This edition very much has an ‘above the clavicles’ theme. Traumatic brain injury (TBI) has become one of the major concerns for many militaries across the world and enormous research projects are underway to try and elucidate better ways of detecting and monitoring this entity. What is becoming apparent is that this doesn't only apply to those significant head injuries with clearly demonstrable intracranial haemorrhage and obvious sensorimotor deficits, but includes much more subtle injuries with long term neurocognitive impairment from repeated mild TBI and from blast induced TBI.

I am delighted that this edition showcases a broad range of work on this topic from UK and overseas including outcome data from those head injured on recent UK operations. Of equal importance, and with equal if not greater media presence, is the ongoing concerns over the mental health of UK service personnel and veterans and I am equally delighted to showcase this problem from several different angles—training, treatment and outcome.

CENTER-TBI Trial

Wheble and Menon's overview of the ongoing CENTER-TBI trial highlights what could well turn out to be one of the most influential head injury trials ever. Aiming to recruit over 5000 patients in the three clinical strata of ‘discharged from ED’, ‘admitted for observation’ ‘requires ICU management’ and followed by a battery of clinical, radiological and biomarker studies for up to 24 months from injury it aims to fully map the spectrum of brain injury across Europe and identify those interventions of benefit.

Vocational Outcome

Bahadur et al's work is enormously important. It demonstrates how poor initial GCS can be at predicting eventual outcome with ten out of eleven casualties with initial GCS 3 being able to return to useful work. Indeed all seven casualties who had GCS 3 and ISS 75 at presentation have returned to essentially independent living. This is both a testament to the exemplary trauma care pathway from point of wounding through to rehabilitation, but also probably suggests that both scoring systems are perhaps not ideal for the casualty cohorts that the campaigns in Iraq and Afghanistan generated.

Vocational rehab

Olivier and colleagues at the Defence Medical Rehabilitation Centre provide an overview of the vocational rehabilitation pathway that has evolved over many years for servicemen with involvement of a latitude of agencies with excellent outcomes in terms of returning neurologically impaired service personnel (be that from trauma or medical reasons such as stoke) back to useful employment. The team at DMRC are to be commended.

Mental health doesn't necessarily get better with time

The fascinating study reported by Banwell and colleagues form the Kings College Mental Health unit provides food for thought. The assumption that mental health symptoms would get better with time after return from deployment didn't seem to be true as most measures worsened. Poor mental health functioning on return from deployment was a predictor of transition and relationship difficulties down the line. More work with longer follow up is clearly needed to make sure we provide the best possible mental health services for serving and retired personnel.

. . . . . And finally

Colonel Stanworth's resume of a century of British military neurosurgery is an interesting reflection of what has changed—and what has not. It is a fascinating read and covers all major conflicts of the last hundred years