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We report a case of associated vertebromedullary and ureteral lesions in a severely injured patient, a victim of a gunshot aggression in Africa. Urine extended from the ureteral fistula through the third lumbar vertebral body, blended with cerebrospinal fluid from the dural attrition, and flowed very slowly through the dorsal exit ballistic hole. This is to our knowledge the first such case described in the literature. Uro-computed tomography scan finally made the diagnosis of ureteral fistula after two neurosurgical procedures determined that initially presumed dural persistent fistula needed to be closed. [ABSTRACT FROM AUTHOR]

Introduction: Instant messaging applications (MAs) represent a major component of modern telecommunications for data transmission. During overseas deployments, military doctors increasingly rely on MAs due to their availability and the urgent need to obtain advice from specialists for optimal patient management. In this study, we aimed to describe and analyze the context and usage characteristics of these MAs for transmitting medical data by military general practitioners (GPs) during overseas missions., Materials and Methods: This observational study was conducted between June 2020 and December 2020, based on a survey sent to GPs from the French Military Health Service who had been deployed overseas in military operations between 2010 and 2020., Results: We received 233 surveys of which 215 were analyzed. Among these, 141 military GPs used instant MAs to transmit medical data during deployment. Notably, WhatsApp was used by 97% of the participants. The military GPs mainly used these applications for the speed of exchanges (45%) and their ease of use (28%). The physician specialties predominantly involved in data sharing were trauma and orthopedic surgery (38%) and dermatology (31%). The correspondents were mainly military specialist physicians from French military teaching hospitals (85%). A response time of less than 1 h was reported in 78% of the cases. Additionally, 72 doctors (51%) undertook their last deployment in an isolated post., Conclusion: MAs were extensively utilized communication tools among GPs during their overseas deployments. Although the use of these applications seems essential in telemedicine, it raises several legal and ethical questions. Thus, we recommend employing these tools while ensuring medical and military confidentiality., (© The Association of Military Surgeons of the United States 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: The French mobile neurosurgical unit (MNSU) is used to provide specific support to remote military medicosurgical units deployed in foreign theatres. If a neurosurgical casualty is present, the Role 2 team may request the MNSU to be deployed directly from France. The deployed neurosurgeon can then perform surgery in Role 2 or decide to evacuate the casualty and perform surgery in Role 4 in France. We provide an epidemiological analysis of MNSU missions between 2001 and 2023 and investigate the value of the MNSU for the French Armed Forces., Methods: We conducted a retrospective case series that included patients managed by the MNSU from 1 January 2001 to 31 January 2023. We collected epidemiological data (eg, age, military or civilian status, delay between transmission and takeoff, origin of the injury and mission location), clinical records (aetiologies of the injury and disease), data on surgical intervention (operator nature and type of surgery) and data on postoperative outcomes recorded at the time of discharge from hospital., Results: 51 patients were managed by the MNSU. 36 (70.5%) and 3 (5.8%) patients underwent surgery on Role 2 and Role 4, respectively. 39 (76.9%) interventions were due to traumatic injury, 4 (7.8%) due to hydrocephalus, 4 (7.8%) due to vascular causes, 3 (5.9%) due to tumour and 1 (2%) due to spine degeneration. In 30 (76.9%) of these cases, the first operator was a neurosurgeon from the MNSU, whereas in the remaining 9 (23.1%) cases, procedures were initially performed by a non-neurosurgeon., Conclusion: The MNSU contribution to D1 casualties' strategic evacuation (STRATEVAC) is important. The MNSU provides additional support for STRATEVAC during the reorganisation of French Armed Forces engaged in several fronts. With the return of high-intensity wars, the French MNSU must develop and adjust for the management of massive influxes of casualties., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: During deployment of military medical teams similarly to prehospital practice, without immediate computed tomography scan access, identifying patients requiring neuro-specific care to manage pragmatic triage proves crucial. We assessed the contribution of this portable near-infrared spectroscope (NIRS) handheld device, Infrascanner Model 2000 (InfraScan Inc.; Philadelphia, PA), to screen patients suspected to require specific neurosurgical care., Materials and Methods: This single-center retrospective analysis was based on the data from the medical records of the traumatic brain injured patients. We analyzed all the patients strictly over 18 years old presenting a clinical history of traumatic brain injury (TBI) with a Glasgow Coma Scale (GCS) < 15., Results: Thirty-seven medical records of patients admitted for TBI met the inclusion criteria for our analysis. The median GCS was 9 [3-14]. Eight patients (21.6%) underwent neurosurgery and 25 (67.6%) required intensive care unit (ICU) admission, after initial assessment and resuscitation. The NIRS was the most sensible to detect intracranial hematoma (n = 21), intracranial hematoma leading to surgery (n = 8), and intracranial hematoma leading to admission in ICU (n = 25). Its negative predictive value was 100% regarding hematomas leading to surgery. False-positive results were encountered in 10 cases (27.0%). Excluding cases harboring confounding extracranial hematomas, parietal area was still the most represented (n = 3)., Conclusion: The NIRS was relevant to detect hematoma leading to prompt surgery in our study. The lack of specificity in a nonselected cohort of patients underlines the need to associate simple clinical feature such as neurological deficit and NIRS results to perform rational triage., (© The Association of Military Surgeons of the United States 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: The military operations carried out by the French armed forces, occasionally require the use of the Surgical Life-saving Module (SLM), to ensure the surgical support of its soldiers. Due to its extreme mobility and capacity of fast deployment, SLM is particularly useful in small-scale military operations, such as Special Forces missions. In 2017, the French SLM was for the first time used to ensure surgical support of allied forces, which were lacking forward surgical capabilities., Materials and Methods: the SLM is a mobile, heliborne, airborne, surgical structure with parachuting capability onto land or sea, therefore essentially focused on life-saving procedures, also known as "damage control" surgery. Due to the need for mobility and rapid implementation, the SLM is limited to a maximum of 5 interventions or, in terms of injuries, to 1 or 2 seriously injured patients., Results: Over a period of 2 months, 5 medical teams were successively deployed with the SLM. A total of 157 casualties were treated. The most common injuries were caused by shrapnel 561%), followed by firearms (36%), and blunt trauma (2.5%). Injuries included the limbs (56%), thorax (18%), abdomen (13%), head (11%), and neck (2%). The average ISS was 8.5 (1-25) with 26 patients presenting with an ISS greater than or equal to 15. The average NISS was 10.8 (1-75) with 34 casualties having an NISS equal to or greater than 15. The surgical procedures were broken down as follows: 126 dressings, 16 laparotomies, 7 thoracotomies, 12 isolated thoracic drains (without thoracotomy), 1 cervicotomy, 12 amputations, 7 limb splints, 2 limb fasciotomies, 2 external fixators and 1 femoral fracture traction., Conclusions: The numerous SLM deployments in larger operations highlighted its ability to adapt both in terms of equipment and personnel. Continuous management of equipment logistics, robust personnel training, and appropriate organization of the evacuation procedures, were the key elements for optimizing combat casualty care. As a consequence, the SLM appears to be an operational surgical unit of choice during deployments., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

