SECTION: NEWS; Pg. 3

[Pages:6]NewYorkLawJournal November3,2003,Monday

SECTION:NEWS;Pg.3 HEADLINE:TrialAdvocacy; TheCross-ExaminationoftheRadiologistinaSoftTissueCase BYLINE:ByBenB.RubinowitzandEvanTorgan;BenB.RubinowitzisapartneratGair,Gair,Conason, Steigman&Mackauf.Healsoisanadjunctprofessoroflaw,teachingtrialpracticeatHofstraUniversity SchoolofLaw.EvanTorganisamemberofTorgan&Cooper.Heisanadjunctprofessoroflaw,teaching trialpracticeatBenjaminN.CardozoSchoolofLaw.RichardSteigman,anassociateatGair,Gair, assistedinthepreparationofthisarticle. BODY: Thereisnomorecrucialpieceofevidenceduringthesofttissueinjurytrialthanmagneticresonance imaging.AnMRIdiffersfromanordinaryX-rayinthatitallowstheexaminertoseemorethanjust bones:inbackcases,itshowstheactualspinalcord,discsandnerveroots;inkneecasesitreveals articularcartilage,menisciandligaments.Therefore,effectivecross-examinationoftheopposing radiologistiscritical.Thistaskmayseemintimidating,butwithproperpreparation,agoodgraspofthe anatomyandathoroughunderstandingofradiologicalstudies,thetrialattorneycanmakegreatstrides towardsconvincingthejuryofthevirtueofhiscaseandtheseriousnessoftheinjuries.

PretrialPreparation

Thoroughpretrialpreparationisessential.First,learnthespecificanatomyinvolvedinthecase.Oneof theeasiestwaystodothatistoperusemedicalartistDr.ter's[amedicaldoctor]Atlasof HumanAnatomy,whichcontainsauthoritativedrawingsofthehumananatomy.Itwilleasilyteachyou thegeneralanatomyandallowyoutotakethefirststepinreadingtheactualMRIs.

Thenextstepismeetingwithyourexperttogiveyouacursoryreviewofhowtheanatomylooksonthe specificradiologicalstudies.Thatisagoodtimeforhertopointouttheabnormalfindingsonthose radiologicalstudiesandhavehermarkthemwitharedgreasepencil.Thenextstepistoprocureand readsometextbooks,bothmajorandminor,inthefieldofradiologytogiveyouagreaterbankof knowledgeinthefield.OnesuchtextisMichaelT.Modic'sMagneticResonanceImagingoftheSpine.By comparingtherelevantfilmsforyourcasewithexamplesofsimilarpathologyinmedicaltexts,youcan actuallygetafirmhandleonthepathologyshownonyourstudies.

Itisalsohelpfultolearnasmuchasyoucanaboutyouropposingexpert.Performajuryverdictsearch onher.Determinetheamountoftimesshehastestified,thetypesofcasesinwhichshehasbeen involved,andseewhatherpastdiagnoseshavebeeninvolvingallegationsofsimilarinjuries.Theverdict

searchshouldleadyoutotherelevanttranscripts.Asistruewithallexperts,findingtranscriptswhere shehastestifiedontheoppositesideoftheissuewouldbeincrediblyhelpful.Forexample,inmostsoft- tissuebackinjurycases,thedefensesaysthediscismerelybulging,whiletheplaintiffsaysitis herniated:thedefensetakingthepositionthatbulgingdiscsarecausedbylong-standingdegeneration causedbyagingandthatherniationsarecausedbyacutetrauma.Itiscertainlyhelpfulgettinga transcriptofadefenseradiologistpreviouslytestifyingforaplaintiffthathisbulgingdiscwascausally relatedtothetraumaticaccidentinquestion.

