hronic pain from battle- and non-battle-related injuries is an epidemic in modern-day armed forces, with far-reaching consequences. In an epidemiological study conducted by Cohen et al.,¹ the authors found that only 2 percent of soldiers medically evacuated from Operation Iraqi Freedom for chronic pain who were treated at pain clinics in Landstuhl, Germany, or Walter Reed Army Medical Center in Washington, D.C., returned to theater. What makes these data even more striking is that approximately 80 percent of soldiers treated with similar conditions by a pain specialist at a combat support hospital (CSH) in Balad, Iraq, remained in-theater and returned to their units (personal communication from Lt. Col. [ret] Allan Hayes, 21st CSH, Balad, Iraq). While anecdotal, these statistics indicate the importance of early and aggressive pain treatment, which is best accomplished in theaters of operation.

Injuries that result in chronic pain may be more prevalent in the armed services than in a civilian cohort,^2-4 as reported in a series of articles describing the prevalence of injuries during training of light infantry, engineers, artillery and airborne soldiers. This “hidden epidemic” of non-battle-related injuries and chronic pain conditions was brought to the forefront by Surgeon General of the U.S. Army Major General James B. Peake.⁵ From October 2006 to May 2007, one of us (Dr. White) was assigned to the 10th CSH, which was located on the site of Ibn Sina Hospital in Baghdad. This was formerly Saddam Hussein’s personal hospital and the facility where he was treated after being captured by U.S. Forces in December 2003. This three-story concrete building remains the only fixed U.S. treatment facility in Iraq [Figure 1].

Figure 1 The Ibn Sina Hospital front entrance. To the left is the outpatient center; on the right are the temporary barracks.

The vision of the bombed-out Palestine Hotel, which had just been destroyed by a car bomb, portended the eight months spent in-country as an anesthesiologist and the only pain specialist. Each day continuous fighting from insurgents with mortars, rocket-propelled grenades and small arms ensured an unending supply of surgical and acute pain patients. But the 10th CSH was well-equipped to handle this burden. In addition to full surgical capabilities, a radiologist and temporary housing for soldiers requiring outpatient services, we also had a computed tomography (CT) scanner, ultrasound machine and a C-arm fluoroscope at our disposal.

The first interventional pain clinic in a forward-deployed area was a converted supply room. Information was distributed and screened through military channels to ensure that the limited capabilities were utilized on the urgent cases most amenable to treatment. Consults came from a variety of sources but primarily through e-mails from battalion and brigade surgeons. Soldiers would fly to Baghdad for processing and evaluation through a variety of outpatient clinics. Through them Dr. White and the other pain management anesthesiologist, Michael Gehrke, M.D., coordinated imaging, medications, nothing-by-mouth status, housing, return helicopter flights, follow-up visits and the timing of interventions. Similar to civilian trauma centers, an algorithm exists by which patients are triaged to fulfill the mission of the military medical corps: to preserve the fighting force. Thus the management of chronic pain patients often took a backseat to the multitude of trauma and acute pain patients treated daily. Pain patients were nevertheless evaluated during either scheduled clinic hours or breaks in the emergency schedule and, when indicated, were treated with nerve blocks late in the afternoon on the day of arrival. Following these interventions, they were sent to the pharmacy to pick up medications and placed in temporary housing. The next day, most soldiers were sent to the Baghdad Embassy helipad to return to their bases where follow-up care was coordinated with battalion and brigade surgeons. A few patients, however, remained in temporary housing for additional treatment (e.g., repeat epidural steroid injections in patients with acute sciatica), and about 6 percent were shipped out of theater for more specialized treatment at pain clinics in Landstuhl and Walter Reed Army Medical Center.