This article aims to describe the French concept regarding combat casualty neurosurgical care from the theater of operations to a homeland hospital. French military neurosurgeons are not routinely deployed to all combat zones. As a consequence, general surgeons initially treat neurosurgical wounds. The principle of this medical support is based on damage control. It is aimed at controlling intracranial hypertension spikes when neuromonitoring is lacking in resource-limited settings. Neurosurgical damage control permits a medevac that is as safe as can be expected from a conflict zone to a homeland medical treatment facility. French military neurosurgeons can occasionally be deployed within an airborne team to treat a military casualty or to complete a neurosurgical procedure performed by a general surgeon in theaters of operation. All surgeons regardless of their specialty must know neurosurgical damage control. General surgeons must undergo the required training in order for them to perform this neurosurgical technique.

Introduction: France deployed to Afghanistan from 2001 to 2014 within the International Security and Assistance Force. A French role 3 hospital was built in 2009 in the vicinity of Kabul International Airport (KaIA). The objectives of this study were to describe the epidemiology, management, and outcome of war-related craniocerebral injuries during the Afghan campaign in a French role 3 hospital., Methods: From March 1, 2010 to September 30, 2012, we conducted a retrospective descriptive study in Kabul, Afghanistan. All patients presenting with a ballistic craniocerebral injury to the KaIA role 3 hospital were included., Results: We analyzed 48 records. Mean age was 21.9 years (1-46 years) with a 37:11 (male:female) sex ratio and a majority Afghan population (n = 41). Civilians represented 64.6% (n = 31) of casualties. On the battlefield, mean Glasgow Coma Scale score was 9.4 [3-15]. On arrival at the KaIA field hospital, 20 of the 48 patients were hemodynamically unstable. All patients underwent a full-body computed tomography scan. The majority of our casualties had associated injuries. Neurosurgery was indicated for 42 (87.5%) patients. The surgery consisted of wound debridement plane by plane associated with decompressive craniectomy (n = 11), debridement craniectomy (n = 19), and craniotomy (n = 12). A total of 32.4% wounded died at the point of injury, 8.4% at the emergency department, and 16.9% after surgery., Conclusions: War casualties with ballistic head injuries were predominantly multitraumatized patients with hemodynamic compromise requiring neurosurgical damage control management and multidisciplinary care. The neurosurgeon has thus an essential role to play., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: In 2009, during the war in Afghanistan, the increasing number of head injuries led to the deployment of a military neurosurgeon at the Kabul International Airport (KaIA) medical treatment facility, in March 2010. The main goal of this study was to depict the neurosurgical activity in this centre and to analyse its different aspects., Method: A retrospective study of all the neurosurgical patients treated in KaIA from March 2010 to June 2013., Results: Three hundred and seventy-three interventions performed by the neurosurgeon deployed were reported for 373 surgeries, in 335 patients, representing 10.6 % of the overall surgical activity of the centre. Among the 69 interventions performed on soldiers, 57 surgeries were undertaken in emergency (82.6 %), while 12 were elective procedures (17.4 %). On the other hand, 289 surgeries were performed in civilian Afghans, with 126 emergency procedures in (43.6 %), against 163 elective interventions (56.4 %). Among the 44.5 % (n = 149) of the traumatic casualties, cerebral lesions represented 28.7 % (n = 96) and spinal lesions 12.4 % (n = 42). Ninety patients had multiple injuries. Additionally, patients without trauma accounted for 55.5 % (n = 186) of the overall population. Thus, 49 % (n = 164) were operated on for non-traumatic lesion of the spine. These were mostly civilian Afghans treated under medical aid to the population (90.2 %, n = 148/164)., Conclusions: The military neurosurgeon had two roles in KaIA: both to support the armed forces and to manage medical aid to the civilian population. This study gives food for thought on the neurosurgical needs in modern warfare, and on the skills required for the military neurosurgeon.

