Rehabilitation of Injured U.S. Servicemember with Traumatic Brain Injury, Stroke, Spinal Cord Injury, and Bilateral Amputations: A Case Report

Article excerpt

INTRODUCTION

On October 7, 2001, the United States began combat operations in Afghanistan, referred to as Operation Enduring Freedom (OEF), in response to the September 11 terrorist attacks. On March 2003, the United States became engaged in military operations in Iraq, referred to as Operation Iraqi Freedom (OIF), as part of the Global War on Terror. OIF was completed as of August 31, 2010, and transitioned to Operation New Dawn (OND) as of September 1, 2010. The OEF/OIF/OND conflicts have been the longest, continuous military campaign in the history of the United States, with more than 2.2 million troops deployed as of December 2010. These conflicts have spawned more powerful explosive devices that use creative detonation methods and carry devastating blast components, leading to multiple organ system injuries, known as the polytrauma condition. Blast injury from explosive forces has proven to be the most devastating injury seen in OIF/OEF. The pervasiveness of blast exposures, especially in the form of improvised explosive devices (IEDs), and their impact on the brain have resulted in traumatic brain injury (TBI) being referred to as the "signature wound" of this war [1]. Fortunately, despite these tactics, the ability of the U.S. military's trauma teams to rapidly treat, stabilize, and aeromedically evacuate servicemembers with severe injuries has resulted in an increased survivability compared with the Vietnam war [2].

This case presentation describes a combat-injured servicemember with highly complex rehabilitation needs who was successfully returned to the community. To date, no other cases with such severe injuries in one individual have been described in the literature (search parameters included amputation, stroke, spinal cord injury [SCI], and TBI). This case demonstrates the level of coordination required to seamlessly navigate the combined Department of Defense (DOD) and Department of Veterans Affairs (VA) system and the vital role that rehabilitation services may play in optimal recovery after blast injury.

CASE REPORT

E.M. is a 32-year old, right-hand dominant, previously healthy medic in the U.S. Army who sustained an IED blast on July 2, 2010, while stationed in Afghanistan as part of OEF. As a result of the blast, he experienced the following injuries:

1. Severe TBI with multiple facial fractures, including the right pterygoid process lateral plate, the right parasymphyseal mandible, the left maxillary sinus medial wall, and the nasal septum.

2. Right middle cerebral artery (MCA) distribution infarction.

3. Bilateral anterior cerebral artery (ACA) watershed infarctions.

4. Traumatic, bilateral below-knee amputations (BKAs).

5. Lumbar (L) 1 American Spinal Injury Association (ASIA) Impairment Scale (AIS)-B SCI from an unstable, comminuted burst fracture of L4 with retropulsed fracture, resulting in 30 percent effacement of the central canal [3].

6. L1-L2 superior endplate compression fracture.

7. Left transverse process fractures of L1, L2, L3, and L4, with associated retroperitoneal, paravertebral hematomas.

8. Coccyx fracture.

9. Right lung middle and posterior segment lobe contusions with hematoma.

He had an initial loss of consciousness in the field following the blast, became alert and agitated while being aeromedically evacuated to the Bagram Airfield military hospital (Bagram, Afghanistan), and was noted to be comatose with a Glasgow Coma Scale (GCS) of 6 on arrival at Bagram [4]. He was intubated, sedated, and placed in a cervical collar (C-collar). Initial head computed tomography (CT) scan was normal. A diagnostic peritoneal lavage was negative. There was no detectable blood flow to his lower limbs, and therefore, he underwent surgical revision of the bilateral BKAs. A postoperative head CT was significant for a right MCA infarction. On July 4, he was aeromedically evacuated to Landstuhl Regional Medical Center (LRMC) (Landstuhl, Germany). …