Craniectomy in Severe Brain Injury Patient Had Poorer Results 6 months post Injury

Some of the very serious traumatic brain injury cases I have handled involved swelling of the brain.  A procedure to relieve pressure against the hard skull is a craniectomy.  This is a surgery where part of the skull is removed to allow the brain extra space to swell without damaging the brain cells.  This state of the art procedure has been done on a number of my clients with results ranging from less severe impairments to permanent severe brain damage. Though the procedure is considered a last resort, some evidence suggests that it does improve outcomes by lowering intracranial pressure (ICP), the pressure within the skull.However, the only randomised controlled trial has shown that, despite reducing ICP, decompressive craniectomy (in the absence of a mass lesion) results in poorer long-term outcomes. 

A new study published in the New England Journal of Medicine reveals unexpected results.  Those patients with severe brain injury with intracranial pressure had lower ICU stays and lowered intracranial pressure then those who received standard care.  However the standard care patients faired better on the Extended Glasgow Coma Scale 6 months post injury.

Decompressive craniectomy is increasingly performed in many neurotrauma centers internationally.  The unexpected findings prompt the authors to underscore the critical importance of conducting such trials to test common therapies.

Read more at Decompressive Craniectomy in Diffuse Traumatic Brain Injury by Cooper et al.

Motorcycle Helmet Repeal is Bad Idea

Since I received a flurry of comments on my Motorcycle Helmet Blog of recent, see Nevada Helmet Law Repeal and comments at http://brainandspine.titololawoffice.com/2011/05/articles/brain-injury/nevada-helmet-law-repeal/ , I thought I would forward a tweet by fellow blogger Steve Gursten.  Steve is a great Michigan Personal Injury Trial Attorney.

The title of the article EDITORIAL: Helmet law repeal is a horrible idea  is http://theoaklandpress.com/articles/2011/06/09/opinion/doc4df0f7e007da2700519623.txt?viewmode=default

Has Neuroscience Redefined Free Will?

 The Brain On Trial

Is Criminal behavior regulated by “free will?” Is free will something that is actually free at all? Neuroscientist, David Eagleman[1], recently published an article in The Atlantic, July/August 2011, The Brain on Trial.[2] He describes how the foundations of our criminal-justice system are beginning to crumble, and proposes a new way forward for law and order.

My interest in theological, philosophical, psychological and biological explanations ranging from the reason for suffering in this world and free will versus fate/destiny was discussed in my blog a few years back.

Can I freely choose to not eat chocolate cake? Can I freely invoke my long term understanding of the cake’s short term benefits versus its long term costs to overpower my short term understanding of my desire to eat it? Clearly the obesity crisis in our country and others would say ‘sometimes, but not most.’ Certainly eating chocolate cake is not a crime. But let’s apply the same ideas to crime and recidivism.

Neuroscientist, Wolf Singer argued that crime itself should be taken as evidence of brain abnormality, even if no abnormality can be found, and criminals treated as incapable of having acted otherwise.[3]

Conversely, at an Ethics and Public Policy Conference on Neuroscience and the Human Spirit,[4]  the question was asked: "Do . . . scientific advances challenge the first principles that the majority of our citizens believe provide the very foundation upon which our civilization rests—free will and the capacity to make moral choices? . . . Does [the] growing understanding of genetic and environmental influences on human behavior leave any room for free will?"

The conclusion advanced “accepting a compatibilist, naturalistic view of freedom and morality will unify our self-understanding. Since moral mechanisms have a clear social function that science can help us to understand and improve, no longer will morality have to seek shelter from science. We may not be free in the exceptional, ultimate sense we once supposed, but we are more than compensated by the pragmatic benefits that flow from recognizing our complete inclusion in the causal order. The "human spirit"—our dignity, freedom, and power—is not threatened by science, only shown its true home in the natural world.”

In his lengthy article, David Eagleman sets out court dramas of those recently brought to trial. Judges and juries compare, as they instruct and are instructed, to weigh their analysis against a “reasonable person” standard. Many times, we all engage in the blame game by asserting, “Well I would not have done that.” However that may be missing the point according to Eagleman. “Changes in the balance of brain chemistry, even small ones, can also cause large and unexpected changes in behavior [:]” Addictive personalities and gambling; Pedophiles and the desire to look at children. Also included are not just unacceptable behaviors but, as mentioned earlier, compulsive eating, excessive alcohol consumption, and hypersexuality, to name a few.

“The lesson from all these stories is the same: human behavior cannot be separated from human biology….Perhaps not everyone is equally “free” to make socially appropriate choices.” Do we really have free will to choose or is that really an illusion? Eagleman states “Many of us like to believe that all adults possess the same capacity to make sound choices. It’s a charitable idea, but demonstrably wrong. People’s brains are vastly different.”

Starting at birth we are the product of our parent’s genes. “When it comes to nature and nurture, the important point is that we choose neither one. We are each constructed from a genetic blueprint, and then born into a world of circumstance that we cannot control in our most-formative years….The unique patterns of neurobiology inside each of our heads cannot qualify as choices; these are the cards we are dealt.”

Turing to the legal system and courts, the standard applied assumes we are ‘practical reasoners’ which, in turn, presumes beings with free will. Eagleman uses the example of those inflicted with Tourette’s syndrome, who suffer from doing things they do not will to do: sticking out her tongue, voicing inappropriate language and others. The point is that a Tourette’s patient’s free will cannot over ride her sense of free won’t.” Similarly, high-level behaviors can take place in the absence of free will.

