The Impact of Modern Warfare on the Nature of Spinal Injuries in Combat Trauma

Study Design. Nationwide retrospective cohort study. Objective. To determine the incidence and epidemiology of combat-related spinal injuries during the Israel-Hamas war. Summary of Background Data. In recent conflicts, injury mechanisms have evolved. Advancements in body armor and trauma care have increased survival rates, significantly altering the epidemiology of combat trauma and leading to changes in the characteristics of combat-related spinal injuries. Methods. This retrospective cohort study included patients hospitalized between October 9, 2023, and October 31, 2024, with combat-related injuries. Data were obtained from the Israel National Trauma Registry, focusing on soldiers with spinal injuries, defined by specific ICD-9 codes. Data collected included demographics, injury mechanisms, vital signs, additional injuries, injury severity, hospital resource utilization, and clinical outcomes. Statistical analysis included descriptive statistics and multivariate logistic regression to identify factors associated with spinal injury. Results. Out of 2182 combat-related hospitalizations, 93 patients (4.3%) sustained spinal injuries, predominantly fractures affecting the lumbosacral spine. Explosions were the leading cause of injury (53.8%), followed by blunt trauma (24.7%) and ballistic injuries (21.5%). Serious concomitant injuries were common, with 50.5% of patients experiencing polytrauma. 23.7% had severe injuries (ISS 16-24) and 36.6% had critical injuries (ISS ≥25). Intensive care unit admission was required for 47.3%, and 65% were discharged to rehabilitation facilities. The in-hospital mortality rate was 5.4%. Patients with spinal trauma had significantly longer hospital stay and higher rates of intensive care unit admission compared with those without spinal injuries. Polytrauma and blunt trauma were independently associated with spinal injuries. Conclusions. Spinal injuries are common in modern combat, typically caused by high-energy blasts, with the lumbosacral region most frequently affected. Clinicians should maintain a high index of suspicion in severe injury or blunt trauma cases. As neurogenic shock is uncommon early post-injury, other causes of hypotension should be considered. Only a minority of casualties require neurosurgical intervention. Level of Evidence. III.