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Editorial. Assessing outcomes of combat-related penetrating brain injury

Randall R. McCafferty

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Common chemical agent threats

Randall R. McCafferty and Peter J. Lennarson

The events of September 11, 2001, highlight the fact that we live in precarious times. National and global awareness of the resolve and capabilities of terrorists has increased. The possibility that the civilian neurosurgeon may confront a scenario involving the use of chemical warfare agents has heightened. The information reported in this paper serves as a primer on the recognition, decontamination, and treatment of trauma patients exposed to chemical warfare agents.

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Neural function preservation and early mobilization after resection of metastatic sacral tumors and lumbosacropelvic junction reconstruction

Report of three cases

Sean A. Salehi, Randall R. McCafferty, Dean Karahalios, and Stephen L. Ondra

✓ The management of tumors that metastasize to the sacrum remains controversial. Typically, resection of such tumors and reconstruction of the lumbopelvic junction requires sacrifice of neural elements resulting in neurological dysfunction and prolonged periods of bed rest. This severely affects the quality of life in patients in whom there is frequently a limited life expectancy.

The authors describe three patients who underwent subtotal resection of metastatic sacral tumors. Postoperatively, good outcome was demonstrated in all patients.

The authors present a technique for debulking and reconstruction that provides immediate spinopelvic junction stability and allows for early mobilization. Quality of life is significantly improved compared with that resulting from either medical treatment or traditional surgery.

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Ossification of the anterior longitudinal ligament and Forestier's disease: an analysis of seven cases

Randall R. McCafferty, Michael J. Harrison, Laszlo B. Tamas, and Mark V. Larkins

✓ A retrospective review was conducted on the records and radiographs of six symptomatic patients and one asymptomatic patient with Forestier's disease. No other series of patients with this disease is found in the neurosurgical literature. Forestier's disease, also known as diffuse idiopathic skeletal hyperostosis (DISH), is an idiopathic rheumatological abnormality in which exuberant ossification occurs along ligaments throughout the body, but most notably the anterior longitudinal ligament of the spine. It affects older men predominantly; all of our patients were men older than 60 years of age. The disease is usually asymptomatic; however, dyspnea, dysphagia, spinal cord compression, and peripheral nerve entrapment have all been documented in association with the disorder. Five of the six symptomatic patients presented with dysphagia due to esophageal compression by calcified anterior longitudinal ligaments, and one patient developed recurrent spinal stenosis when scar tissue from a previous decompressive laminectomy became calcified. All patients responded well to surgery. Two of the four patients who underwent removal of cervical osteophytes required several months following surgery for the dysphagia to resolve. This would support the hypothesis that not all cases of dysphagia in Forestier's disease are due to mechanical compression. Dysphagia may result from inflammatory changes that accompany fibrosis in the wall of the esophagus or from esophageal denervation. Evaluation of dysphagia even in the presence of Forestier's disease must rule out occult malignancy. The authors' experience suggests that dysphagia in the setting of Forestier's disease is an underrecognized entity amenable to surgical intervention.

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Neurosurgery in Afghanistan during “Operation Enduring Freedom”: a 24-month experience

Brian T. Ragel, Paul Klimo Jr., Robert J. Kowalski, Randall R. McCafferty, Jeannette M. Liu, Derek A. Taggard, David Garrett Jr., and Sidney B. Brevard


“Operation Enduring Freedom” is the US war effort in Afghanistan in its global war on terror. One US military neurosurgeon is deployed in support of Operation Enduring Freedom to provide care for both battlefield injuries and humanitarian work. Here, the authors analyze a 24-month neurosurgical caseload experience in Afghanistan.


Operative logs were analyzed between October 2007 and September 2009. Operative cases were divided into minor procedures (for example, placement of an intracranial pressure monitor) and major procedures (for example, craniotomy) for both battle injuries and humanitarian work. Battle injuries were defined as injuries sustained by soldiers while in the line of duty or injuries to Afghan civilians from weapons of war. Humanitarian work consisted of providing medical care to Afghans.


Six neurosurgeons covering a 24-month period performed 115 minor procedures and 210 major surgical procedures cases. Operations for battlefield injuries included 106 craniotomies, 25 spine surgeries, and 18 miscellaneous surgeries. Humanitarian work included 32 craniotomies (23 for trauma, 3 for tumor, 6 for other reasons, such as cyst fenestration), 27 spine surgeries (12 for degenerative conditions, 9 for trauma, 4 for myelomeningocele closure, and 2 for the treatment of infection), and 2 miscellaneous surgeries.


Military neurosurgeons have provided surgical care at rates of 71% (149/210) for battlefield injuries and 29% (61/210) for humanitarian work. Of the operations for battle trauma, 50% (106/210) were cranial and 11% (25/210) spinal surgeries. Fifteen percent (32/210) and 13% (27/210) of operations were for humanitarian cranial and spine procedures, respectively. Overall, military neurosurgeons in Afghanistan are performing life-saving cranial and spine stabilization procedures for battlefield trauma and acting as general neurosurgeons for the Afghan community.