Committee on Surgical Combat Casualty Care position statement: Neurosurgical capability for the optimal management of traumatic brain injury during deployed operations
Authors: Gurney Jennifer M. , Tadlock Matthew D. , Dengler Bradley A. , Gavitt Brian J. , Dirks Michael S. , Holcomb John B. , Kotwal Russ S. , Benavides Linda C. , Cannon Jeremy W. , Edson Theodore , Graybill John C. , Sonka Brian J. , Marion Donald W. , Eckert Matthew J. , Schreiber Martin A. , Polk Travis M. , Jensen Shane D. ,   Commentaries Provided by: Matthew J. Martin, MD, FACS, DABA, Bellal A. Joseph, MD, FACS, Alex Valadka, MD, FAANS, FACS, and Jeffrey D. Kerby, MD, PhD, FACS
Published: May 2023

BACKGROUND
Experiences over the last three decades of war have demonstrated a high incidence of traumatic brain injury (TBI) resulting in a persistent need for a neurosurgical capability within the deployed theater of operations. Despite this, no doctrinal requirement for a deployed neurosurgical capability exists. Through an iterative process, the Joint Trauma System Committee on Surgical Combat Casualty Care (CoSCCC) developed a position statement to inform medical and nonmedical military leaders about the risks of the lack of a specialized neurosurgical capability.

METHODS
The need for deployed neurosurgical capability position statement was identified during the spring 2021 CoSCCC meeting. A triservice working group of experienced forward-deployed caregivers developed a preliminary statement. An extensive iterative review process was then conducted to ensure that the intended messaging was clear to senior medical leaders and operational commanders. To provide additional context and a civilian perspective, statement commentaries were solicited from civilian clinical experts including a recently retired military trauma surgeon boarded in neurocritical care, a trauma surgeon instrumental in developing the Brain Injury Guidelines, a practicing neurosurgeon with world-renowned expertise in TBI, and the chair of the Committee on Trauma.

RESULTS
After multiple revisions, the position statement was finalized, and approved by the CoSCCC membership in February 2023. Challenges identified include (1) military neurosurgeon attrition, (2) the lack of a doctrinal neurosurgical capabilities requirement during deployed combat operations, and (3) the need for neurosurgical telemedicine capability and in-theater computed tomography scans to triage TBI casualties requiring neurosurgical care.

CONCLUSION
Challenges identified regarding neurosurgical capabilities within the deployed trauma system include military neurosurgeon attrition and the lack of a doctrinal requirement for neurosurgical capability during deployed combat operations. To mitigate risk to the force in a future peer-peer conflict, several evidence-based recommendations are made. The solicited civilian commentaries strengthen these recommendations by putting them into the context of civilian TBI management. This neurosurgical capabilities position statement is intended to be a forcing function and a communication tool to inform operational commanders and military medical leaders on the use of these teams on current and future battlefields.

LEVEL OF EVIDENCE
Prognostic and Epidemiological; Level V.