed tomographic scans is not recommended. Electromyography and nerve conduction studies are also usually unavailable in theater.

Another key difference is time constraints. Time allotted to return to duty (RTD) can vary based on a unit’s mission, one’s military occupational specialty and its need, the availability of replacements, and a host of other factors. For this reason, diagnosis is often subordinated to treatment, such that patients may receive multiple therapeutic procedures concurrently or undergo a "definitive" treatment without the benefit of a prognostic block (eg, facet joint radiofrequency denervation without a facet block).



Classification

Table 1

The most important distinction in the categorization of spinal pain is between neuropathic and nociceptive pain as this affects treatment paradigms at all levels. In prospective studies using instruments designed to discriminate between neuropathic and nociceptive or mechanical pain, researchers have estimated that between 37% and 55% of patients with chronic spinal cord injury suffer from predominantly neuropathic symptoms (Table 1). [46, 47]

      Neuropathic pain

Herniated disc is the leading cause of neuropathic spine pain from the third to fifth decades of life. Young people with radiculopathy are more likely to recall a specific inciting event and experience an abrupt onset than elderly patients with stenosis, which probably reflects the greater force required to herniate less degenerated discs. [48] Neuropathic pain from a herniated disc tends to respond better to both pharmacological and interventional treatment than spinal stenosis, which in turn has a better prognosis than chronic axial pain. In studies conducted among spine pain evacuees from OIF and OEF, 69% and 84% service members with back and neck pain, respectively, had primarily radicular symptomatology. [34, 35]

Table 2

A good history and physical examination is reasonably accurate in discriminating between neuropathic and nociceptive pain. In one prospective study following 50 patients who underwent successful single-level cervical decompression surgery, neurological examination showed a two-thirds rate of agreement with radiological imaging for cervical myelopathy. [49]

For lumbosacral radiculopathy, a systematic review found the straight leg-raising test to be 85% sensitive and 52% specific based on operative and radiological findings. [50]

For cervical radiculopathy, systematic reviews have found Spurling test to have low to moderate sensitivity but high specificity, whereas upper limb tension test is characterized by high sensitivity and low specificity (Table 2). [51]

      Nociceptive pain

Nociceptive pain results from tissue or potential tissue injury, which is often the result of increased load bearing. Between 80% and 90% of patients with acute spine pain episodes no longer seek care after 3 months, although recent studies suggest that more than one-third will experience persistence or recurrences in the next few years. [52, 53] Although the precise etiologic breakdown of these cases is unknown, many experts attribute most cases to soft-tissue origin. Similar to athletes, the incidence of myofascial spinal pain in service members is estimated to exceed that of the general population. [54]

Service members with persistent pain limiting their ability to perform their duties warrant further attention. Unlike neuropathic spinal pain, radiological imaging is generally not helpful in identifying the pain generator(s) in patients with axial pain as research has shown low sensitivity for the diagnosis of facetogenic or sacroiliac (SI) joint pain and poor specificity for discogenic pain. [44, 55] Discogenic and facetogenic pain tend to develop insidiously as a result from chronic low-level strain and degeneration, whereas between 40% and 50% of cases of injection-confirmed SI joint pain occur after a specific inciting event, with the two most common causes being motor vehicle accidents and falls — two of the more common injuries in counterinsurgency operations. [56, 57] The mechanism of SI joint injury is often described as a combination of axial loading and rotation, with injury to the extra-articular joint complex being especially common in airborne soldiers and after long road marches.

The reference standard for diagnosing both facet and SI joint pain is diagnostic blocks, which are characterized by high false-positive rates (20–40%). Nevertheless, because of time constraints and travel risks, there is no place for controlled blocks downrange.



Treatment

In view of the inherent difficulties involved in conducting research in theater, many of the treatments used in deployed service members are extrapolated from studies performed in civilian populations. Because soldiers in combat environments are subject to increased physical (eg, body armor) and psychosocial stressors, which have been associated with negative treatment results [27–29, 58], outcomes in this context may not be as auspicious.

As in the civilian setting, successful pain management in the deployed setting is increasingly multimodal and multidisciplinary. The use of complementary techniques, such as injections, physical therapy, psychological interventions, such as cognitive-behavioral therapy, and alternative medicine may improve treatment outcomes compared with traditional pharmaceuticals. Concern for side effects from traditional pharmaceuticals is at least one factor that has driven this change. The idea that analgesic medications may impair decision making or slow reaction times has often been postulated, but little clinical research has been conducted in simulators or on the battlefield. For opioids, most research has focused on driving. Most studies have found that patients on stable doses of opioids do not exhibit increased psychomotor impairment or higher rates of motor vehicle accidents, but the findings regarding cognitive impairment in patients on chronic opioids are more evenly split. [59] In contrast, drug interactions, abuse, and diversion by soldiers are frequently reported in the popular media. [60]

      Interventional procedures

Although preliminary reports on the use of interventional spine treatments such as ESIs to treat deployed soldiers are encouraging, all are limited by their observational nature, small sample sizes, and nonstandardized follow-up. In an observational study by White and Cohen [61] published in 2007, the authors reported that all 93 patients with spinal pain treated in a CSH returned to duty after interventional treatments. Although the study population was comprised of self-selected motivated service members who wanted to remain in theater, it augurs positively for early and aggressive treatment.

