post-concussional symptoms, financial compensation outcome ... · post-concussional...

Journal ofNeurology, Neurosurgery, and Psychiatry 1983;46:1084-1091

Post-concussional symptoms, financial compensationand outcome of severe blunt head injuryWW McKINLAY, DN BROOKS, MR BOND

From the Department ofPsychological Medicine, University of Glasgow, Glasgow, Scotland

SUMMARY Two groups, each of 21 cases of severe blunt head injury, were compared. Patients inone group were pursuing claims for financial compensation while patients in the other were not.Patients were assessed on cognitive tests, and both patients and relatives were interviewed at 3, 6and 12 months after injury. There were few differences between claimants and non-claimants:post-concussional symptoms were common in both, cognitive performance was equal, and thereports given by relatives of changes in the patients were very similar. However, the reports givenby patients themselves differed with claimants reporting slightly more symptoms than non-

claimants.

It is generally agreed that severe blunt head injurymay result in significant distress for both the injuredand their families. A variety of cognitive deficitshave been demonstrated particularly in memory andconcentration and generally in the more fluid, lesshighly practised abilities.'-5 The subjective, emo-tional and behavioural changes which may occur inthe patient following injury have also beendescribed, as have the effects of these "psychoso-cial" changes on family life.6` However, the extentto which these sequelae are related to the nature andthe severity of the original injury and the extent towhich they are secondary has been less thoroughlyexplored. Secondary factors may include individualdifferences in reaction to disability, the availabilityof social support, and whether or not financial com-pensation is being claimed. The last mentioned willbe considered in this paper, along with the relatedissue of post-concussional symptoms.The literature on the role of financial compensa-

tion following severe head injury is sparse, butwhere it has been discussed it has usually been in thecontext of drawing a distinction between the mildlyinjured and the severely injured. In the mildlyhead-injured, a post-concussional syndrome ofheadache, dizziness, poor concentration and mem-

Address for reprint requests: Mr WW McKinlay, University ofGlasgow, Department of Psychological Medicine, 6 WhittingehameGardens, Glasgow G12 OAA, Scotland.

Received 15 June 1983Accepted 20 June 1983

ory, fatigue and irritability has often been attributedto psychological rather than organic factors."2 How-ever, in a recent review of the evidence, Jennett andTeasdale draw the conclusion that "even brief con-cussion usually entails some structural damage tothe brain" (ref 12, p 259) and that "the damagedone by and the symptoms subsequently sufferedafter mild head injuries are frequently underesti-mated" (ibid p 263). In particular they noted thatneuro-otological and psychological examinationshave revealed a high incidence of abnormalities inmildly injured patients who show no abnormal signson routine clinical neurological examination. Recentwork on evoked potentials'3 represents anotherpromising route to exploring this area.

While research of this sort suggests that there maybe an organic component underlying post-concussional symptoms, the desire for financialcompensation has also been suspected of playing apart. Cook'4 compared two groups of mildly injuredcases (mean post-traumatic amnesia less than 30minutes) and found claimants had more persistentpost-concussional symptoms and longer absencefrom work than non-claimants. However, the factthat these conclusions were based on a response ofless than 50% to a postal questionnaire detractsfrom their value. Cartlidge'5 studied a group of pre-dominantly mildly injured patients and found thatthose who had an increasing incidence of symptomsas time progressed were more likely to be claimingcompensation than those with subsiding symptoms.Cartlidge and Shaw,'6 reporting on the same groupof cases, noted that the patients with anxiety and

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Post-concussional symptoms, financial compensation and outcome of severe blunt head injurydepression were more likely to be claiming compen-sation than those in whom these symptoms wereabsent.Miller has argued strongly for a link between

