Military neurosurgery: epidemiology, ethics, and future of armed conflicts

The changing nature of modern armed conflicts brings new challenges in the field of military neurosurgery. The purpose of this review article is to systematize knowledge on the epidemiology of neurosurgical injuries in different types of conflicts, present the ethical and legal frameworks of operation, and describe future technological directions. A literature review and synthesis method was used (2010–2025) in the fields of military medicine, neurosurgery, international humanitarian law, and medical ethics. The results show that explosive injuries (especially from improvised explosive devices) are the predominant mechanism in asymmetric operations (70–80%), while in conventional warfare, gunshot wounds prevail (55–65%). Triage in the military environment is based on the principle of “the greatest good for the greatest number,” using four categories (red, yellow, green, black). International humanitarian law (Geneva Conventions) provides protection for medical personnel, but allows limitations in case of hostile acts. Future developments include artificial intelligence for triage and diagnostics, use of drones for equipment delivery and evacuation, improved ballistic protection (e.g., ECH and NGCH helmets), and strengthening civil‑military cooperation. Limitations of the review depend on available secondary sources and heterogeneity of conflicts. We conclude that military neurosurgery requires integration of clinical, ethical, and technological competencies, with a key understanding of the pathophysiology of secondary brain injury.