What spinal degeneration actually is, and what many think it is, are two different things. Medical professionals are commonly just as confused as lay people. Unfortunately, defense experts and attorneys will often attempt to exploit this confusion. Fortunately, spine medical societies have authored widely accepted guidelines on how to consider spinal degeneration and its significance. In 2001 a combined task force of the ASSR, ASNR and NASS tackled this with the first ever publication on guidelines for classifying lumbar disc changes. In 2014 the same societies revised and updated their guidelines. Most major international spine medical societies have since adopted these guidelines.
Trauma
First, let us distinguish “trauma” from degeneration. Defense attorneys will often question whether a spine MRI shows signs of trauma. The answer is usually no. Trauma is defined as a fracture, dislocation (disconnected spinal joints), subluxation (dislocated spinal joints with slippage) or missile injury (shrapnel, etc.) If it is none of the above, then it is not trauma and that term is inappropriate.
Injury
What about injury, something less than a fracture or a bullet? The guidelines tell us that imaging is not used to determine if an abnormality on MRI relates to an injury. To determine an injury, one must consider the clinical factors of the case and not make the diagnosis in a vacuum, based solely on imaging. In other words, a clinician must consider the temporal relationship (onset of symptoms after injury event), the symptoms themselves and any associated signs (physical exam findings) before determining whether the findings on MRI relate to an injury. Quite simply, a radiologist does not diagnose injury by reading an MRI. Conversely, a defense radiology expert does not deny injury by reading an MRI.
There are important reasons why guidelines tell us not to diagnose injury on MRI. Firstly, while trauma on an MRI is obvious, injury is not. Some injuries, like facets, do not show up on MRI at all. Neither do a lot of annular fissures. Secondly, spinal structures, mostly discs, can be indelibly changed after an injury. Therefore, one cannot tell on MRI whether the finding is related to the index injury or a past one. Lastly, intervertebral discs are joints, and like all joints, they degenerate after injury. Thus, post-injury degeneration is really in the spectrum of post-injury findings. These post-injury degenerative findings may overlap with painless degeneration or degeneration after a past injury. Again, correlation with clinical circumstances would be necessary to attribute the MRI findings to the index injury.
Post injury degeneration: Intervertebral osteochondrosis
So, what are the typical patient’s MRI findings, and can they be related to a patient’s injury? It turns out that all findings other than trauma, tumor or infection have been lumped by professional guidelines as degenerative findings. Multi-society guidelines define post-injury changes as a form of degeneration. The guidelines state that tearing of the disc annulus or disc herniation is always an abnormal finding. The disc changes that occur from such injuries, like protrusion of the disc, darkening of the disc, fissures and narrowing of the disc are regarded as disc degeneration. Since these changes are always considered abnormal by the guidelines, it follows that this is post injury degeneration. These post injury degenerative changes seen on imaging are called “intervertebral osteochondrosis.”
Normal degeneration: Spondylosis deformans
Typical degeneration that occurs from normal wear and tear is distinguishable from post injury degeneration, even though it falls under the umbrella of degeneration. Wear and tear of the disc is ubiquitous in human beings after the teen years. These changes include disc bulging and spurring of the vertebra. These normal wear and tear changes are not painful. They are classified as “spondylosis deformans” and are considered a consequence of normal aging.
Conclusion
Defense experts and attorneys will exploit the confusion inherent in distinguishing post injury degeneration from normal wear and tear degeneration. They attempt to blanket label all changes as simply degenerative because this conjures up images of a chronically worn and stressed spine, something that was likely already symptomatic before an injury. Therefore, it is important to obtain testimony that can distinguish post injury changes from normal wear and tear and can educate juries on the differences. This testimony should also be able to analyze imaging findings in the context of the patient’s clinical situation to satisfy the guidelines’ requirement that injury is a clinical, not a radiological diagnosis.
So, when a defense attorney asks an expert “can you see evidence of injury on the MRI” the question is ill informed or merely meant to mislead. The answer should be “Injury is not diagnosed on an MRI. It is diagnosed by a clinician.”
Tertius Lydgate, MD
The views expressed are the personal views of the author and do not represent the views of The Brain, Spine and Joint Group, its managers, affiliates, partners, employees or its clients. Furthermore, the information provided by the author is not intended to be expert or legal advice.
The content of this newsletter is confidential. It is strictly forbidden to copy, forward, reveal the content of or share any part of this newsletter content with any third party, without a written consent of The Brain, Spine and Joint Group. If you received this newsletter, or a link to it, by mistake, please message This email address is being protected from spambots. You need JavaScript enabled to view it. and follow with its deletion, so that we can ensure such a mistake does not occur in the future.