Book Review

Brain Injury Medicine: Principles and Practice

N Engl J Med 2007; 356:2333-2334May 31, 2007

Article

Brain Injury Medicine: Principles and Practice
Edited by Nathan D. Zasler, Douglas I. Katz, and Ross D. Zafonte. 1275 pp., illustrated. New York, Demos, 2007. $199. ISBN: 978-1-888799-93-4

Traumatic brain injury often results in a combination of physical, cognitive, and behavioral impairments. Surprising to many is the fact that every year an estimated 1.5 million Americans sustain a traumatic brain injury, exceeding the combined incidence of breast cancer, HIV and AIDS, spinal cord injury, and multiple sclerosis. A more alarming figure, derived by the Centers for Disease Control and Prevention, is the 5.3 million Americans who have an impairment related to traumatic brain injury, making it one of the most common disabling conditions. Despite its high prevalence, historically, it has been poorly understood and under-recognized because of its hidden nature — that is, it often presents without obvious physical impairment but instead with serious long-term cognitive and behavioral problems that effectively prevent injured individuals from fulfilling their previous societal roles. Now that traumatic brain injury has become the signature injury of the conflicts in Iraq and Afghanistan, the situation is likely to change, and for this reason the publication of Brain Injury Medicine is timely.

The book, which includes 66 chapters spanning nearly 1300 pages, is accurately described by the editors as a “go-to” reference for any clinician treating individuals with traumatic brain injury. It is the first text on the subject in many years and is clearly the most comprehensive, covering epidemiology, pathology, pathophysiology, diagnosis, imaging, prevention, research, prognosis, theories about recovery, alternative and complementary approaches to care, and psychosocial issues. It also includes an exhaustive list of treatments for medical, neurologic, psychological, and rehabilitation problems. It covers the whole continuum of care, from prevention to acute trauma management, acute and subacute rehabilitation, long-term care, and reintegration into the community.

Confocal Micrograph Showing Damaged Astrocytes.

Most of the book deals with practical problems; numerous chapters are particularly noteworthy for their pragmatic approach and assemblage of hard-to-find facts. These chapters cover complex issues pertaining to prognosis, assessment of the decision-making capacity of cognitively impaired patients, and life expectancy. Others provide clear and practical reviews of topics such as cranial nerve dysfunction, functional assessment instruments, disorders of consciousness, post-traumatic seizures, and sexual dysfunction — controversial issues that are often overlooked by many health care providers. Other chapters explore psychosocial issues and medicolegal aspects of traumatic brain injury that are often both poorly understood and addressed in clinical practice.

While the comprehensive approach of this book is a considerable strength — and a necessity given the scope of traumatic brain injury — it is also a weakness in that its attempt to cover some topics extensively does not allow for sufficient detail on other topics. For instance, alternative and complementary approaches to various conditions are covered in three chapters when one would suffice, whereas the same number of chapters deal with the pharmacotherapy of cognitive and behavioral problems, the most disabling problems associated with this injury. Surprisingly, there is no chapter dedicated to common orthopedic problems, such as heterotopic ossification and fracture management; information on these topics is instead dispersed throughout the text. Similarly, other topics with a shared theme, such as pathology and pathophysiology, are covered in different sections rather than contained within a single location. And still other topics — like that of chapter 3, which addresses international perspectives on rehabilitation — could easily be integrated into other chapters or simply eliminated without sacrificing the text's utility or comprehensive nature. Last, there is occasional bias in the way certain conditions, such as postconcussion disorder, are presented.

Despite these minor concerns, the editors have assembled a single resource for physiatrists, neurologists, psychiatrists, therapists, nurses, psychologists, and other medical specialists, as well as for legal professionals and patient advocates. A medical condition of this magnitude and scope requires the thoughtful and wide-ranging coverage this text provides. It will quickly become the authoritative desk reference sought by clinicians practicing brain injury medicine.

Steven Flanagan, M.D.
Mount Sinai School of Medicine, New York, NY 10029