Interventional procedures are frequently performed at CSH, but it is important to understand the unique considerations. First, although qualified physicians with interventional experience and even subspecialty training are frequently available, deployment slots are allocated based on primary specialty (eg, anesthesiology). Second, because pain management is not a primary mission, patients are treated on a "time and space available" basis. Third, transport to and from adjacent air bases is not without peril, which often justifies multiple interventions during a single session. Nevertheless, the low complication rates warrant their consideration in a deployed setting whereby sterility may be compromised.

In patients who present with radiculopathy, there is a strong consensus that ESIs can provide at least short-term relief, although controversy exists regarding long-term efficacy. [62–64] Transforaminal injections may be more efficacious than the interlaminar approach [65], but the higher risk in the cervical region precludes their use in austere environments. [66]

In patients with purported facetogenic pain, intraarticular steroids are relatively easy to perform and have anecdotally been reported to provide short-term benefit to a small portion of patients with an acute inflammatory process, but there is no evidence to support long-term benefit. [67] For patients who obtain good relief from diagnostic blocks, there is limited evidence to support a modest intermediate-term treatment effect for radiofrequency denervation, which may be more effective for neck pain than midback pain or LBP. [63, 64] Although observational studies performed in stateside-level 4 military treatment facilities (MTFs) have reported that approximately half of treated personnel will experience some benefit [68], in deployed settings, the evidence supporting facet joint radiofrequency denervation is limited to a small case series. [69] Both peri- and intra-articular corticosteroids may provide short-term relief for SI joint pain, although the few controlled studies lacked long-term follow-up. One controlled study conducted at a Level 4 MTF found SI joint denervation to provide intermediate-term (median, 8 months) pain relief. [70]

The combination of a long recuperative period, concerns over infection, and a lack of high-grade supporting evidence makes intradiscal procedures a poor treatment choice in combat zones. These concerns also render implantation procedures (eg, spinal cord stimulation) inappropriate during deployment. However, a small case series described five patients who deployed downrange with spinal cord stimulators in place, four of whom successfully completed their tours of duty. [71]

      Pharmacotherapy

Most classes of analgesic medications in the civilian setting are available to deployed providers, although choices within each class may be limited. Conventional medications offer several advantages in the deployed setting. First, they are readily available through the pharmacy system in theater. Second, they require little specialized training on the part of providers, and their use can be standardized with clinical practice guidelines. Finally, once started, medication therapies can be continued at remote locations in an environment where the risk of travel to a site with a pain provider exceeds the dangers posed by drug-related side effects. Non-opioid analgesics commonly used in deployed settings include nonsteroidal anti-inflammatory drugs and muscle relaxants for axial pain and antidepressants and anticonvulsants for radiculopathy. The main drawback of adjuvants is the central nervous system depressant effects, which may adversely affect reaction time. One study showed a higher rate of motor vehicle collisions, which is a major cause of injury in theater, among patients taking the muscle relaxants carisoprodol and diazepam. [72]

Most physicians believe that opioids are a reasonable treatment option for acute spinal episodes, but their use in this capacity must be carefully weighed against their proven adverse cognitive effects, such as impaired reaction time, attention, balance and memory, which are especially pronounced after initiation of treatment. [59, 73] The principal drawbacks of opioid use relate to late complications, often occurring after deployment, when patients maintained on multiple medications can suffer infrequent but serious complications, including death from intentional and accidental overdose. Risks of misuse, diversion, and other aberrant behaviors are more likely to occur in individuals who fit the demographic and clinical profile of young combat-exposed service members, many of whom suffer from multiple physical and psychological maladies and have poorly developed coping skills. [74] These are just some of the factors that led to the establishment of Warrior Transition Units, which aim to make treatment of high-risk patients safer.