During the 10th CSH’s year-long tenure, a total of 201 chronic pain patient encounters and 796 interventional pain procedures — 397 of which were fluoroscopically guided — were performed on personnel from every branch of the U.S. and foreign armed services, other sectors of the U.S. federal government and Iraqi citizens. Our hard work and effort paid big dividends for the patients we treated and the military we serve. Our return-to-duty rate was 94 percent, which compares favorably to data reported by non-forward-deployed military pain clinics [Figure 2].¹

There were many memorable cases, but one in particular comes to mind that is illustrative of the need for forward-deployed pain treatment capabilities. A bedridden British sergeant major presented to our clinic with severe low-back and left leg pain, ostensibly for recommendations for medical evacuation back to England. After performing empirical trigger-point injections in his lumbar paraspinous muscles, a CT of his lumbar spine revealed an L4-5 herniated disc. The patient was then treated with two transforaminal epidural steroid injections followed by a continuous epidural infusion of 0.2 percent ropivacaine. Three days later, the epidural infusion was discontinued and the patient reported almost complete resolution of his pain coupled with dramatic functional improvement. Much to our surprise, he elected to remain in-country with his troops. Although he returned two more times for repeat transforaminal epidural steroid injections, he was able to complete his full tour of duty. This treatment was subsequently repeated on two more soldiers, an Australian major and a U.S. Army specialist, with similar results.

In summary, chronic pain is a major cause of disability in modern-day soldiers. Strong anecdotal evidence suggests that prompt and aggressive treatment of pain in forward-deployed areas may benefit soldiers and their units by dramatically reducing the need for medical evacuation. Ideally these clinics should be run by board-certified pain specialists and, at minimum, contain diagnostic imaging capabilities, a well-equipped pharmacy and a portable C-arm to facilitate minimally invasive interventions.

Choppers landing at the helipad, bringing the wounded and soldiers for outpatient visits (pain patients).

Acknowledgements: Special thanks to Lt. Col. Mike Gehrke, M.D. (chief, Anesthesia and Operative Services), Capt. Rick Erff, M.D. (staff anesthesiologist), Maj. Dan Davis, M.D. (staff anesthesiologist), Lt. Col. Mark Smith, M.D. (Deputy Commander), Lt. Col. Matthew Cowell, (CRNA), Lt. Col. Bruce Schmidt, R.N. (Chief Operating Room Nurse) and Col. Dennis D. Doyle (Commander, Medical Task Force 10) for their help in facilitating the development of the 10th CSH Pain Clinic — the first wartime interventional pain clinic.

References:
1. Cohen SP, Griffith S, Larkin TM, Villena F, Larkin R. Presentation, diagnoses, mechanisms of injury, and treatment of soldiers injured in Operation Iraqi Freedom: An epidemiological study conducted at two military pain management centers. Anesth Analg. 2005; 101:1098-1103.
2. Potter RN, Gardner JW, Deuster PA, et al. Musculoskeletal injuries in an army airborne population. Mil Med. 2002; 167:1033-1040.
3. Reynolds K, Cosio-Lima L, Creedon J, Gregg R, Zigmont T. Injury occurrence and risk factors in construction engineers and combat artillery soldiers. Mil Med. 2002; 167:971-977.
4. Smith TA, Cashman TM. The incidence of injury in light infantry soldiers. Mil Med. 2002; 167:104-108.
5. Peake JB. Reflections on injuries in the military: The hidden epidemic. Am J Prev Med. 2000; 18(3S):4-5.

Steven P. Cohen, M.D., Col., U.S. Army Reserve, is Associate Professor, Department of Anesthesiology, Johns Hopkins School of Medicine and Department of Surgery, Walter Reed Army Medical Center, Washington, D.C.

Ronald L. White, M.D., Maj., Medical Corps, U.S. Army, is Former Chief, Acute and Chronic Pain Management Services, Ibn Sina Hospital, Baghdad, Iraq, and Assistant Professor of Anesthesiology, Uniformed Services University of the Health Sciences F. Edward Hébert School of Medicine Department of Anesthesiology, Bethesda, Maryland, and Pain Management Fellow, Walter Reed Army Medical Center, Washington, D.C.