“Historically, clinicians and lawyers have agreed on an intuitive distinction between neurological disorders (“brain problems”) and psychiatric disorders (“mind problems”). The two ends of the spectrum have been those whose brain injuries (e.g. Parkinson’s) who cannot help some of their behavior, while most others are simply thought of as freely choosing actors.

Therefore, prisons have, according to Eagleman, become de-facto mental-health-care institutions. Incarceration does little to rehabilitate those with mental illness and increases cases of recidivism.   Courts around the country and in Nevada have begun mental-health courts and drug courts based on better understanding of the problems of recidivism. 

Eagleman proposes a new approach. He posits the understanding that the brain “operates like a team of rivals, with different neural populations competing to control the single output channel of behavior.” Something he terms the ‘prefontal-workout.’ Essentially he is trying to defeat the short term brain circuits to overcome bad behavior. It is similar to bio-feedback of the 1970s. So when we see that delicious piece of chocolate cake, we can overcome the choice to eat it, which is essentially against our will. More importantly when one is faced with a socially unacceptable behavior, can he invoke a system to squelch the urge and make a better choice?

Eagleman concludes by saying that “neuroscience is beginning to touch on questions that were once only in the domain of philosophers and psychologists, questions about how people make decisions and the degree to which those decisions are truly ‘free.’ These are not idle questions. Ultimately, they will shape the future of legal theory and create a more biologically informed jurisprudence.”

David Eagleman’s article is available on The Atlantic's site and in print.



[1] David Eagleman is a neuroscientist and a New York Times bestselling author. He directs the Laboratory for Perception and Action and the Initiative on Neuroscience and Law at Baylor College of Medicine. He is best known for his work on time perception, synesthesia, and neurolaw.

[2] Quotes are largely taken from David Eagleman’s article. http://www.theatlantic.com/magazine/archive/2011/07/the-brain-on-trial/8520/

 

Cell Phones Linked to Brain Cancer

Cell Phone Use Causes Concern for Damaging the Brain.

First they thought coffee was bad for you, now they see it has benefits.  Same for moderate Red wine intake.  Now cell phones are under scrutiny.

The dramatic increase in use of cellular telephones has generated concern about possible negative effects of radiofrequency signals delivered to the brain. However, whether acute cell phone exposure affects the human brain is unclear.  Cell phones have not been persuasively linked to brain cancer, but that doesn't mean that their associated radiation has no effect on our brains and bodies.  

A new study shows that these pervasive devices can alter the brain's glucose metabolism, a marker of neuronal activity.The findings are published in the February 23 issue of  JAMA, Journal of the American Medical Association.

In healthy participants and compared with no exposure, 50-minute cell phone exposure was associated with increased brain glucose metabolism in the region closest to the antenna. This finding is of unknown clinical significance.

The bottom line is we know it affects the brain but we do not know to what end.  I will follow this issue.

 

Chiropractic Manipulation Effective for Back Injury and Pain

New research of several sources confirm that spinal manipulation such as is received with chiropractic care is at least on par with medicinal treatment.  Pain killers do not heal the injury but simple mask the pain until the body heals with often reduced range of motion and compromised function.

If you're suffering from chronic lower back pain, a new review of existing research finds that spinal manipulation, the kind of hands-on regimen that a chiropractor might perform on you, is as helpful as other common treatments like painkillers.

Back pain affects 80% of Americans at some time in their lives. It comes in many forms, from lower back pain (lumbar-sacral), middle back pain, (lumbar-thoracic) or upper back pain (cervical) to low back pain with sciatica. Common back pain causes include nerve and muscular problems, degenerative disc disease, and arthritis. Many people find relief from symptoms of back pain with pain medication or pain killers.  But this is not the best way to cure what ails you.

Surveys suggest that half of working Americans suffer from back pain each year. An estimated 25 percent of American adults reported that they suffered from back pain for at least a day within the last three months, according to a 2006 Centers for Disease Control and Prevention report, and lower back pain is the fifth most common reason that people go to the doctor.

Patients frequently turn to painkillers, which can cause side effects and be addictive, or to physical therapy, which is time-consuming and expensive. The new review looks at a third option - spinal manipulation.

Blogger D. Denoon writes of the 9 Painkiller Mistakes.

They are:

  • Pain Medications Mistake No.1: If 1 Is Good, 2 Must Be Better
  • Pain Medications Mistake No. 2: Duplication Overdose
  • Pain Medications Mistake No. 3: Drinking While Taking Pain Drugs
  • Pain Medications Mistake No. 4: Drug Interactions
  • Pain Medications Mistake No. 5: Drugged Driving
  •  Pain Medications Mistake No. 6: Sharing Prescription Medicines
  • Pain Medications Mistake No. 7: Not Talking to the Pharmacist
  • Pain Medications Mistake No. 8: Hoarding Dead Drugs
  • Pain Medications Mistake No. 9: Breaking Unbreakable Pills

 Consider seeing a chiropractor if you experience back or neck pain.  Even if you are referred to your family doctor, inquire of a chiropractor for treatment rather than simply taking pain medication.

Nevada Governor Sandoval Signs Head Injury Bill into Law

Governor Sandoval signed Assembly Bill 455 into law. School Districts and the Nevada Interscholastic Activities Association are required to set policy for handling head injuries by student athletes. Those policies must mandate students be removed immediately from competitive sports if they suffer a concussion or head injury and not be able to return to play until they are examined and cleared by a doctor.