Military Management of Traumatic Brain Injury

Traumatic brain injury (TBI) has become the most common injury among US service members and has been named “the signature injury” of the conflicts in Afghanistan and Iraq. Despite evidence of surgical treatment of combat-related TBI in skulls dating from antiquity, the military approach to TBI sustained in battle, has largely developed into its present form in only the past two centuries. Though composing the vast majority of TBIs in the past two decades, mild TBI has only recently been recognized as a “silent epidemic,” an injury with potentially long-lasting cognitive effects and implications for personal life and return-to-duty. Comprehensive efforts to improve the military approach to mild TBI have led to significant advances in the surveillance, screening, treatment, and follow-up of service members sustaining mild TBI. The surgical treatment of combat-related severe and penetrating TBI has evolved from the highly morbid surgeries of the American Civil War, through the aggressive debridement that characterized the approach of World War I (WWI) neurosurgeons such as Harvey Cushing, to the present-day posture of early decompressive craniectomies, followed by expeditious aeromedical evacuation to definitive care. Here, we explore the history of the military approach to TBI, present the contemporary management of patients with combat-related head injuries, and discuss current research that will inform the future treatment of service members with TBI.