Byron Cone Pavehouse Young Neurosurgeon Resident Award: Astute bedside clinical examination can limit costly and unnecessary military medical evacuations.

Introduction: Military medical air evacuation is extremely expensive and places the unit at a tactical disadvantage through attrition. Operational costs for C-17 aircraft have been quoted at $24,000 per hour. Once equipment and personnel costs are factored in, the expense of a single medical evacuation mission can exceed $1 million.

Methods: The authors report a series of unnecessary air evacuations from the theater which were initiated in order to obtain advanced imaging and expert consultation for conditions mimicking urgent/emergent surgical pathology of the spine.

Results: Over a 4 year period, records were available for 21 service members that were medically evacuated with a working diagnosis of “rule out cauda equine syndrome (CES)”. All patients underwent emergent imaging and were evaluated by a neurosurgeon. Within the cohort, only two cases were confirmed (9%) to represent CES, with the other 19 individuals presenting with routine spinal conditions. Additionally, during this period, three service members were evacuated for presumed acute cervical spine pathology, with the diagnosis being Parsonage-Turner syndrome in two, and
brachial plexus traction injury after a parachuting accident in one. Finally, two soldiers were evacuated with a working diagnosis of “foot drop”, both of whom were ultimately elucidated to exhibit common peroneal nerve palsy.

Conclusion : Bedside clinical examination skills have deteriorated in recent decades, resulting in an overreliance on advanced medical imaging. The reasons are myriad, and at least in part are likely reactionary to the litigious nature of our society. Detailed bedside examination is paramount in triaging neurosurgical patients. In the military setting, an astute clinical examination can not only lead to considerable financial savings through avoidance of unnecessary medical evacuation but will also strengthen unit readiness.