Spine J. 2012 (Sep); 12 (9): 833-842 ~ FULL TEXT
Steven P. Cohen, MD, Rollin M. Gallagher, MD, MPH, Shelton A. Davis, MD,
Scott R. Griffith, MD, Eugene J. Carragee, MD
Pain Management Division, Department of Anesthesiology & Critical Care Medicine,
Johns Hopkins School of Medicine,
Baltimore, MD 21205, USA.
BACKGROUND CONTEXT: non-battle illnesses and injuries are the major causes of unit attrition in modern warfare. Spine-area pain is a common disabling injury in service members associated with a very low return-to-duty (RTD) rate.
PURPOSE: To provide an overview of the current understanding of epidemiology, possible causes, and relative prognosis of spine-area pain syndromes in military personnel, including a discussion of various treatment options available in theaters of operation.
STUDY DESIGN: Literature review.
METHODS: Search focusing on epidemiology, etiology and associative factors, and treatment of spinal pain using electronic databases, textbooks, bibliographic references, and personal accounts.
RESULTS: Spine-area pain is the most common injury or complaint "in garrison" and appears to increase during training and combat deployments. Approximately three-quarters involve low back pain, followed by cervical and midback pain syndromes. Some predictive factors associated with spine-area pain are similar to those observed in civilian cohorts, such as psychosocial distress, heavy physical activity, and more sedentary lifestyle. Risk factors specific to military personnel include concomitant psychological trauma, g-force exposure in pilots and airmen, extreme shock and vibration exposure, heavy combat load requirements, and falls incurred during airborne, air assault, and urban dismounted ground operations. Effective forward-deployed treatment has been difficult to implement, but newer strategies may improve RTD rates.
CONCLUSIONS: Spine-area pain syndromes comprise a major source of unit attrition and are often the result of duty-related burdens incurred during combat operations. Current strategies in theaters of operation that may improve the low RTD rates include individual and unit level psychological support, early resumption of at least some forward-area duties, multimodal treatments, and ergonomic modifications.
Keywords: Back pain; Neck pain; non-battle injury; Soldier; War
From the FULL TEXT Article:
Epidemiology of war injuries
There is a common misconception regarding the physical
risks of war. Since accurate statistics have been kept,
the leading cause of hospitalization and medical evacuation
has not been direct combat but rather disease and non-battle
injuries. In World War I, World War II, and the Korean conflict,
respiratory and infectious illnesses were the number
one cause of hospitalization. By Vietnam, non-battle injuries
had surpassed all other disease categories as the leading
cause of service member attrition and has remained so ever
In addition to changes in the patterns of injury, battle injury
survival rates have changed in parallel. In World War I,
the wounded-in-action:killed-in-action ratio was about 2:1.
Over the course of the next century, this increased incrementally
to around 8:1 in the Operation Iraqi Freedom
(OIF) and Operation Enduring Freedom (OEF).  This decreasing
mortality rate has led to an increased emphasis on
returning injured service members to their predeployment
physical and psychological conditions.
Burden of spinal pain
The administrative designation "spinal pain" has previously
been used in evacuation databases to describe pain
syndromes in the back and neck, although it must be emphasized
that this is an unvalidated diagnosis that reflects
only one of several potential anatomical sources of pain.
For the purposes of this article, the term "spinal pain" refers
to the location of pain (ie, neck, midback, or low back)
rather than structural pathology.
In Operation Desert Storm (Gulf War), Operation Joint
Endeavor (Bosnia), OIF, and OEF, the number one reason
for hospitalization and medical evacuation was musculoskeletal
conditions, representing between one-fourth and one-third
of all injuries. [3–5] Spinal pain accounts for about
one-quarter of these injuries. Between 2004 and 2007,
2,445 service members were medically evacuated out of theater
from OIF and OEF with a primary designation of "spine pain," comprising 7.2% of all evacuees.  In deployed non-service
members, spinal pain accounted for a slightly lower
proportion of evacuated personnel (4.5%); however, this discrepancy
may be attributable to differences in treatment paradigms.  Low back pain (LBP) syndromes are the primary
complaint in approximately three-quarters of personnel with
spinal pain (Figure).