Purpose: Although there is no standard treatment for recurrent glioblastoma, prospective data in selected patients have suggested the usefulness of bevacizumab. We report our single center experience with bevacizumab in a cohort of patients treated for a relapsing glioblastoma., Methods: We performed a retrospective analysis of consecutive patients treated with bevacizumab for a relapsed glioblastoma, between 2008 and 2013. Tumor responses, toxicities, time to progression and overall survival rates were analyzed., Results: Thirty-five consecutive patients were identified. They were treated with bevacizumab 10mg/kg biweekly, associated with irinotecan (n=29; 84%), temozolomide (n=3; 9%) or as single agent (n=3; 9%) for a glioblastoma relapsing after chemoradiation (n=29) or after first line temozolomide only because of a poor general health status or because of multifocal tumor. Two (6%), 28 (80%) and five (14%) patients presented with Recursive Partitioning Analysis (RPA) III, IV and V-VI, respectively. After 2-3 months of treatment, median dose of prednisolone per patient was decreased three times. Clinical improvements or stability were reported in eight (23%) and 17 patients (49%). The best tumor response was partial response in 14 patients (40%), stable disease in nine patients (26%) and tumor progression in 11 patients (31%). Toxicities requiring treatment disruption were reported in five patients (14%). Median survival was 18.4 months (5-41 months). Median time interval between bevacizumab initiation and its disruption because of clinical/radiological progression and/or toxicity was 5.0 months (0.6-21.4 months). Median survival from bevacizumab initiation was 8.1 months (1.4-34 months)., Conclusion: This single center retrospective experience suggests that bevacizumab is active for recurrent glioblastoma, in a series of poorly selected patients. Median survival times were in the range of those reported in therapeutic trials. This study questions the validity of usual predictive factors in the era of bevacizumab., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Background: We present here a description of the experience in whole-blood transfusion of a health service team deployed to a medical treatment facility in Afghanistan from June 2011 to October 2011. The aim of our work was to show how a "walking blood bank" could provide a sufficient supply., Methods: We gathered the blood-group types of military personnel deployed to the theater of operations to evaluate our "potential walking blood bank," and we compared these data with our needs., Results: Blood type frequencies among our "potential walking blood bank" were similar to those observed in European or American countries. Our resources could have been limited because of a low frequency of B blood type and negative rhesus in our "potential walking blood bank." Because of the large number of potential donors in the theater of operations, the risk of blood shortage was quite low and we did not face blood shortage despite significant transfusion requirements. Actually, 93 blood bags were collected, including rare blood types like AB and B blood types., Conclusion: In our experience, this international "walking blood bank" provided a quick, safe, and sufficient blood supply. More research in this area is needed, and our results should be confirmed by further prospective trials., Level of Evidence: Therapeutic study, level V.

We retrospectively assessed the outcome of patients receiving emergency spinal radiation therapy (RT) concurrently with bevacizumab. Clinical records of 18 consecutive patients receiving emergency spinal RT for symptomatic vertebral metastases during the course of bevacizumab-based therapy were examined. Patients were receiving biweekly bevacizumab combined with paclitaxel (n=17) or with docetaxel/carboplatin (n=1) or as a single agent (n=1) for advanced metastatic carcinoma. RT was delivered at doses of 30 Gy in 10 fractions (n=8), 20 Gy in five fractions (n=9) or 18 Gy in nine fractions (n=1). In 10 patients (56%), irradiation field encompassed the thoracic vertebrae. The median time interval between the bevacizumab infusion and the RT course was 1.5 days (0-8 days). The median follow-up was 8.3 months (2 days-42 months). A clinical benefit of RT was reported in 13 patients (72%), including four patients with complete pain relief. Two of the three patients with neurological impairment at the time of RT experienced a partial improvement in their symptoms. No pain recrudescence was reported within the irradiated field after RT completion. All toxicities were mild to moderate, with no acute toxicity reported in 13 patients (72%). No RT disruption was necessary because of acute toxicity. No delayed toxicity was reported within RT fields among 11 patients with at least 6 months of follow-up. Spinal RT during the course of bevacizumab-based therapy was not associated with the occurrence of unexpected adverse effects. This suggests that emergency RT should not be contraindicated in these patients, provided that doses and treatment volumes are defined carefully.