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Survival after traumatic brain injury improves with deployment of neurosurgeons: a comparison of US and UK military treatment facilities during the Iraq and Afghanistan conflicts
  1. John Breeze1,
  2. Douglas M Bowley2,
  3. Stuart E Harrisson3,
  4. Justin Dye4,
  5. Christopher Neal5,
  6. Randy S Bell6,
  7. Rocco A Armonda7,
  8. Andrew D Beggs8,
  9. Jospeh DuBose9,
  10. Rory F Rickard1,
  11. David Bryan Powers10
  1. 1Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
  2. 2Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
  3. 3Department of Neurosurgery, University Hospital of North Staffordshire NHS Trust, Stoke-on-Trent, Staffordshire, UK
  4. 4Department of Neurosurgery, Loma Linda University, Loma Linda, California, USA
  5. 5Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
  6. 6National Capital Neurosurgery Consortium, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
  7. 7Department of Neurosurgery, Georgetown University Medical Center, Washington, DC, USA
  8. 8Surgical Research Laboratory, University of Birmingham, Birmingham, UK
  9. 9Center for the Sustainment of Trauma and Readiness Skills, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
  10. 10Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery, Duke University Medical Center, Durham, North Carolina, USA
  1. Correspondence to Dr John Breeze, Royal Centre for Defence Medicine, Birmingham B15 2WB, UK; johno.breeze{at}


Introduction Traumatic brain injury (TBI) is the most common cause of death on the modern battlefield. In recent conflicts in Iraq and Afghanistan, the US typically deployed neurosurgeons to medical treatment facilities (MTFs), while the UK did not. Our aim was to compare the incidence, TBI and treatment in US and UK-led military MTF to ascertain if differences in deployed trauma systems affected outcomes.

Methods The US and UK Combat Trauma Registries were scrutinised for patients with HI at deployed MTFs between March 2003 and October 2011. Registry datasets were adapted to stratify TBI using the Mayo Classification System for Traumatic Brain Injury Severity. An adjusted multiple logistic regression model was performed using fatality as the binomial dependent variable and treatment in a US-MTF or UK-MTF, surgical decompression, US military casualty and surgery performed by a neurosurgeon as independent variables.

Results 15 031 patients arrived alive at military MTF after TBI. Presence of a neurosurgeon was associated with increased odds of survival in casualties with moderate or severe TBI (p<0.0001, OR 2.71, 95% CI 2.34 to 4.73). High injury severity (Injury Severity Scores 25–75) was significantly associated with a lower survival (OR 4×104, 95% CI 1.61×104 to 110.6×104, p<0.001); however, having a neurosurgeon present still remained significantly positively associated with survival (OR 3.25, 95% CI 2.71 to 3.91, p<0.001).

Conclusions Presence of neurosurgeons increased the likelihood of survival after TBI. We therefore recommend that the UK should deploy neurosurgeons to forward military MTF whenever possible in line with their US counterparts.

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  • Contributors JB and DBP planned, conducted and reported the study. DMB conducted and reported the study. SEH, JuD, CN, RF, RSB, RAA, JoD and ADB reported the study. JB and ADB undertook the statistical analysis.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Ethical approval was not required as this was a retrospective epidemiological study in which all data have been anonymied, and no patient identifiable data are included.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available. Due to the restricted nature of the military databases from which the data are derived, it is not freely available to share.