Studies that focus only on evacuees likely underrepresent
the burden of spinal pain. Although the precise incidence
of service members who seek medical attention for
spinal pain at forward-area treatment points is unknown, it
is estimated that a large majority (80%) do not require
Several studies have sought to evaluate the peacetime
prevalence rates for spinal pain in service members. Six-month
observational cohort studies conducted in Finnish
military conscripts (median age, 19 years) found a 33% prevalence
rate for musculoskeletal disorders necessitating medical
attention.  A plurality (20%) of injuries involved the
low back, with thoracic and cervical spine pain accounting
for another 6%. Approximately one-third were for recurrent
injuries, with more than 80% occurring during training exercises
(40%) or other physical activities.
study performed in 6,488 Norwegian conscripts found
LBP to be the leading musculoskeletal complaint during
basic training (19% of all complaints), with an occurrence
rate of 4.3% of conscripts.  In a prospective study evaluating
the incidence of LBP in 3,555 British military recruits,
Stowbridge  reported an LBP occurrence rate of 6.1 per
1,000 soldiers per month for male service members and
14.0 for female service members. Military duty can also
increase the frequency of back pain episodes in individuals
with a pre-existing history. A study comparing pre- and
post-enlistment injury in 245 male service members with
a history of chronic LBP found a 2.4–fold increase in the
frequency of injuries requiring medical consultation after
A systematic review examining the prevalence of thoracic
spine pain in various cohorts reported 1–year prevalence
rates in service members ranging between 4.3% and
32%, with the highest prevalence rate in fighter pilots.  Previous studies also found the prevalence rates of
neck pain in fighter pilots (19%) to be higher than the general
More recent work suggests that back pain in service
members engaged in heavy physical training may be more
the "rule" than the "exception".  A 5–year prospective
cohort study followed 154 US Army Special Operations reserve
soldiers who reported no history of back pain over
a 3–year period. Over the next 18 months, these service
members were queried on a monthly basis regarding back
pain and disability. The cumulative percentages of subjects
reporting mild and moderate back pain over the study period
were 84% and 64%, respectively.
There is evidence that deployment to a combat zone increases
the risk of spinal pain. This appears to be a multifactorial
effect secondary to increased psychosocial stressors,
greater time spent wearing heavy equipment, and increased
duty hours. In a retrospective study conducted in 68 deployed
helicopter pilots, Nevin and Means  found a significant
increase in myriad pain complaints after deployment. Among
individuals who logged more flight hours compared with
predeployment status, 37%, 30%, and 70% reported increased
neck pain, midback pain, and LBP, respectively. In individuals
whose work hours stayed relatively constant, these
increases were 22%, 20%, and 39%, respectively (Figure).
Risk factors for spinal pain
There are a number of physical factors that can lead to
complaints of spine pain in service members. Many of these
factors involve poor ergonomics. Research by Attwells et al.  suggests that biomechanically, the cervical and lumbar
spine work in concert to counterbalance loads carried in
a rucksack, and the muscle tension necessary to sustain these
changes is associated with an increased risk of musculoskeletal
injury. In an account of the Roman Army by Goldsworthy , the loads of legionnaires on the march were typically 60
pounds over a day’s march of 20 miles. A historical review by
Knapik et al.  reported that load carriage has increased for
the infantry soldier since the 18th century, when loads typically
weighed no more than 15 kg. Although each individual
item tends to be lighter and more compact, an increased number
of "essential" items has resulted in a greater load burden.
Carrying weights 45 kg or greater is not uncommon with
the use of body armor and a full combat load, which may be
needed to sustain operations in hostile environments for
several days. This added weight creates shearing forces that
can impact the lumbar spine, and to a lesser extent, the neck
and upper back. When a service member goes on missions
with this added gear, he is often required to perform various
operations that place him in positions that can further stress
spinal structures. The adverse effects of load carriage can
theoretically be minimized by reducing loads, improving
load distribution, optimizing load-carriage equipment, and
taking preventive actions. Whether these strategies (eg, reducing
body armor) put the soldier at greater risk for combat
injuries is mission dependent.
