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Charles A. Miller, Jason H. Boulter, Daniel J. Coughlin, Michael K. Rosner, Chris J. Neal, and Michael S. Dirks


Symptomatic cervical spondylosis with or without radiculopathy can ground an active-duty military pilot if left untreated. Surgically treated cervical spondylosis may be a waiverable condition and allow return to flying status, but a waiver is based on expert opinion and not on recent published data. Previous studies on rates of return to active duty status following anterior cervical spine surgery have not differentiated these rates among military specialty occupations. No studies to date have documented the successful return of US military active-duty pilots who have undergone anterior cervical spine surgery with cervical fusion, disc replacement, or a combination of the two. The aim of this study was to identify the rate of return to an active duty flight status among US military pilots who had undergone anterior cervical discectomy and fusion (ACDF) or total disc replacement (TDR) for symptomatic cervical spondylosis.


The authors performed a single-center retrospective review of all active duty pilots who had undergone either ACDF or TDR at a military hospital between January 2010 and June 2017. Descriptive statistics were calculated for both groups to evaluate demographics with specific attention to preoperative flight stats, days to recommended clearance by neurosurgery, and days to return to active duty flight status.


Authors identified a total of 812 cases of anterior cervical surgery performed between January 1, 2010, and June 1, 2017, among active duty, reserves, dependents, and Department of Defense/Veterans Affairs patients. There were 581 ACDFs and 231 TDRs. After screening for military occupation and active duty status, there were a total of 22 active duty pilots, among whom were 4 ACDFs, 17 TDRs, and 2 hybrid constructs. One patient required a second surgery. Six (27.3%) of the 22 pilots were nearing the end of their career and electively retired within a year of surgery. Of the remaining 16 pilots, 11 (68.8%) returned to active duty flying status. The average time to be released by the neurosurgeon was 128 days, and the time to return to flying was 287 days. The average follow-up period was 12.3 months.


Adhering to military service-specific waiver guidelines, military pilots may return to active duty flight status after undergoing ACDF or TDR for symptomatic cervical spondylosis.

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Randy S. Bell, Corey M. Mossop, Michael S. Dirks, Frederick L. Stephens, Lisa Mulligan, Robert Ecker, Christopher J. Neal, Anand Kumar, Teodoro Tigno, and Rocco A. Armonda


Decompressive craniectomy has defined this era of damage-control wartime neurosurgery. Injuries that in previous conflicts were treated in an expectant manner are now aggressively decompressed at the far-forward Combat Support Hospital and transferred to Walter Reed Army Medical Center (WRAMC) and National Naval Medical Center (NNMC) in Bethesda for definitive care. The purpose of this paper is to examine the baseline characteristics of those injured warriors who received decompressive craniectomies. The importance of this procedure will be emphasized and guidance provided to current and future neurosurgeons deployed in theater.


The authors retrospectively searched a database for all soldiers injured in Operations Iraqi Freedom and Enduring Freedom between April 2003 and October 2008 at WRAMC and NNMC. Criteria for inclusion in this study included either a closed or penetrating head injury suffered during combat operations in either Iraq or Afghanistan with subsequent neurosurgical evaluation at NNMC or WRAMC. Exclusion criteria included all cases in which primary demographic data could not be verified. Primary outcome data included the type and mechanism of injury, Glasgow Coma Scale (GCS) score and injury severity score (ISS) at admission, and Glasgow Outcome Scale (GOS) score at discharge, 6 months, and 1–2 years.


Four hundred eight patients presented with head injury during the study period. In this population, a total of 188 decompressive craniectomies were performed (154 for penetrating head injury, 22 for closed head injury, and 12 for unknown injury mechanism). Patients who underwent decompressive craniectomies in the combat theater had significantly lower initial GCS scores (7.7 ± 4.2 vs 10.8 ± 4.0, p < 0.05) and higher ISSs (32.5 ± 9.4 vs 26.8 ± 11.8, p < 0.05) than those who did not. When comparing the GOS scores at hospital discharge, 6 months, and 1–2 years after discharge, those receiving decompressive craniectomies had significantly lower scores (3.0 ± 0.9 vs 3.7 ± 0.9, 3.5 ± 1.2 vs 4.0 ± 1.0, and 3.7 ± 1.2 vs 4.4 ± 0.9, respectively) than those who did not undergo decompressive craniectomies. That said, intragroup analysis indicated consistent improvement for those with craniectomy with time, allowing them, on average, to participate in and improve from rehabilitation (p < 0.05). Overall, 83% of those for whom follow-up data are available achieved a 1-year GOS score of greater than 3.


This study of the provision of early decompressive craniectomy in a military population that sustained severe penetrating and closed head injuries represents one of the largest to date in both the civilian and military literature. The findings suggest that patients who undergo decompressive craniectomy had worse injuries than those receiving craniotomy and, while not achieving the same outcomes as those with a lesser injury, did improve with time. The authors recommend hemicraniectomy for damage control to protect patients from the effects of brain swelling during the long overseas transport to their definitive care, and it should be conducted with foresight concerning future complications and reconstructive surgical procedures.