      Psychological interventions

The treatment of patients with spine pain with cognitive-behavioral therapy has been shown to result in better outcomes, including better quality of life, less pain, and lower health-care costs. [75] Cognitive-behavioral therapy is presently being used successfully to treat the combination of pain and psychological distress, including PTSD, so commonly associated with military service on the battlefield. [76]

      Physical therapy

Physical therapy is widely used to treat back and neck pain in theater, both at CSH and battalion aid stations. Advantages include negligible risk, proven efficacy, and widespread availability of services. One randomized study performed in European military personnel found comparable efficacy for regular physical therapy, consisting of general exercise and specific back strengthening. [77] Although there is some evidence to support physical therapy modalities "in garrison" and in non-military members, there are no published studies in peer-reviewed literature involving spine pain in deployed soldiers.

      Complementary and alternative medicine

There are many forms of complementary and alternative medicine available for spinal pain, with the two most common being acupuncture and spinal manipulation. In both garrison and deployed settings, acupuncture has been shown to relieve acute pain conditions, including but not limited to spinal pain. A small randomized study comparing acupuncture to Thai traditional massage in young military personnel with myofascial back pain found that although both treatments alleviated pain, acupuncture was superior. [78] In addition to the published literature, the use of acupuncture in deployed and non-deployed service members has benefited from anecdotal success and the absence of reported complications. A short funded training program to teach deploying physicians the technique has helped move this modality to the front lines and into military medical centers. [79, 80]

Spinal manipulation therapy by doctors of osteopathy or other trained personnel is offered when such providers are deployed. One of the main benefits of manipulative therapy is the relatively low risk involved for high velocity and low-amplitude manipulation. There is currently only anecdotal evidence supporting osteopathic manipulation in deployed service members. [81]



Effect of treatment location on return-to-duty rates

The primary mission of the Medical Corps is to "preserve the fighting force." Consequently, the most relevant outcome measure for military doctors who treat spine pain is "RTD" (return to duty) status. A service member who reports minimal pain but cannot work because of back problems is of less use to the military than one who can complete a mission despite low-grade spinal pain.

The effect that treatment location has on the categorical outcome measure RTD is well documented. In an epidemiological study performed in evacuees from OIF and OEF seen at pain clinics in fourth-level MTFs in Landstuhl, Germany, a transit point for almost all injured service members from OIF and OEF, and Walter Reed National Military Medical Center, Cohen et al. [82] found that less than 2% returned to their deployed unit. Over two-thirds of these patients presented with spinal pain. But when a forward-deployed pain clinic was set up near a major airfield at a CSH in Baghdad, Iraq, more than 95% of service members were able to RTD. [61] Approximately 80% of these individuals had spinal pain. It should be emphasized that these patients may not have had comparable military responsibilities and motivations. Studies conducted in evacuees from OIF and OEF have consistently shown that officers and females, who tend to have less physically demanding jobs than lower enlisted personnel, have higher RTD rates across the board for all medical conditions, including back and neck pain. [5, 34, 35] But although some of this discrepancy may be because of job descriptions, logistical issues, greater disease burden, and psychiatric comorbidity in those service members already evacuated, the difference in outcomes is nevertheless compelling.

Considering the strong parallel relationship between psychopathology and chronic spinal pain, it is not surprising that a similar pattern has been observed for combat stress. For example, the RTD rate when treating early combat stress symptoms with forward-deployed combat stress teams in Iraq is greater than 95%. If similar symptoms are addressed at CSHs in theater, or nearby in Kuwait or Qatar, the RTD rates decline to approximately 70% and 50%, respectively. A service member with signs of post-traumatic stress syndrome who makes it as far as the fourth-level MTF in Germany has only a 9% chance of returning to combat duty. And if the service member ends up in the United States for treatment, he has virtually no chance of returning to duty in theater. [83]

Table 3

These statistics must be placed in the context of resource availability, inherent treatment constraints in an austere environment, and psychophysical risks of delayed treatment. The medical treatment system in wartime was designed and implemented in World War II to facilitate the rapid transport of injured personnel to increasingly sophisticated treatment facilities, thereby maximizing capacity in the event of mass casualties. This system was not established to provide long-term treatment, rehabilitation, or intensive psychotherapy. Treatment in most cases is, therefore, limited based on time, resources, and capacity (Table 3).



CONCLUSIONS

Spinal pain, which for the purpose of this article refers to spine-area pain syndromes that include soft-tissue pathology, exacts an enormous toll in military personnel, representing the leading cause of medical boards across all services. This burden is increased during wartime as a result of several factors, including increased physical stressors and myriad psychosocial dynamics. Similar to civilian personnel, the treatment of spine pain in deployed service members has become increasingly multimodal to include injections, judicious pharmacotherapy, physical therapy, complementary and alternative medicine if available, and psychotherapy as indicated. Based on the extant literature, aggressive treatment in theater appears to offer the greatest chance of keeping an injured service member with their unit.



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