Similar to non-service members, occupational driving, especially
under suboptimal circumstances, can increase the
risk for neck and back pain.  Although most military vehicles
are designed to minimize the impact of improvised explosive
devices, they are often poorly suited to provide
proper ergonomic and comfortable seating. Whole-body
shock and vibration associated with all-terrain vehicle driving
and rotary wing aircraft has been shown in most, but not
all studies, to increase the risk for LBP, midback pain, and
neck pain. [19–21]
Studies conducted in a wide array of non-military cohorts
have found psychosocial factors to be major predictors of
persistence of pain after injury. A study of 7–year outcomes
of 567 patients seen in emergency rooms with severe limb
trauma showed that predictors of poor outcomes included
premorbid alcohol abuse, low "self-efficacy," and a host
of postmorbid (at 3 months) factors, such as acute pain intensity,
anxiety, depression, and sleep disturbance. 
These are similar to the risk factors for poor return-to-work
outcomes in prospective studies conducted in civilian
populations with spine injuries. [23–25] These factors, and
others, such as somatization, catastrophization, and poor
coping skills, also appear to influence the effectiveness of
treatments for spine pain. [26–29] Evidence-based lessons
regarding early intervention to maintain psychosocial integrity
for acute back pain in the civilian sector are reflected in
military’s strategy for early intervention after combat injury
in the present conflict in the Middle East.  The goals of
this approach include reducing immediate stress and pain
associated with physical and psychological trauma, maintaining
injured troops close to the field with their units,
and restoring role functioning as soon as possible. 
The high rates of psychiatric comorbidity complicating
combat exposure, such as mood and anxiety disorders, including
post-traumatic stress disorder (PTSD), and neuropsychiatric
complications of blast injuries, demand
sensitive screening for these conditions in troops with spine
pain. A large-scale cross-sectional study among Gulf War
Veterans with PTSD found that more than 95% continued
to experience persistent musculoskeletal complaints. 
A prospective study by Shaw et al.  found that coexisting
diagnoses of generalized anxiety, PTSD, and major depression
were associated with 2.5–, 3.2–, and 5.0–fold increases
in risk for transitioning from new onset to chronic back pain,
respectively. Among service members evacuated from OIF
and OEF for back and neck pain, the presence of a concurrent
psychiatric illness decreased the likelihood of returning to
duty 31% and 56%, respectively. [34, 35] These statistics
strongly augur for the identification and prompt treatment
of comorbid psychiatric conditions as a means to reduce
the burden of spine pain in service members.
A substantial body of literature has examined neck pain
in fighter pilots. In a study by De Loose et al. , the authors
found that pilots with neck pain were more likely to
sit for longer periods of time, frequently held their neck
in a forward bent posture, and were more physically and
emotionally fatigued than non-pilots and pilots without neck
pain. Studies have also demonstrated electromyographic
differences and increased levels of myoelectric activity in
pilots with cervical symptoms compared with asymptomatic
pilots and non-pilots. [36, 37]
Cohen et al.  performed an epidemiological study analyzing
clinical and prognostic factors in 374 service members
medically evacuated out of OIF and OEF with a primary
complaint of neck pain. Among the 35.3% who could identify
an inciting event, the most common etiologies were
prolonged driving (10%),
lifting (9%), and
wearing Kevlar (5%).
Few studies have sought to determine the causes of mid-back
pain in military cohorts. Hamalainen  found
a strong association between the number of GZ flight hours
and the incidence of midback pain and LBP among fighter
pilots. Similar to civilian cohorts, a retrospective review by
Morken et al.  conducted in 2,265 Norwegian naval
personnel determined that low levels of physical activity
were moderately correlated with cervical, thoracic, and
lumbar spine pain.
Low back pain
A service member’s job can be linked to sources of LBP.