claims for financial compensation and symptoms inthe mildly head injured. The post-concussional syn-drome is "graven on the heart of every claimant forcompensation" following mild injury and symptomsnearly always remit on settlement of their claim-"win or lose"." Such cases are sharply contrastedwith the severely brain-injured where post-concussional symptoms " are conspicuouslyabsent" :18 this absence in the more severely injuredcases seems to suggest a non-organic aetiology in themildly injured. However, Miller's conclusions mustbe set against a good deal of evidence to the con-trary. Merskey and Woodforde'9 found that theprospect of financial gain did not account for theclinical picture in their group of mild injuries, andKelly20 has shown that many claimants make goodrecoveries before settlement while many non-claimants develop post-concussional symptoms.Moreover, Rimel et a12' found high rates of morbid-ity and absence from work in their sample ofpatients 3 months after minor head injury, despitean absence of clinical signs, and this finding was notattributable to litigation. The disagreement betweenMiller's conclusions and others' findings may reflectthe fact that Miller's sample was grossly atypical ofthe head injured population as a whole, consistingwholly of medico-legal referrals.22 As Cartlidge andShaw note:-". . . in the context of medico-legalexamination (symptoms) are apt to be attributed toattempted deception for the basest of motives, yethow often are they encountered in everyday practicewhere 'functional overlay' is readily accepted on thebasis of anxiety or diminished expectation of per-formance" (ref 16, p 153). In short, there is somecontroversy over the aetiology of post-concussionalsymptoms following mild head injury. The currentview seems to be that the role of an organic compo-nent may have been underestimated in the past, butthat psychological factors including compensationmay play some part. There has been less comment inthe literature on the link between compensation andsymptoms in more severely injured cases. Not onlyis it evident that there is genuine organic impairmentin such cases, but post-concussional symptoms havebeen thought by some authors to be relatively rare.Miller suggested that post-concussional symptomsare "conspicuously absent" in severe cases and thatthere is an inverse relationship between the likeli-hood of accident neurosis and severity of injury." 18

The aim of the present paper is to examine theincidence of post-concussional symptoms and theeffects, if any, that claiming compensation has on

cognitive and psychosocial recovery during the firstyear following severe head injury. This is an issue ofparticular interest to both medical practitioners andclinical psychologists since they are often asked bylawyers to assess the extent of the mental andbehavioural disturbance in patients following headinjury and also to assess the extent to which suchchanges are directly attributable to the injury.Group comparison data will be reported to assessthe overall significance of compensation in elevatingcomplaints in the severely head injured in the yearfollowing injury. This group comparison is based ondata collected in the course of a wider study of thepsychological and social consequences of severehead injury some reports of which have alreadybeen published.4'0 ,,

Method

PatientsTwo groups were drawn, by the method described below,from a larger group of 55 patients who, together with theirrelatives, were the subject of a wide ranging study into thepsychological and social consequences of severe blunt headinjury. Patients aged between 16 and 60 years were admit-ted to the study. "Severe" injury was defined by at least 2days post-traumatic amnesia (PTA) assessed retrospec-tively and "blunt" injury was taken to include depressedfractures but to exclude penetrating localised wounds (forexample, gunshot). Patients known to have pre-existingneurological impairments were excluded. All patients hadpassed through the neurosurgical unit at the Institute ofNeurological Sciences (INS) in Glasgow, which is a secon-dary facility serving the West of Scotland to which headinjured patients are transferred for investigations andtreatments not available at primary receiving hospitals.From the sample of 55 cases obtained in this way two

groups, each of 21 cases, were selected. The first groupconsisted of all those cases in whom a claim for financialcompensation was being pursued and which remained out-standing throughout the 12 months of the follow-up. Thesecond group consisted of all those cases in which no suchclaim was being pursued. In the remaining 13 cases, therewas doubt as to whether they had grounds or sufficientevidence to pursue a claim. A description of the demo-graphic and clinical characteristics of the two groupsstudied is provided in tables 1-5, which indicate inter aliathat the sample was on the whole very severely injured.More non-claimants had a neurosurgical operation, reflect-ing differences between groups in the number ofhaematomas. Previous research' has indicated that bettercognitive outcome was associated with operatedhaematomas but this was attributable to shorter PTA inthe operated group. In the present study non-claimantstended to have shorter PTA but not to a statisticallysignificant extent (p > 0.05). Sex and social class distribu-tions were very similar for each group as was the relation-ship of relatives interviewed to patients. However, claim-ants were significantly younger than non-claimants

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Table 1 Nature ofinjury

Claim No Claim

Location or cause:Road traffic accident 10 6Accident at work 5 0Assault 6 3Other 0 12

21 21

Major complications:Skull fracture only 7 3Haematoma only 4 3Both 4 12Neither 6 3

21 21

Neurosurgical operation:Yes 7 15No 14 6

21 21

Table 2 Duration ofpost-traumatic amnesia (PTA)

Claim No Claim

2- 7 days 5 48-14 days 2 415-30 days 4 731-60 days 3 561-90 days 2 1Over 90 days 3 0

19* 21

Median PTA is 29-7 days for the claim group and 20-7 days for theno claim group.*In 2 of the 21 cases in this group, no reliable estimate of PTAcould be obtained.

