Neurological opinion: why it is so important in medico-legal practice

by Dr MICHAEL GOSS MA MB BChir MD FRCP, consultant neurologist and founder member of the Expert Witness Institute (MEWI)

CONSULTANT neurologists undergo the longest training in clinical practice and it would be true to say that we never stop learning – both from advances in science and from our patients.

Neurology involves the assessment of the nervous system, which can be divided into the brain and spinal cord – known as the central nervous system – and the nerve roots, peripheral nerves and muscles which effectively make up the peripheral nervous system.

Neurologists are different from nearly all other specialties because it is vital with any symptom in neurological practice to ask whereabouts in the nervous system that symptom is being generated. There may be numbness, for instance, in a foot, but which end of the nervous system is generating that symptom?

One-third of neurological practice involves headache sufferers; one-third fits, faints, funny turns and dizziness; and the final third all the other neurological conditions, such as multiple sclerosis, stroke, Parkinson’s disease and peripheral neuropathy.

In fact there are more than 700 neurological diagnoses without considering all of the newly-discovered genetic disorders of the nervous system. That is probably more diagnoses than the rest of medicine put together.

Neurologists obviously deal with all kinds of brain and spinal injury. They frequently find themselves like the conductors of an orchestra of colleagues, all of whom feed back to the neurologist with their specialist input. We frequently ask neuropsychologists, neuropsychiatrists, clinical psychologists and all therapists to help with the management of our patients, so we are well used to discussing and dealing with their opinions, both clinically and within the medico-legal world.

Neurologists also deal with every aspect of pain. That shouldn’t be surprising, as pain can only be perceived by the central nervous system and is as a consequence of fine nerve fibres generating neural impulses that are perceived as pain.

We are also used to dealing with people who have symptoms that just cannot be explained medically, or who have a complex range of psychological disorder, which in turn generates quite complex constellations of symptoms.

There is usually little controversy over severe traumatic brain injury, although there may be discussions about the amount of care and the level of employability. The new Mental Capacity Act also leads to discussions, with the neurologist contributing to that discussion. Similarly, in matters of disability discrimination involving neurological illness it is once again the neurologist who is able to shed quite a lot of light on how the nervous system works.

Over the years I have found that the legal process has difficulty in understanding that pain does not necessarily equate to functional handicap. There seems to be a general acceptance that, if an individual does have any kind of pain or even any symptom, then it is perfectly reasonable to suggest that they can never work again or in fact can just spend their life doing nothing. In clinical practice that just isn’t the case and the literature clearly demonstrates that the more an individual does with appropriate therapy and counselling the better in fact they get and not surprisingly suffer much less severe symptoms.

Such commentary applies particularly to mild traumatic brain injury, where in clinical practice nearly everybody makes a full recovery, whereas in medico-legal practice mild traumatic brain injury is perceived as causing devastating handicap.

Neurologists supervise and analyse a whole range of investigations, including MRI scanning, CT scanning, neurophysiology testing and assessment of the balance mechanism. Although usually the neurologist doesn’t carry out the tests themselves, most will be used to handling such information, and occassionally there will be joint accreditation with neurophysiology.

It is imperative for the neurologist to have as much information available in order to prepare their report. If an individual indicates that, following an accident, they are unable to do something, then clearly that can be validated by looking at their life in detail during that time window. If, on the other hand, what they say is not validated, then further questions would need to be asked.

The neurologist finds the history the most important part of the assessment process, and like all clinical specialists dependent on what they are told by the patient or claimant being assessed. There are many injured people who are entirely consistent with their history and do not elaborate on their symptoms.

To balance that comment, however, there are a number of individuals for whom their relatively minor injury is a way out of the workforce and into a comfortable early pension.

If you feel that this comment is too tough, consider the case where a mother has been found guilty of turning her six-year old child into the ‘sickest child in England’ to gain staggering sums of money in benefits, as well as publicity and other gains.