A literature review by Pelham et al.  found that whole-body
vibration and in-flight sitting posture may be associated
with the development of LBP in rotary wing pilots but are not
clearly causative. In a Finnish study that followed 245 male
conscripts, the authors found that the same inciting events
that precipitated LBP before enlistment, namely lifting and
carrying, were most likely to incite back pain during military
service. Among various military activities, combat training
(11%) and marching (10%) were the two events most likely
to result in injury.  Rohrer et al.  reported that
prolonged standing, twisting, vibration, and heavy work
were associated with chronic LBP in 1,398 Swiss conscripts.
A large prospective study (n = 53,555) conducted in British
service members found that military exercises, regular work,
off-duty activities, and sports were the most common etiologies.  The observation that LBP episodes surge during
military training is supported by work by Carragee and
Cohen , who reported an approximately 10% increase
in the monthly incidence of moderate LBP, and a three-fold
to four-fold increase in disability, during heavy training. In
an epidemiological study evaluating back pain evacuees
from OIF and OEF, the three leading reported precipitating
events were lifting (18%), falls (11%), and pain incurred
during driving (8%). 
The workup of spinal pain in forward-deployed areas is
different than in civilian settings. Equipment and personnel
resources are limited in war zones, and magnetic resonance
images are generally not available. Computed tomographic
scans are available at combat support hospitals (CSHs) and
are approximately 90% sensitive and 70% specific in detecting
disc pathology with magnetic resonance imaging as the
reference standard.  In view of the poor correlation between
advanced imaging pathology and symptoms at all spinal
levels [43, 44], the failure to demonstrate that radiological
studies improve outcomes , and the fact that epidural
injectates spread to multiple spinal levels, imaging is not essential
when selecting patients for lumbar epidural steroid
injection (ESI). For safety reasons, performing thoracic or
cervical ESI without viewing computed tomographic scans
is not recommended. Electromyography and nerve conduction
studies are also usually unavailable in theater.
Another key difference is time constraints. Time allotted
to return to duty (RTD) can vary based on a unit’s mission,
one’s military occupational specialty and its need, the availability
of replacements, and a host of other factors. For this
reason, diagnosis is often subordinated to treatment, such
that patients may receive multiple therapeutic procedures
concurrently or undergo a "definitive" treatment without
the benefit of a prognostic block (eg, facet joint radiofrequency
denervation without a facet block).
The most important distinction in the categorization of
spinal pain is between neuropathic and nociceptive pain
as this affects treatment paradigms at all levels. In prospective
studies using instruments designed to discriminate between
neuropathic and nociceptive or mechanical pain,
researchers have estimated that between 37% and 55% of
patients with chronic spinal cord injury suffer from predominantly
neuropathic symptoms (Table 1). [46, 47]
Herniated disc is the leading cause of neuropathic spine
pain from the third to fifth decades of life. Young people
with radiculopathy are more likely to recall a specific
inciting event and experience an abrupt onset than elderly
patients with stenosis, which probably reflects the greater
force required to herniate less degenerated discs.  Neuropathic
pain from a herniated disc tends to respond better
to both pharmacological and interventional treatment than
spinal stenosis, which in turn has a better prognosis than
chronic axial pain. In studies conducted among spine pain
evacuees from OIF and OEF, 69% and 84% service members
with back and neck pain, respectively, had primarily
radicular symptomatology. [34, 35]
A good history and physical examination is reasonably
accurate in discriminating between neuropathic and nociceptive
pain. In one prospective study following 50 patients
who underwent successful single-level cervical decompression
surgery, neurological examination showed a two-thirds
rate of agreement with radiological imaging for
cervical myelopathy. 
For lumbosacral radiculopathy,
a systematic review found the straight leg-raising test to
be 85% sensitive and 52% specific based on operative
and radiological findings. 
For cervical radiculopathy,
systematic reviews have found Spurling test to have low
to moderate sensitivity but high specificity, whereas upper
limb tension test is characterized by high sensitivity and
low specificity (Table 2). 
Nociceptive pain results from tissue or potential tissue
injury, which is often the result of increased load bearing.
