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Randy S. Bell, Chris J. Neal, and Randall McCafferty

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Callum D. Dewar, Jason H. Boulter, Brian P. Curry, Dana M. Bowers, and Randy S. Bell

Medical malpractice suits within the military have historically been limited by the Feres Doctrine, a legal precedent arising from a Supreme Court decision in 1950, which stated that active-duty personnel cannot bring suit for malpractice against either the United States government or military healthcare providers. This precedent has increasingly become a focus of discussion and reform as multiple cases claiming malpractice have been dismissed. Recently, however, the National Defense Authorization Act of 2020 initiated the first change to this precedent by creating an administrative body with the sole purpose of evaluating and settling claims of medical malpractice within the military’s $50 billion healthcare system. This article seeks to present the legal history related to military malpractice and the Feres Doctrine as well as discuss the potential future implications that may arise as the Feres Doctrine is modified for the first time in 70 years.

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Joshua J. Wind, Randy S. Bell, William O. Bank, and John S. Myseros

The authors present the case of a 3-month-old boy with a third ventricular tumor consistent with a choroid plexus papilloma. This child presented with macrocephaly, irritability, inability to roll over, and vomiting. He was found to have an enlarged head circumference, a full and tense fontanel, splayed sutures, and forced downward gaze. Imaging revealed severe ventriculomegaly and a brightly enhancing third ventricular lesion consistent with papilloma. Treatment planning included placement of a ventriculoperitoneal shunt to treat hydrocephalus and to allow the child to grow prior to resection. Due to the vascular nature of these tumors and the age of this child, the tumor was embolized with a plan for eventual resection; however, embolization resulted in involution and total regression of the tumor. There is no residual disease at last follow-up of 16 months. In this specific scenario of a choroid plexus papilloma in an infant, when operative intervention may be technically difficult and associated with significant morbidity, embolization with close observation may be a valid treatment option. If used, the patient would need to be closely followed for evidence of residual or recurrent disease, which would require operative intervention.

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Sudhakar Vadivelu, Randy Scott Bell, Ben Crandall, Tom DeGraba, and Rocco A. Armonda

Blast-induced neurotrauma is a leading cause of military casualties. Its effects on cerebrovascular structures are not well understood. Vascular injury resulting from overpressure shock wave impact may have a delayed presentation and detection. The authors present the cases of 2 patients who sustained blast-induced craniofacial trauma and brain injury. Detection of a cervical dissection was delayed in one patient, and detection of carotid-cavernous fistulas was delayed in both patients. The authors report the successful obliteration of both the dissection and the carotidcavernous fistulas via an endovascular approach. Endovascular management provides both a reasonable and effective therapeutic option to blast-induced cerebrovascular injuries.

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Randy S. Bell, Alexander H. Vo, Patrick B. Cooper, Carrie L. Schmitt, and Michael K. Rosner

✓ Eosinophilic meningitis has been defined as meningitis in which a total cerebrospinal fluid (CSF) sample is found to have more than 10 eosinophils per millimeter or is composed of greater than 10% eosinophils. The differential diagnosis is broad and the clinical presentation, lacking an internalized CSF diversion system, is often nonspecific. With respect to patients with shunt systems, a positive correlation exists between CSF eosinophilia and eventual shunt failure requiring revision. In this paper the authors present the highest reported level of CSF eosinophilia in conjunction with a rifampin and minocycline–impregnated ventriculostomy catheter recently approved by the Food and Drug Administration.

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Richard Menger, Benjamin F. Mundell, J. Will Robbins, Peter Letarte, Randy Bell, and in conjunction with Council of State Neurosurgical Societies and AANS/CNS Joint Committee of Military Neurosurgeons

OBJECTIVE

Papers from 2002 to 2017 have highlighted consistent unique socioeconomic challenges and opportunities facing military neurosurgeons. Here, the authors focus on the reserve military neurosurgeon who carries the dual mission of both civilian and military responsibilities.

METHODS

Survey solicitation of current active duty and reserve military neurosurgeons was performed in conjunction with the AANS/CNS Joint Committee of Military Neurosurgeons and the Council of State Neurosurgical Societies. Demographic, qualitative, and quantitative data points were compared between reserve and active duty military neurosurgeons. Civilian neurosurgical provider data were taken from the 2016 NERVES (Neurosurgery Executives Resource Value and Education Society) Socio-Economic Survey. Economic modeling was done to forecast the impact of deployment or mobilization on the reserve neurosurgeon, neurosurgery practice, and the community.

