04/09/2013 // Concord, CA, USA // LifeCare123 // Greg A. Vigna M.D., J.D. // (press release)

Medical Perspective:

Diffuse axonal injury is believed to be the primary mechanism of brain damage in most traumatic brain injury and an understanding of the anatomy of the brain is necessary to understand the mechanism of injury and to understand the short and long-term manifestations of mild traumatic brain injuries and concussions. The cerebral cortex, referred as the grey matter, makes up ‘two thirds of the weight of the brain and is responsible for thinking, perceiving, producing and understanding language’, and the other complex functions required to be a human. The midbrain and brain stem are the white matter of the brain and consist of the nerve fibers (axons) that are covered with myelin which gives it the white appearance. The white matter are the major ‘highway’ of the brain and densely packed with the nerve fibers that resemble cables. The brain sits in the skull very much like a yolk would sit in an egg. During the rapid acceleration and deceleration of the head that occurs in a traumatic brain injury the brain will quickly go forward and backwards inside the skull, very much like the yolk would if you were to shake an egg. What this rapid acceleration and deceleration causes significant shear that acts to stretch and damage some of the nerve fibers (axons) that form the cables. Some of these nerve fibers that are stretched will result in the cells to irreversible die while others following the injury and others will be nonfunctional for a period of time but capable of recovery. Conceptually it is important to think that the more severe the brain injury the more cells irreversibly die while the more mild the injury fewer cells die. In more severe TBI, imaging studies will be able to detect injuries in the white matter that are consistent with diffuse axonal injury.

‘Traumatic brain injury is defined as mild by a Glasgow Coma Scale (GCS) score of 13 to 15, as moderate head injury with GCS score of 9 to 12, and severe head injury with GCS of 3 to 8.

The term concussion is often used in the medical literature as a synonym for mild TBI, but it probably describes a subset of milder brain injury and is defined by the American Academy of Neurology defined as a trauma-induced alteration in mental status that may or may not involve loss of consciousness’. Most concussions result in no loss of consciousness. Concussions will generally have normal imaging studies, and believed to result in a temporary period of mental disturbances that is short lived due to the cells in the white matter being nonfunctional for a period of time following the injury rather than from cells being irreversibly dead.

The most important symptom of a concussion is confusion and amnesia occurring immediately after the head trauma or appearing after several minutes. Memory impairment may involve difficulty recalling events just prior to the injury (retrograde amnesia) or inability to recall events after the injury (anterograde amnesia). ‘There are other important symptoms or signs which include loss of consciousness, confusion, dizziness, headache, and nausea and vomitting. Families of a person who have suffered a concussion may notice irritability, memory impairments, and disorientation. In patients with a mild TBI with cognitive or psychologic complaints neuropsychological testing may be indicated to detect potentially mild deficits in attention, processing speed, working memory, and reaction time. These deficits tend to be transitory and may disappear over time.’

There are well described medical conditions associated with concussions. Post-concussive syndrome includes a group of symptoms which include dizziness, headache, malaise, and cognitive impairment. It develops a few days following an injury and may persist for a few months. Patients with post-concussive syndrome should undergo a MRI to rule out associated injuries such as a brain contusion or other problems unrelated to the trauma. ‘Post-traumatic epilepsy (seizures) are twice as likely in mild TBI for the first five years after the injury’ and post-traumatic headaches occur in more than one out of three patients with mild TBI.

Life Care Planner Perspective:

It is important for a life care planner to understand the medical, physical, and psychosocial impact regarding mild TBI when developing a life care plan. These issues are often present in patients with associated injuries that are likely the primary disabling condition presented to the life care planner and not the mild TBI. Depression, chronic pain, and mild cognitive impairment may be long term sequale from the mild TBI and contribute to the disability of the patient. Failure to consider this in the life care plan will lead to inadequate long-term treatment of the patient which may result in medical and psychosocial complications. Chronic pain, depression, failed employment, and family dysfunction may all result if a life care planner does not take into consideration the effect of a mild TBI combined with the primary disabling condition. Psychologic evaluation and counseling, a formal pain program, physical therapy, routine medical follow up, and vocational counseling may be necessary and appropriate management for the patient with mild TBI and associated injuries.

Lawyer Perspective:

A lawyer must prove past and future economic and noneconomic damages. Past damages may include medical costs and lost wages. Future damages include medical costs that are reasonable and necessary in the management of a patient that are related or were proximately caused (defined as a substantial factor) for the negligent (careless) acts of a wrongdoer. Future lost wages can be calculated by the actual lost wages multiplied by the life expectancy of a the permanently injure client or they can be calculated by determining the client’s lost “earning capacity”. Future medical costs of associated injuries requires a knowledge of the client, an intimate knowledge of the medical history of the client, and a thorough understanding of all injuries and how those injuries are effected by both the disability and the injury. Overlooking the effects of a mild TBI that combine with the patients primary disabling condition will lead to a dreadfully low judgment that will not reflect the impact of the injury on the patient’s life. Fair compensation is simply not possible if the jury does not understand the impact of the TBI on the patient and it the lawyer’s job to provide the medical evidence by way of medical testimony to prove these damages to get the necessary compensation for the necessary care going forward.

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