Between 80% and 90% of patients with acute spine pain episodes
no longer seek care after 3 months, although recent
studies suggest that more than one-third will experience
persistence or recurrences in the next few years. [52, 53] Although
the precise etiologic breakdown of these cases is unknown,
many experts attribute most cases to soft-tissue
origin. Similar to athletes, the incidence of myofascial
spinal pain in service members is estimated to exceed that
of the general population. 
Service members with persistent pain limiting their ability
to perform their duties warrant further attention. Unlike
neuropathic spinal pain, radiological imaging is generally
not helpful in identifying the pain generator(s) in patients
with axial pain as research has shown low sensitivity for
the diagnosis of facetogenic or sacroiliac (SI) joint pain
and poor specificity for discogenic pain. [44, 55] Discogenic
and facetogenic pain tend to develop insidiously as a result
from chronic low-level strain and degeneration, whereas
between 40% and 50% of cases of injection-confirmed SI
joint pain occur after a specific inciting event, with the
two most common causes being motor vehicle accidents
and falls — two of the more common injuries in counterinsurgency
operations. [56, 57] The mechanism of SI joint injury
is often described as a combination of axial loading
and rotation, with injury to the extra-articular joint complex
being especially common in airborne soldiers and after long
The reference standard for diagnosing both facet and SI
joint pain is diagnostic blocks, which are characterized by
high false-positive rates (20–40%). Nevertheless, because
of time constraints and travel risks, there is no place for
controlled blocks downrange.
In view of the inherent difficulties involved in conducting
research in theater, many of the treatments used in deployed
service members are extrapolated from studies
performed in civilian populations. Because soldiers in combat
environments are subject to increased physical (eg,
body armor) and psychosocial stressors, which have been
associated with negative treatment results [27–29, 58], outcomes
in this context may not be as auspicious.
As in the civilian setting, successful pain management in
the deployed setting is increasingly multimodal and multidisciplinary.
The use of complementary techniques, such as
injections, physical therapy, psychological interventions,
such as cognitive-behavioral therapy, and alternative medicine
may improve treatment outcomes compared with traditional
pharmaceuticals. Concern for side effects from
traditional pharmaceuticals is at least one factor that has
driven this change. The idea that analgesic medications
may impair decision making or slow reaction times has often
been postulated, but little clinical research has been conducted
in simulators or on the battlefield. For opioids, most research
has focused on driving. Most studies have found
that patients on stable doses of opioids do not exhibit increased
psychomotor impairment or higher rates of motor
vehicle accidents, but the findings regarding cognitive
impairment in patients on chronic opioids are more evenly
split.  In contrast, drug interactions, abuse, and diversion
by soldiers are frequently reported in the popular media. 
Although preliminary reports on the use of interventional
spine treatments such as ESIs to treat deployed soldiers are
encouraging, all are limited by their observational nature,
small sample sizes, and nonstandardized follow-up. In an observational
study by White and Cohen  published in
2007, the authors reported that all 93 patients with spinal
pain treated in a CSH returned to duty after interventional
treatments. Although the study population was comprised
of self-selected motivated service members who wanted to
remain in theater, it augurs positively for early and aggressive
Interventional procedures are frequently performed at
CSH, but it is important to understand the unique considerations.
First, although qualified physicians with interventional
experience and even subspecialty training are frequently
available, deployment slots are allocated based on primary
specialty (eg, anesthesiology). Second, because pain management
is not a primary mission, patients are treated on
a "time and space available" basis. Third, transport to and
from adjacent air bases is not without peril, which often
justifies multiple interventions during a single session. Nevertheless,
the low complication rates warrant their consideration
in a deployed setting whereby sterility may be
In patients who present with radiculopathy, there is
a strong consensus that ESIs can provide at least short-term
relief, although controversy exists regarding long-term
efficacy. [62–64] Transforaminal injections may be
more efficacious than the interlaminar approach , but
the higher risk in the cervical region precludes their use in
austere environments. 