Table 3 Age, sex and marital status

Claim No Claim

Age at injury (mean, SD) 31-2, 12-7 43-2, 12-5Sex (males, females) 18, 3 18, 3Marital status:

Married/cohabiting 12 16Separated/divorced/widowed 2 0

Single 7 5

21 21

Table 4 Social class distribution: number ofpatients ineach of the Registrar-General's social classes

Social class Total

1 2 3 4 5

Claim 0 3 7 6 5 21No claim 1 2 4 4 10 21

McKinlay, Brooks, Bond

Table 5 Relationship ofinformants to patients3 months 6 months 12 months

Claim No claim Claim No claim Claim No claim

Spouse 11 15 11 15 12 15Parent 7 2 9 3 8 2Other 3 4 1 3 1 4

21 21 21 21 21 21

Note: All informants were involved in day-to-day contact with thepatients, and where possible the same informant was inter-viewed at each follow-up.

(p < 0.01) and this difference will be considered in thegroup comparisons to be reported.

ProcedureAssessments were carried out at 3, 6 and 12 months afterinjury using a battery of psychometric measures and a briefstructured interview asking patients about symptoms whichthey had noticed since injury. Relatives were also inter-viewed separately from the patients on each occasion andwere asked to report changes in the patient which emergedafter injury. All relatives interviewed bore a major day-to-day responsibility for care of the patient.

Results

1. Psychometric test scoresClaimants and non-claimants were compared onpsychometric test performance on a range of tests:these were tests of Verbal IQ (Mill Hill VocabularyScale23), Non-verbal IQ (Raven's Progressive Mat-rices24), immediate and delayed verbal recall (Logi-cal Memory Sub-Test from the Wechsler MemoryScale25), immediate and delayed visual recall (ReyPicture Test26), receptive language (number correcton Part 5 of the Token Test27) and expressive lan-guage (Word Fluency Test28). A series of two-tailedt tests was carried out to determine if there were anydifferences between claimants and non-claimants.Eight of the 24 comparisons generated in this waywere significant (p < 0-05) and all of these indicatedthat the claimants had performed better on the teststhan non-claimants. However, there was a statisti-cally significant (p < 0-01) tendency for the claim-ants to be younger and since this clearly might havean influence on test scores a series of analyses ofco-variance was carried out using age as co-variate.When this was done, all but two of the significantdifferences disappeared leaving only two differenceswhich were significant at the 5% level. With onlytwo out of 24 comparisons reaching the 5% level ofsignificance, it may be concluded that there was nooverall difference in psychometric test performancebetween claimants and non-claimants.



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Post-concussional symptoms, financial compensation and outcome of severe blunt head injury2. Relatives' reports ofpatients' syndromesA series of analyses was carried out on the informa-tion given by relatives about changes in the patients.On the basis of the structured interviews which hadbeen carried out with relatives at each follow-up, wecalculated the mean number of changes which therelatives reported in each of seven areas of function-ing. This number was scaled as if "out of 10" so thatthe number of changes reported in each area wouldbe comparable, and the results are summarised inthe figure. In both claim and no claim groups emo-tional and subjective changes were most frequentlyreported and the profiles of the claim and no-claimgroups were very similar indeed. Claim and no-claim groups were compared statistically on each ofthe seven areas of functioning at each of the threefollow-ups. T tests indicated that none of the 21comparisons reached the 5% level of significance(two-tailed). These results fail to provide supportfor the proposition that the relatives of claimantsreport more extensive changes in the patients thando relatives of non-claimants. In order to excludethe possibility of a specific difference in respect ofpost-concussional symptoms, a further analysis wascarried out. The numbers of post-concussional

-~ Claiming compensation........... Not claiming compensation

3 months after injuryPhysical -SubjectiveLanguageEmotionalDependenceDisturbed -behaviourMemory

0 1

6 months after injuryPhysicalSubjectiveLanguageEmotionalDependenceDisturbedbehaviourMemory *

0

12 months aftePhysicalSubjectiveLanguageEmotionalDependenceDisturbedbehaviourMemory.

