title: Spinal injuries after improvised explosive device incidents: implications for Tactical Combat Casualty Care.
abstract: BACKGROUND
  Tactical Combat Casualty Care aims to treat preventable causes of death on the battlefield but deemphasizes the importance of spinal immobilization in the prehospital tactical setting. However, improvised explosive devices (IEDs) now cause the majority of injuries to Canadian Forces (CF) members serving in Afghanistan. We hypothesize that IEDs are more frequently associated with spinal injuries than non-IED injuries and that spinal precautions are not being routinely employed on the battlefield.
  
  
  METHODS
  We examined retrospectively a database of all CF soldiers who were wounded and arrived alive at the Role 3 Multinational Medical Unit in Kandahar, Afghanistan, from February 7, 2006, to October 14, 2009. We collected data on demographics, injury mechanism, anatomic injury descriptions, physiologic data on presentation, and prehospital interventions performed. Outcomes were incidence of any spinal injuries.
  
  
  RESULTS
  Three hundred seventy-two CF soldiers were injured during the study period and met study criteria. Twenty-nine (8%) had spinal fractures identified. Of these, 41% (n = 12) were unstable, 31% (n = 9) stable, and 28% indeterminate. Most patients were injured by IEDs (n = 212, 57%). Patients injured by IEDs were more likely to have spinal injuries than those injured by non-IED-related mechanisms (10.4% vs. 2.3%; p < 0.01). IED victims were even more likely to have spinal injuries than patients suffering blunt trauma (10.4% vs. 6.7%; p = 0.02). Prehospital providers were less likely to immobilize the spine in IED victims compared with blunt trauma patients (10% [22 of 212] vs. 23.0% [17 of 74]; p < 0.05).
  
  
  CONCLUSIONS
  IEDs are a common cause of stable and unstable spinal injuries in the Afghanistan conflict. Spinal immobilization is an underutilized intervention in the battlefield care of casualties in the conflict in Afghanistan. This may be a result of tactical limitations; however, current protocols should continue to emphasize the judicious use of immobilization in these patients.
authors.affiliation: Canadian Forces Health Services, Toronto, Ontario, Canada.
authors.forename: Sean
authors.initials: S
authors.lastname: Comstock
authors.forename: Dylan
authors.initials: D
authors.lastname: Pannell
authors.forename: Max
authors.initials: M
authors.lastname: Talbot
authors.forename: Lisa
authors.initials: L
authors.lastname: Compton
authors.forename: Nicholas
authors.initials: N
authors.lastname: Withers
authors.forename: Homer C
authors.initials: HC
authors.lastname: Tien
mesh_terms: D000328:Adult; D055826:Afghan Campaign 2001-; D001753:Blast Injuries / Q000453:epidemiology / Q000601:surgery* / Q000628:therapy; D002170:Canada / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D006772:Hospitals, Military; D006801:Humans; D015994:Incidence; D008297:Male; D008887:Military Medicine / Q000379:methods*; D008889:Military Personnel; D019637:Orthopedic Procedures / Q000379:methods; D012189:Retrospective Studies; D013124:Spinal Injuries / Q000453:epidemiology / Q000601:surgery* / Q000628:therapy; D015599:Trauma Severity Indices