In patients with purported facetogenic pain, intraarticular
steroids are relatively easy to perform and have anecdotally
been reported to provide short-term benefit to
a small portion of patients with an acute inflammatory process,
but there is no evidence to support long-term benefit.  For patients who obtain good relief from diagnostic
blocks, there is limited evidence to support a modest
intermediate-term treatment effect for radiofrequency denervation,
which may be more effective for neck pain than midback
pain or LBP. [63, 64] Although observational studies
performed in stateside-level 4 military treatment facilities
(MTFs) have reported that approximately half of treated personnel
will experience some benefit , in deployed settings,
the evidence supporting facet joint radiofrequency
denervation is limited to a small case series.  Both peri- and
intra-articular corticosteroids may provide short-term
relief for SI joint pain, although the few controlled studies
lacked long-term follow-up. One controlled study conducted
at a Level 4 MTF found SI joint denervation to provide
intermediate-term (median, 8 months) pain relief. 
The combination of a long recuperative period, concerns
over infection, and a lack of high-grade supporting evidence
makes intradiscal procedures a poor treatment choice in
combat zones. These concerns also render implantation procedures
(eg, spinal cord stimulation) inappropriate during
deployment. However, a small case series described five patients
who deployed downrange with spinal cord stimulators
in place, four of whom successfully completed their tours of
Most classes of analgesic medications in the civilian setting
are available to deployed providers, although choices
within each class may be limited. Conventional medications
offer several advantages in the deployed setting. First, they
are readily available through the pharmacy system in theater.
Second, they require little specialized training on the part of
providers, and their use can be standardized with clinical
practice guidelines. Finally, once started, medication therapies
can be continued at remote locations in an environment
where the risk of travel to a site with a pain provider exceeds
the dangers posed by drug-related side effects. Non-opioid
analgesics commonly used in deployed settings include nonsteroidal
anti-inflammatory drugs and muscle relaxants for
axial pain and antidepressants and anticonvulsants for radiculopathy.
The main drawback of adjuvants is the central
nervous system depressant effects, which may adversely affect
reaction time. One study showed a higher rate of motor
vehicle collisions, which is a major cause of injury in theater,
among patients taking the muscle relaxants carisoprodol and
Most physicians believe that opioids are a reasonable
treatment option for acute spinal episodes, but their use in
this capacity must be carefully weighed against their proven
adverse cognitive effects, such as impaired reaction time, attention,
balance and memory, which are especially pronounced
after initiation of treatment. [59, 73] The principal
drawbacks of opioid use relate to late complications, often
occurring after deployment, when patients maintained on
multiple medications can suffer infrequent but serious complications,
including death from intentional and accidental
overdose. Risks of misuse, diversion, and other aberrant behaviors
are more likely to occur in individuals who fit the demographic
and clinical profile of young combat-exposed
service members, many of whom suffer from multiple physical
and psychological maladies and have poorly developed
coping skills.  These are just some of the factors that led
to the establishment of Warrior Transition Units, which aim
to make treatment of high-risk patients safer.
The treatment of patients with spine pain with cognitive-behavioral
therapy has been shown to result in better outcomes,
including better quality of life, less pain, and lower
health-care costs.  Cognitive-behavioral therapy is presently
being used successfully to treat the combination of pain
and psychological distress, including PTSD, so commonly
associated with military service on the battlefield. 
Physical therapy is widely used to treat back and neck
pain in theater, both at CSH and battalion aid stations.
Advantages include negligible risk, proven efficacy, and
widespread availability of services. One randomized study
performed in European military personnel found comparable
efficacy for regular physical therapy, consisting of general
exercise and specific back strengthening.  Although
there is some evidence to support physical therapy modalities "in garrison" and in non-military members,
there are no published studies in peer-reviewed literature involving
spine pain in deployed soldiers.