0 10

No of changes 'n each area

(out of 10)Fig Mean changes in patients as reported by relatives.

symptoms present in claim and no-claim groupswere compared using the group of four core post-concussional symptoms suggested by Miller," thatis, headaches, dizziness, irritability and poor con-centration (table 6). At each follow-up, comparisonby Mann-Whitney U test revealed no statisticallysignificant difference.

3. Patients' reports of their symptomsThe next series of analyses carried out was on thepatients' own responses to the structured interviewmentioned above. Firstly, three of the four corepost-concussional symptoms were examined (poorconcentration, dizziness and irritability). A questionabout headache had not been included in thepatients' structured interview because we hadaccepted the view-which we now believe to bemistaken-that post-concussional symptoms arerare after severe head injury. The number of thesepost-concussional symptoms reported by thepatients in each group is given in table 7. Claimantstended to report more symptoms than non-claimants, this difference reaching statisticalsignificance on the Mann-Whitney U test (p < 0.05)at 3 and 12 months follow-up. Next, the total num-ber of symptoms reported by patients from a wider-ranging list of 20 items was calculated. The claimand no-claim groups were compared (table 8). Ttests indicated that there was a significant differenceat each follow-up. When the effects of age and PTAwere co-varied out the difference remainedsignificant at the 5% level at all three follow-uptimes indicating an overall tendency for patientswho were claiming compensation to report moresymptoms than those who were not claiming.

4. Retumrn to workThe numbers of claimants and non-claimants whohad returned to work at each follow-up were com-pared. Only patients who had returned to work orthose who had not done so only because they were"unfit for work" were included: patients who wereunemployed for reasons unrelated to injury wereexcluded as were the retired, students and house-wives. These data are summarised in table 9. Nostatistically significant association between claimingcompensation and return to work was found at anyfollow-up using Fisher's exact test or the Chi-squaretest as appropriate (p > 0.05).

5. Post-concussional symptomsA substantial number of these severely injuredpatients experienced some post-concussional symp-toms according to the reports both of the patientsthemselves and their relatives (tables 6 and 7). As a

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Table 6 Number ofpatients with "post-concussional"symptoms (headache, dizziness, irritability, poorconcentration) as reported by relatives as a function ofcompensation claim.

Number ofsymptoms N

0 1 2 3 4

3 months after injury No Claim 3 5 5 4 1 18

No Claim 3 5 6 4 1 206 months after injury Claim 34 5 74 2 20NoClaim 3 4 5 7 2 2112 months after injury NClaim 5 3 6 5 1 20

At each follow-up, comparison of claim and no claim groups byMann-Whitney U test (2-tailed) reveals no significant diference.(p > 0-05)

Table 7 Number ofpatients reporting"post-concussional" symptoms (poor concentration,dizziness, irritability) as a fiunction ofcompensation claim

Number ofsymptoms N

0 1 2 3

3 months after injury No Claim 10 7 1 0 17p (Mann-Whitney U, 2-tailed) < 0 05

6 months after injury Claim 5 7 5 3 20p (Mann-Whitney U, 2-tailed) > 0-05

12 months after injury Claim 3 8 8 2 21

p (Mann-Whitney U, 2-tailed) < 0-05

Table 8 Total number ofsymptoms (out of20) reportedby patients as a function ofcompensation claim

Time after injury

3 months 6 months 12 months

Claim 6-2 6 5 7-3No Claim 4-2 3-8 4 5Significance of:

t test (2-tailed) p < 0 05 p < 0-01 p < 0-01ANCOVA withAge and PTAas covariates p < 0-05 p < 0.05 p < 0.05

Table 9 Return to work as a function ofcompensationclaim

Working Not working N

3 months after injury C laim 3 11 12aftNClaim 3 11 14

6 months afterinjury No Claim 6 8 14NoClaim 9 6 1512 months after injury C laim 6 6 12

In each case, the Fisher exact test or the chi-square test, asappropriate, indicates no significant association (p > 0-05) betweenthe variables.


Table 10 Number ofpatients reporting post-concussionalsymptoms as a function ofcompensation claim(C = claim group, NC = no-claim group)

Time after injury3 months 6 months 12 months

C NC C NC C NC

Poor concentration 9/17 5/19 8/20 8/20 8/21 2/21Depressed mood 11/18 8/18 12/20 7/20 11/21 9/21Irrntability 9/17 5/18 13/20* 5/20 15/21 9/21Fatigue 11/16 7/18 14/20 10/20 15/21 9/21

*p (Chi-square) < 0-05.For ali other comparisons, p (Chi-square) > 0-05.

