Inflicted head injury: future directions and prevention

Although described only a quarter century ago, progress in this area is rapid and increasing at an accelerated rate. As a group, neurosurgeons, and particularly pediatric neurosurgeons, potentially have a lot to offer, both in the hospital, the courtroom, and the laboratory. As practitioners who see large numbers of brain injuries, both accidental and inflicted, they can provide a unique perspective to child abuse colleagues; unfortunately, neurosurgeons shy away from doing so for a variety of reasons: (1) they are too busy with clinical practice and cannot afford to devote the (largely uncompensated) time involved in keeping up with the literature on the subject, reviewing the case files in detail, and testifying in court; (2) they are reluctant to take the stand and potentially be subjected to the ridicule (and even abuse) hurled by attorneys in the defense of their clients; (3) they are uncertain in their minds about the validity of the evidence in some cases, especially when the evidence is not iron-clad; and (4) they perhaps fear later retribution from people they have helped convict for these crimes. Whatever the reasons, neurosurgeons need to be more involved in these cases and to be both knowledgeable and reasonable in assessments of the cause of injury. In no other area of neurosurgery is the truth so critical, because the lives of the infants for whom they care, and those who might be accused unjustly of perpetrating a crime that they did not commit, hang in the balance. Neurosurgeons must be unerringly accurate in obtaining and recording clinical information and physical findings. When asked, they must not shy away from providing an answer, but only if well enough versed in the literature to be capable of so doing, because to provide false or inaccurate information is a disservice; to do so may condemn an innocent person to prison, or an innocent infant to death. If there is uncertainty, it is probably in the best interests of the child to have the case analyzed and represented by an expert who knows the literature well; there are many excellent and objective child abuse experts who can do this. Finally, the author believes that this should be a much more active area of research for neurosurgeons. Although there has been much progress, there are also a number of uncertainties that remain to be answered, only a few of which have been touched on here. There is much to be done in this important field; neurosurgeons must concentrate on finding adequate answers for those questions that remain.