Complementary and alternative medicine
There are many forms of complementary and alternative
medicine available for spinal pain, with the two most common
being acupuncture and spinal manipulation. In both
garrison and deployed settings, acupuncture has been shown
to relieve acute pain conditions, including but not limited to
spinal pain. A small randomized study comparing acupuncture
to Thai traditional massage in young military personnel
with myofascial back pain found that although both treatments
alleviated pain, acupuncture was superior.  In addition
to the published literature, the use of acupuncture in
deployed and non-deployed service members has benefited
from anecdotal success and the absence of reported complications.
A short funded training program to teach deploying
physicians the technique has helped move this modality to
the front lines and into military medical centers. [79, 80]
Spinal manipulation therapy by doctors of osteopathy or
other trained personnel is offered when such providers are
deployed. One of the main benefits of manipulative therapy
is the relatively low risk involved for high velocity and low-amplitude
manipulation. There is currently only anecdotal
evidence supporting osteopathic manipulation in deployed
service members. 
Effect of treatment location on return-to-duty rates
The primary mission of the Medical Corps is to "preserve
the fighting force." Consequently, the most relevant outcome
measure for military doctors who treat spine pain is "RTD" (return to duty)
status. A service member who reports minimal pain but cannot
work because of back problems is of less use to the military
than one who can complete a mission despite low-grade
The effect that treatment location has on the categorical
outcome measure RTD is well documented. In an epidemiological
study performed in evacuees from OIF and OEF seen
at pain clinics in fourth-level MTFs in Landstuhl, Germany,
a transit point for almost all injured service members from
OIF and OEF, and Walter Reed National Military Medical
Center, Cohen et al.  found that less than 2% returned
to their deployed unit. Over two-thirds of these patients presented
with spinal pain. But when a forward-deployed pain
clinic was set up near a major airfield at a CSH in Baghdad,
Iraq, more than 95% of service members were able to RTD.  Approximately 80% of these individuals had spinal
pain. It should be emphasized that these patients may not have
had comparable military responsibilities and motivations.
Studies conducted in evacuees from OIF and OEF have consistently
shown that officers and females, who tend to have
less physically demanding jobs than lower enlisted personnel,
have higher RTD rates across the board for all medical conditions,
including back and neck pain. [5, 34, 35] But although
some of this discrepancy may be because of job descriptions,
logistical issues, greater disease burden, and psychiatric
comorbidity in those service members already evacuated,
the difference in outcomes is nevertheless compelling.
Considering the strong parallel relationship between psychopathology
and chronic spinal pain, it is not surprising that
a similar pattern has been observed for combat stress. For example,
the RTD rate when treating early combat stress symptoms
with forward-deployed combat stress teams in Iraq is
greater than 95%. If similar symptoms are addressed at CSHs
in theater, or nearby in Kuwait or Qatar, the RTD rates decline
to approximately 70% and 50%, respectively. A service
member with signs of post-traumatic stress syndrome who
makes it as far as the fourth-level MTF in Germany has only
a 9% chance of returning to combat duty. And if the service
member ends up in the United States for treatment, he has
virtually no chance of returning to duty in theater. 
These statistics must be placed in the context of resource
availability, inherent treatment constraints in an austere environment,
and psychophysical risks of delayed treatment.
The medical treatment system in wartime was designed
and implemented in World War II to facilitate the rapid
transport of injured personnel to increasingly sophisticated
treatment facilities, thereby maximizing capacity in the
event of mass casualties. This system was not established
to provide long-term treatment, rehabilitation, or intensive
psychotherapy. Treatment in most cases is, therefore, limited
based on time, resources, and capacity (Table 3).
Spinal pain, which for the purpose of this article refers to
spine-area pain syndromes that include soft-tissue pathology,
exacts an enormous toll in military personnel, representing
the leading cause of medical boards across all services.
This burden is increased during wartime as a result of several
factors, including increased physical stressors and myriad
psychosocial dynamics. Similar to civilian personnel, the
treatment of spine pain in deployed service members has become
increasingly multimodal to include injections, judicious
pharmacotherapy, physical therapy, complementary
and alternative medicine if available, and psychotherapy as
indicated. Based on the extant literature, aggressive treatment
in theater appears to offer the greatest chance of keeping
an injured service member with their unit.
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