RESULTS

Seventy-five percent (12/16) of current reserve neurosurgeons reported that they are satisfied with their military service. Reserve neurosurgeons make significant contributions to the military’s neurosurgical capabilities, with 75% (12/16) having been deployed during their career. No statistically significant demographic differences were found between those serving on active duty and those in the reserve service. However, those who served in the reserves were more likely to desire opportunities for improvement in the military workflow requirements compared with their active duty counterparts (p = 0.04); 92.9% (13/14) of current reserve neurosurgeons desired more flexible military drill programs specific to the needs of practicing physicians. The risk of reserve deployment is also borne by the practices, hospitals, and communities in which the neurosurgeon serves in civilian practice. This can result in fewer new patient encounters, decreased collections, decreased work relative value unit generation, increased operating costs per neurosurgeon, and intangible limitations on practice development. However, through modeling, the authors have illustrated that reserve physicians joining a larger group practice can significantly mitigate this risk. What remains astonishing is that 91.7% of those reserve neurosurgeons who were deployed noted the experience to be rewarding despite seeing a 20% reduction in income, on average, during the fiscal year of a 6-month deployment.

CONCLUSIONS

Reserve neurosurgeons are satisfied with their military service while making substantial contributions to the military’s neurosurgical capabilities, with the overwhelming majority of current military reservists having been deployed or mobilized during their reserve commitments. Through the authors’ modeling, the impact of deployment on the military neurosurgeon, neurosurgeon’s practice, and the local community can be significantly mitigated by a larger practice environment.

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Stacy A. Shackelford, Deborah J. del Junco, Michael C. Reade, Randy Bell, Tyson Becker, Jennifer Gurney, Randall McCafferty, and Donald W. Marion

OBJECTIVE

In combat and austere environments, evacuation to a location with neurosurgery capability is challenging. A planning target in terms of time to neurosurgery is paramount to inform prepositioning of neurosurgical and transport resources to support a population at risk. This study sought to examine the association of wait time to craniectomy with mortality in patients with severe combat-related brain injury who received decompressive craniectomy.

METHODS

Patients with combat-related brain injury sustained between 2005 and 2015 who underwent craniectomy at deployed surgical facilities were identified from the Department of Defense Trauma Registry and Joint Trauma System Role 2 Registry. Eligible patients survived transport to a hospital capable of diagnosing the need for craniectomy and performing surgery. Statistical analyses included unadjusted comparisons of postoperative mortality by elapsed time from injury to start of craniectomy, and Cox proportional hazards modeling adjusting for potential confounders. Time from injury to craniectomy was divided into quintiles, and explored in Cox models as a binary variable comparing early versus delayed craniectomy with cutoffs determined by the maximum value of each quintile (quintile 1 vs 2–5, quintiles 1–2 vs 3–5, etc.). Covariates included location of the facility at which the craniectomy was performed (limited-resource role 2 facility vs neurosurgically capable role 3 facility), use of head CT scan, US military status, age, head Abbreviated Injury Scale score, Injury Severity Score, and injury year. To reduce immortal time bias, time from injury to hospital arrival was included as a covariate, entry into the survival analysis cohort was defined as hospital arrival time, and early versus delayed craniectomy was modeled as a time-dependent covariate. Follow-up for survival ended at death, hospital discharge, or hospital day 16, whichever occurred first.

RESULTS

Of 486 patients identified as having undergone craniectomy, 213 (44%) had complete date/time values. Unadjusted postoperative mortality was 23% for quintile 1 (n = 43, time from injury to start of craniectomy 30–152 minutes); 7% for quintile 2 (n = 42, 154–210 minutes); 7% for quintile 3 (n = 43, 212–320 minutes); 19% for quintile 4 (n = 42, 325–639 minutes); and 14% for quintile 5 (n = 43, 665–3885 minutes). In Cox models adjusted for potential confounders and immortal time bias, postoperative mortality was significantly lower when time to craniectomy was within 5.33 hours of injury (quintiles 1–3) relative to longer delays (quintiles 4–5), with an adjusted hazard ratio of 0.28, 95% CI 0.10–0.76 (p = 0.012).