Table 11 Number ofpatients suffering post-concussionalsymptoms according to relatives' reports as a function ofcompensation claim.(C = claim group, NC = no-claim group)

Time after injury

3 months 6 months 12 months

C NC C NC C NC

Poor concentration 11/21 6/20 10/20 7/21 10/21 5/20Depressed mood 14/20 11/21 14/21 10/21 13/20 11/21Irritability 12/21 13/21 16/21 13/21 15/21 13/21Fatigue 18/20 15/20 12/20 16/21 15/21 11/21Headaches 12/20 12/21 9/21 12/20 12/21 10/21

For all comparisons, p (Chi-square) > 0 05.

further way of examining the prevalence of post-concussional symptoms, the number of patientsexperiencing particular symptoms was calculated.The symptoms were a selection of those identified as"post-concussional" in the literature.'2 16 17 Thepatients' own accounts are summarised in table 10.Here, similarly to the analyses reported in table 7,there was a tendency for more claimants than non-claimants to report symptoms: all differences werein this direction although only one out of 12 com-parisons reached the 5% level of significance on theChi-square test. The relatives' reports of patients'symptoms are summarised in table 11. Here therewere no significant between group differences,which is consistent with the analyses already carriedout on relatives' reports. In addition to these symp-toms, between one third and one half of the relativesreported that the patients showed intolerance ofnoise and reduced tolerance of alcohol, and mostreported poor memory and increased anxiety. Inshort, relatives reported a wide range of post-concussional symptoms in both claimants and non-claimants.



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Post-concussional symptoms, financial compensation and outcome of severe blunt head injuryDiscussion

This study has found a high level of post-concussional symptoms in the severely head injuredduring the year following injury. This is in accordwith the findings of Kelly,20 who also found suchsymptoms following severe injury. It is at odds withthe view of Miller that post-concussional symptomsare rare and are "hardly ever volunteered in thehistories of patients (with) severe cerebraltrauma"."7 However, failure to "volunteer" is notthe same as absence: in the present study othersymptoms and difficulties were more dramatic andevident but direct questioning uncovered post-concussional symptoms. These symptoms did notoccur in all-or-none fashion but were present in vary-ing numbers. This supports the view of Cartlidgeand Shaw'6 that there is not a well-defined post-concussional syndrome but rather a loosely associ-ated collection of symptoms. Moreover, the pres-ence of post-concussional symptoms in the severelyinjured, especially those not claiming financial com-pensation, leaves open the possibility of an organicbasis which would be much less likely if these symp-toms were largely confined to mildly injured claim-ants, as has been alleged."'There were some differences between claimants

and non-claimants in the present study, and theseshould be considered in the context of the overallgroup comparisons. On psychometric tests, the ten-dency of claimants to obtain higher scores thannon-claimants was attributable to the tendency forclaimants to be younger. When age was controlledstatistically there was no consistent difference bet-ween groups. In short, it seems that claimants didnot attempt to fake low scores in order to present asmore disabled than they were. Of course, this doesnot mean that no one ever tries to fake low scores.However, the present authors believe from theirown clinical experience that serial testing uncoversthis easily in the very few cases where it occurs, andthe present findings support the view that faking lowscores is rare.The accounts of changes in the patients given by

relatives in the course of separate interviews werenot influenced by whether or not financial compen-sation was being claimed. The profiles of changes inclaiming and non-claiming patients, obtained fromrelatives, were very similar indeed (fig) with nosignificant differences at any stage. Both groupsreported the same overall picture as that reported inthe larger group of 55 cases from which they weredrawn:'0 emotional and subjective changes wereconsiderably more common than other kinds ofchange. In addition, relatives' accounts of specificpost-concussional symptoms in the patients did not

differ between claimants and non-claimants. Itseems, therefore, that relatives are good witnessesinasmuch as their accounts are not influenced bywhether or not a claim for financial compensation isbeing made.Unlike psychometric test scores and relatives'

