“There is a great unknown unknown.” Prof Jack Phillips, neurosurgeon. Only place to go now is the neurosurgeon’s office.

“I had a chat with quite a number of neurosurgeons in the last two years and we rarely remember a rugby player coming in requiring attention for a head injury,” said Prof Phillips, who has more than 30 years association with Irish boxing.

“Until recently we couldn’t identify any. We are scratching our heads.”

So concussion was not being reported?

“That’s been the historical position.”

Of course, head injuries were described as anything but concussion until Dr Eanna Falvey stepped over the white line in November 2013 and removed Brian O’Driscoll from the All Blacks match at the Aviva stadium.

This past week the rugby narrative has refused to leave concussion alone.

On Friday last the IRFU felt the need to release a statement (subject matter in bold capitals: ON JOHNNY SEXTON) criticising Laurent Bénézech for questioning the decision to select Sexton against France, carried on page one of The Irish Times, and subsequently interviewed on Newstalk FM.

They branded it: “Disappointing and inaccurate commentary in the media by individuals with no medical expertise.”

After Saturday’s famous victory over France, Ireland coach Joe Schmidt added: “We have absolute faith in our medical people and we rely on them, not someone external who decides that they’re going to voice an opinion and then be given a platform to voice it and almost scaremonger their way through the concussion issue.”

Concern of a nation

Bénézech, a reputed journalist and former international, comes across as an honourable man. His were strong, unsolicited quotes that didn’t feel like needless alarmism. The editors in The Irish Times – hardly a scaremongering cohort – felt the piece warranted the front page on the Friday before Ireland played France in the Six Nations.

The Carton House bubble strongly disagreed but they felt it reflected the general concern of a nation.

Many people feared for the wellbeing of Ireland’s best player and leader, they feared his own bravery and bloody-mindedness would lead to further injury (having witnessed the head trauma Sexton sustained in November and the previous March).

The IRFU correctly noted: “Johnny has been symptom-free for 2 months. Johnny was cleared to return to play on Thursday 5th February, 2015 by: 1) Independent neurologists in France and Ireland 2) The FFR concussion review committee 3) The Racing Metro medical team 4) The Ireland medical team.”

This week Prof Phillips, the eminent Beaumont hospital neurosurgeon, was compelled, again without any prompting, to say: “I sat at the television literally terrified waiting for (Mathieu) Bastareaud to take out Johnny Sexton the first time.

“The whole nation sat terrified. Those of us in the medical profession sat terrified for that to happen. That’s the big reason to tackle this problem – the sheer inequality of size.”

Thankfully, the nation could breathe a collective sigh of relief when it was subsequently proved, in the most gruesome yet heroic way possible, that the 29-year-old was compos mentis after twice clashing heads with Bastareaud.

“We don’t know how often [rugby players] have to get concussed to get a brain injury,” Prof Phillips continued. “We don’t know what kind of brain will absorb lots of concussions, like Johnny Sexton, and still give the fantastic performance he gave the other day.”

The IRFU and Schmidt make a valid point about the media beating the drum about concussion without sourcing expert medical opinion. And in this life-threateningly serious matter the true voices of relevance are not the players nor the coaches but neurosurgeons such as Prof Phillips and Dr Michael Carter.

Accurate data

Dr Carter recently opened an editorial in the British Medical Journal, highlighting the dire need to start compiling accurate data on head trauma in rugby, with: “Anyone who has spent an hour picking skull fragments out of the contused frontal lobes of a teenage rugby player is entitled to an opinion on the safety of youth rugby. As a paediatric neurosurgeon, I’ve done this on several occasions. As a ‘rugby parent’, I’ve observed the school and club game at close quarters, from both sides of the touchline. What I’ve seen and heard suggests that our thinking on the subject may not be altogether rational.”

This, however, changes the point of conversation away from a fit and healthy Sexton (who plays for Racing against Clermont tonight) to the return to play protocols. These require six days to complete if you are a professional but are more pronounced for an amateur adult or under 20 player.

IRFU concussion guidelines state an adult’s minimum rest is 14 days followed by six days “graduated return to play protocols (minimum time out is 21 days or two weekends missed)”. Under-6 to under-20 players must take the same 14 day rest period before an eight day GRTP (“minimum time out is 23 days or three weekends missed”).

This prompted a letter to The Irish Times from Rory O'Carroll, Dublin footballer and Acquired Brain Injury Ireland (ABI) ambassador, who, incidentally, was concussed in the 2013 All-Ireland final against Mayo but was left wandering around Croke Park.