CONCLUSIONS

Postoperative mortality was significantly lower when craniectomy was initiated within 5.33 hours of injury. Further research to optimize craniectomy timing and mitigate delays is needed. Functional outcomes should also be evaluated.

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Randy S. Bell, Robert D. Ecker, Meryl A. Severson III, John E. Wanebo, Benjamin Crandall, and Rocco A. Armonda

The approach to traumatic craniocervical vascular injury has evolved significantly in recent years. Conflicts prior to Operations Iraqi and Enduring Freedom were characterized by minimal intervention in the setting of severe penetrating head injury, in large part due to limited far-forward resource availability. Consequently, sequelae of penetrating head injury like traumatic aneurysm formation remained poorly characterized with a paucity of pathophysiological descriptions. The current conflicts have seen dramatic improvements with respect to the management of severe penetrating and closed head injuries. As a result of the rapid field resuscitation and early cranial decompression, patients are surviving longer, which has led to diagnosis and treatment of entities that had previously gone undiagnosed. Therefore, in this paper the authors' purpose is to review their experience with severe traumatic brain injury complicated by injury to the craniocervical vasculature. Historical approaches will be reviewed, and the importance of modern endovascular techniques will be emphasized.

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Frederick L. Stephens, Correy M. Mossop, Randy S. Bell, Teodoro Tigno Jr., Michael K. Rosner, Anand Kumar, Leon E. Moores, and Rocco A. Armonda

Object

In support of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom-Afghanistan (OEF-A), military neurosurgeons in the combat theater are faced with the daunting task of stabilizing patients in such a way as to prevent irreversible neurological injury from cerebral edema while simultaneously allowing for prolonged transport stateside (5000–7000 miles). It is in this setting that decompressive craniectomy has become a mainstay of far-forward neurosurgical management of traumatic brain injury (TBI).

As such, institutional experience with cranioplasty at the Walter Reed Army Medical Center (WRAMC) and the National Naval Medical Center (NNMC) has expanded concomitantly. Battlefield blast explosions create cavitary injury zones that often extend beyond the border of the exposed surface wound, and this situation has created unique reconstruction challenges not often seen in civilian TBI. The loss of both soft-tissue and skull base support along with the need for cranial vault reconstruction requires a multidisciplinary approach involving neurosurgery, plastics, oral-maxillofacial surgery, and ophthalmology. With this situation in mind, the authors of this paper endeavored to review the cranial reconstruction complications encountered in these combat-related injuries.

Methods

A retrospective database review was conducted for all soldiers injured in OIF and OEF-A who had undergone decompressive craniectomy with subsequent cranioplasty between April 2002 and October 2008 at the WRAMC and NNMC. During this time, both facilities received a total of 408 OIF/OEF-A patients with severe head injuries; 188 of these patients underwent decompressive craniectomies in the theater before transfer to the US. Criteria for inclusion in this study consisted of either a closed or a penetrating head injury sustained in combat operations, resulting in the performance of a decompressive craniectomy and subsequent cranioplasty at either the WRAMC or NNMC. Excluded from the study were patients for whom primary demographic data could not be verified. Demographic data, indications for craniectomy, as well as preoperative, intraoperative, and postoperative parameters following cranioplasty, were recorded. Perioperative and postoperative complications were also recorded.

Results

One hundred eight patients (male/female ratio 107:1) met the inclusion criteria for this study, 93 with a penetrating head injury and 15 with a closed head injury. Explosive blast injury was the predominant mechanism of injury, occurring in 72 patients (67%). The average time that elapsed between injury and cranioplasty was 190 days (range 7–546 days). An overall complication rate of 24% was identified. The prevalence of perioperative infection (12%), seizure (7.4%), and extraaxial hematoma formation (7.4%) was noted. Twelve patients (11%) required prosthetic removal because of either extraaxial hematoma formation or infection. Eight of the 13 cases of infection involved cranioplasties performed between 90 and 270 days from the date of injury (p = 0.06).

Conclusions

This study represents the largest to date in which cranioplasty and its complications have been evaluated in a trauma population that underwent decompressive craniectomy. The overall complication rate of 24% is consistent with rates reported in the literature (16–34%); however, the perioperative infection rate of 12% is higher than the rates reported in other studies. This difference is likely related to aspects of the initial injury pattern—such as skull base injury, orbitofacial fractures, sinus injuries, persistent fluid collection, and CSF leakage—which can predispose these patients to infection.