accounts, the patients' own accounts of their symp-toms revealed consistent differences between claim-ants and non-claimants. Those who were claimingcompensation tended to report more symptoms thanthose who were not claiming. While the differencesmay have been related to the differing age and sev-erity of injury in the two groups, even when thesetwo factors were statistically controlled, significantdifferences remained. Nor can it be argued that onlythose with poor outcomes considered it worth claim-ing: the key element in the decision to claim wasculpability and the availability of witnesses.The tendency for claimants to report more prob-

lems was slight vis-&-vis post concussional symp-toms, reaching statistical significance in some analy-ses only (tables 7 and 10). However, this tendencybecame more robust when all 20 items in the symp-tom checklist were included (table 8) and appearedto be a general effect rather than one specific toparticular symptoms. Nevertheless, the differencebetween groups was fairly modest in size and mustbe considered alongside our other findings. In par-ticular, these patients did not fake low scores onpsychometric tests and this study did not find evi-dence that claimants were absent from work forlonger than non-claimants. Taken together, thesefindings do not support the conclusion that claimantsmake a widespread and concerted effort to presentas more disabled than they are.The findings of this study raise a number of issues.

That different conclusions were reached on the basisof patients' and relatives' reports deserves comment.It has been noted that although agreement betweenpatient and relative is usually quite high, relativessometimes report changes in patients which thepatients themselves fail to admit. This "lack ofinsight" seems to occur mainly over emotional andbehavioural changes and is not generally a functionof the patients' cognitive level.62930 Moreover,further evidence from our own research indicatesthat the personality of relatives may colour theaccounts they give to a modest degree.30Of more importance in the present context is the

question of how we may account for the differencesbetween the reports of patients who claimed com-pensation and those who did not. What factorsunderlie the deficits and symptoms observed afterhead injury? Firstly, it is beyond doubt that organicbrain damage plays an important part both withregard to cognitive and other broader aspects of

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outcome.5 It is also quite possible, as has alreadybeen argued, that post-concussional symptoms havean organic basis. Secondly, it is likely that a varietyof psychological and social factors influence out-come: these may include premorbid personality andavailability of social supports, although precise evi-dence about these remains lacking. In addition,Kelly20 has argued that failure to be offered propertreatment may prolong post-concussional symptomsin claimants for compensation. Thirdly, there is nodoubt that some patients malinger or simulate disa-bility with a view to increasing a claim for financialcompensation. Kelly argues that "The stupid, thegreedy and the histrionic are always with us, but ...it is unreasonable to suppose that (because some)attempt a fraud on insurance companies, all patientswho have suffered a head injury for whom a claim isoutstanding and who have .. . post-traumatic syn-drome should therefore be labelled as fraudulentand refused treatment" (ref 20, p 24).

In the present study, it seems unlikely that organicfactors could account for between group differences.There was no significant difference in PTA betweengroups, and in any event PTA was used as a covari-ate to control for the small difference which didexist. Nor were there differences in cognitive out-come which would have been expected if there weredifferent levels of organic impairment. Malingeringor simulation of disability also seem unlikely. Hadthis been present, one would have expected a grea-ter difference between the reports of claimants andnon-claimants together with some attempt to obtainlow cognitive test scores. Relatives' accounts mightalso have differed between groups.

If neither organic factors nor malingering adequ-ately account for the between group differences, canpsychological factors do so? There is no reason tobelieve that there are systematic premorbidpsychological differences between groups. However,Rutherford et al observed, in relation to mildinjuries, that persisting symptoms may be related toblaming an employer or impersonal body for theinjury, rather than oneself or another individual.32Merskey and Woodforde, again discussing mildinjury, pointed out that the uncertainty whichattaches to the process of litigation may be harm-ful.'9 And Kelly, as already noted, argued for anelement of iatrogenesis.20 It may be that such con-siderations best account for the differences betweenclaimants and non-claimants observed in the presentstudy.

Finally, two practical implications for assessingcompensation claimants are drawn from the study.Firstly, it is important to assess cognitive functionand to conduct separate interviews with relatives toobtain views unbiased by compensation. A careful


interview with the patient is also required if allsignificant symptoms are to be uncovered: post-concussional symptoms are often present in theseverely injured even if less obvious than their otherproblems. Secondly, examination should be made inthe knowledge that major exaggeration of disabilityis rare.

The investigation was supported by the MedicalResearch Council, Grant No. G/9751928.

We are grateful to the Consultant Neurosurgeons atthe Institute of Neurological Sciences, SouthernGeneral Hospital, Glasgow, who allowed theirpatients to be studied.

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