O’Carroll questioned the need for different protocols for amateurs and professionals – noting Rory Best’s return to the Ireland team seven days after sustaining concussion against Italy in Rome.

O’Carroll would not speak directly to The Irish Times but on Friday the ABI emailed us:

“Here is Rory’s question – and Rory would like to note that it is a question and nothing more.

“Why are the IRFU allowing a professional player return to play after seven days by allowing them enter into the six stage return to play process after one day of rest when an amateur player has to allow for a 14-day rest period before entering into the return to play process.

“While the medical care provided may be of a higher standard and more accessible for professionals damage to the brain does not discriminate. The strong force of a knock is what determines the severity of a player’s concussion. In that case is it not the professionals who are taking bigger stronger hits and so the ones who need an extended rest period to ensure player safety?

“Rory would also like to note that this is his question which represents him as an individual and him only.”

Tuesday morning’s inbox kept the issue front and centre: the first email was a retweet from Peter Robinson (father of Ben, the 14-year-old who died from second-impact syndrome on a rugby field in January 2011) of Leinster coach Matt O’Connor’s comment after Tom Denton, Noel Reid and Richardt Strauss were concussed on Sunday: “I think because the awareness has been raised I don’t know if it is more prevalent than it was in the game. I think everyone is hypersensitive to it at the moment . . . It’s pretty obvious to work out when guys have head injuries.”

“It’s alarming. It’s something we need to look at, how we can fix it I don’t really know,” admitted O’Connor.

Next was an email from Bloxham PR revealing “Nutrition X” is entering the Ireland and Northern Ireland market, having previously been the official supplier of supplements for Munster Rugby. “Brand ambassador can be provided upon request.”

Next was confirmation that Cardiff flanker Rory Watts-Jones has retired from professional rugby on “concussion-related grounds”. Next email is a statement from Watts-Jones: “If I could offer one piece of advice it would be to make the most of every minute in the game as you never know when it will be over.”

Then, on Thursday, The Irish Times posted the video of Clongowes hooker John Molony tackling St Michael’s Max Deegan and subsequent events from the February 8th Leinster schools quarter-final. Molony played on.

“If he was my boy I’d have pulled him off,” said Dr Carter.

Following an alarming Irupa player survey on concussion last year, when 28 percent of players thought they had suffered concussion in the last 12 months while seven per cent were unsure and 13 per cent were not confident the injury had cleared when they returned to play, Prof Phillips was sent by the union to speak to the Munster and Connacht squads.

“They listened very attentively. So the IRFU have responded to this challenge.”

The IRFU, via Dr Eanna Falvey, have also released the precise protocols to be followed once a player is taken off the field for a Head Injury Assessment (HIA).

‘Stuck on the rocks’

However, Dr Carter is not fully convinced by this latest method of recognising concussion. “A lot of people insist upon randomised control trials but you don’t need a randomised control trial to tell if you jump off a building you are likely to fall. So a lot of it is common-sense based. This is where the argument has gone at the minute. It’s a little bit stuck on the rocks.”

The evolution of the game, the sheer inequality of size, means Pandora’s Box has been opened with regards concussion in rugby.

“We are learning from a new era of heavy hitting,” said Prof Phillips. “Brian O’Driscoll gave a talk at the College of Surgeons last year. Before I could, somebody asked him the question: what’s going to happen to the physicality?

“ ‘I don’t know,’ he replied. “They are all dodging the question. It’s a gladiator sport.

“But I would think all this is passing through the minds of Eanna Falvey and John Ryan and the IRFU. The International Rugby Board wants rugby to thrive so nothing radical is going to happen here until the figures come in.

“As [consultant neuropathologist at Beaumont] Michael Farrell said to the Dáil [in October]; until the figures come in we can’t, scientifically, be dogmatic.

“We can’t be dogmatic. I mean you take that match on Saturday; nobody was seriously concussed. It’s extraordinary.”

(Scott Spedding was removed due to concussion).

“George North was flipped around like a rag doll and he still came back on against England. There is a lot of normality in contact sport that results in ‘no injury’. It’s been going on for years.”

“We have scratched our heads in the neuroscience units to count the number of people that came in for concussions. Very few.”

Is it increasing enough to act now?

“The figures are just not there to show and say. But the fact that the IRFU have become very aware of this concussion rate (of 28 per cent) among the European Cup players means it probably is more prevalent than anybody is admitting.

“So, there is a great unknown unknown.”

Some call it omertà.