title: Injury severity at presentation is not associated with long-term vocational outcome in British Military brain injury.
abstract: BACKGROUND
  Injury Severity Score (ISS) and GCS can be retrospective markers of injury severity, but if used by clinicians to decide on the treatment of acutely brain-injured casualties at the point of injury may potentially limit interventions on people who may ultimately survive with good functional outcomes.
  
  
  METHODS
  ISS/GCS and long-term outcomes were reviewed by assessing all UK military neurorehabilitation patients with an operational/combat brain injury treated over 4 years (February 2008-July 2012) at Defence Medical Rehabilitation Centre (Headley Court).
  
  
  RESULTS
  34 participants from 9 operational tours of Iraq and Afghanistan were analysed. Overall, 44% of injuries were due to improvised explosive devices (IEDs) and 41% from gunshot wounds; 70.9% of injuries were penetrating wounds with the remainder due to blast/blunt trauma or combined injury. The primary injury was head/neck in 76.5%, although eight patients (23.4%) requiring neurorehabilitation were initially 'non-head injury'. Eight patients (26.5%) sustained more than 10 injuries, and 18 had between three and nine injuries. Eleven patients (32%) had an initial GCS of 3, and 16 (47%) had ISS of 75 (deemed 'unsurvivable'). All patients with ISS of 75 were long-term survivors. At 4 months after discharge, 47% (16) were fully independent, and a further 41% (14) were independent in own homes, but needed assistance with some activities, such as paying bills. Over three-quarters (27 patients, 79%) returned to full/part-time work, 11 of whom returned to military duties; 93% of 'unsurvivable' ISS, and 91% of patients with GCS of 3 were capable of returning/returned to work. In total, 7/11 casualties returning to military duties had major trauma ISS, and two were 'unsurvivable'. All seven casualties with both GCS 3 and ISS 75 survived and returned to independence (help with some activities).
  
  
  CONCLUSIONS
  ISS/GCS at the point of injury does not reflect eventual outcome. IEDs/gunshots cause the greatest number of injuries and the highest incidence of brain injury. Brain injury should be considered in every battlefield casualty, irrespective of whether the head/neck/spinal cord was avoided. ISS should not be considered indicative or predictive of long-term prognosis/quality of life/employability as brain injury in this small cohort is both survivable and recoverable. It should not be used as a retrospective guide to alter treatment pathways, as there is poor correlation with long-term outcome. Subsequent neurorehabilitation should always be considered because survival, return to independence and full employment are very likely.
authors.affiliation: Rehabilitation Medicine and Rheumatology, Defence Medical Rehabilitation Centre, Epsom, UK.
authors.forename: Sardar
authors.initials: S
authors.lastname: Bahadur
authors.affiliation: Neuro-rehabilitation Medicine, Defence Medical Rehabilitation Centre, Epsom, UK.
authors.forename: E
authors.initials: E
authors.lastname: McGilloway
authors.affiliation: Defence Rehabilitation, Defence Medical Rehabilitation Centre, Epsom, UK.
authors.forename: J
authors.initials: J
authors.lastname: Etherington
mesh_terms: D000328:Adult; D055826:Afghan Campaign 2001-; D001930:Brain Injuries / Q000175:diagnosis / Q000534:rehabilitation*; D015331:Cohort Studies; D016208:Databases, Factual; D004651:Employment / Q000706:statistics & numerical data*; D015600:Glasgow Coma Scale; D006801:Humans; D015601:Injury Severity Score; D054542:Iraq War, 2003-2011; D008297:Male; D008889:Military Personnel; D011379:Prognosis; D012189:Retrospective Studies; D062707:Return to Work / Q000706:statistics & numerical data*; D016896:Treatment Outcome; D006113:United Kingdom
keywords: REHABILITATION MEDICINE; TRAUMA MANAGEMENT