EnlargingtheStudies

Onethingwehavelearnedisthatjurorscanactuallybetaughttoreadthesestudiesduringthecourse ofthetrial.Whenscienceisonyourside,whyletthejurydecidethecasebaseduponthecharm,looks orcredentialsofthebattlingexperts?Instead,showthejurythatyourclienttrulydoeshaveaherniated disc.Todothisyoumustenlargethestudiesforthejurytosee.Blowuptheindividualimagesto30 inchesby40inches.Longbeforecrossoftheradiologist,youshouldhavehadyourradiologistor clinicianshowthemtothejuryonyourdirectcase,goingthroughthenormalanatomyonamodeland thendemonstratinghowthatdiscisherniated.UsingthoseenlargedMRIsoncross,however,iseven morecompelling.

UsingenlargedversionsoftheMRIscanbethedifferencebetweenwinningandlosingeitherona thresholdissueorcausationofinjuryissue.Relyingonthesmall,yetoriginal,versionofthestudyisnot enough.Utilizingtheshadowboxfoundinmostcourtroomswillnotallowthejurorstoseetheactual study.Thefilmsaretoosmall,theshadowboxtoodarkandthedistancefromthejuryistoogreat. Moreover,itistoocumbersometocrossanexpertutilizingtheshadowbox.Thecourtroomlogisticsare suchthatthejury,judge,expertandcross-examinerwillnotbeabletofocusonthefilmsatthesame time,ifatall.

TheActualCross-Examination

Asalways,controlisthemostimportantpartofthecross-examination.Telltheradiologisttheanswerin yourquestionandgetheragreement.Demandresponsiveanswersanddonotlethervolunteer gratuitousremarks.Aspartofyourcrossyoumustcontinuetheeducationalprocessofthejuryby instructingitonthesignificanceandmechanismoftheMRI:

Q:NowyoucommentedtothejuryondirectthatyoureviewedtheactualMRIscansinthiscase,true?

Q:MRIstandsforMagneticResonanceImaging,correct?

Q:Whichbasicallyutilizesamagnetandacomputertogenerateanimageonascreenoronfilmright?

Q:AndtheMRIshowsthingsthataplainfilmX-raycouldn'tpossiblyshow,true?

Q:Forexample,anX-raymayshowaninjurylikeafracturetoavertebralbody,true?

Q:Oritmayshownarrowingofadiscspace,right?

Q:Butitwouldn'tshowwhetheradiscisherniated,right?

Q:Bulging,true?

Q:Orprotrudinginanymanner,correct?

Q:ButanMRIhasthecapacitytoshowallthosethings,right?

Q:Aswellascompressiontoanynerverootsorneuralstructuresofanykind?

Q:Andtogetherwithclinicalcorrelationcouldshowwhetheradiscinjuryiscausingpainordisabilityto apatient,correct?

Thenshowtheexpertyourcommandoftheanatomytogainboththeexpertandthejury'srespectfor yourmedicalknowledgewhilecontinuingtoeducatethejuryonanatomy.Gettheradiologisttoagree thatthespinalcolumnrunsfromthebaseoftheskulltothetailboneorsacrum,thatitconsistsofthe cervical,thoracicandlumbarspine,havingseven,12andfivevertebralbodies,respectively.Use demonstrativeevidencesuchasamodelofaspinalcolumnandpointoutthediscs,spinalnervesand cordtothedoctorandjury.Demonstratehowthediscssitbetweenthevertebralbodiesandactas shockabsorbersforthespinalcolumngivingustheabilitytobend,walk,jump,runandmoveflexibly. Demonstrateonthemodelhowthediscsarenumberedbythecorrespondingvertebralbodybetween whichtheysit,suchasthediscsatL1-L2orL4-L5.

Agoodtechniqueofcrossingtheradiologististousehypotheticalquestionsbasedupontheprior testimonyofyourdoctors.Evenifhewillneverconcedetheherniateddisc,youcanremindthejurythat otherphysiciansgaveopinionsquitedifferently.Atthesametimeyoucandrawthebattlelinesforthe jury:

Q:ThediscthatwearediscussingtodayisknownasthediscatL4-L5,right?

Q:MeaningitisthediscthatsitsbetweentheL4vertebraeandtheL5vertebrae?

Q:Youknowthattheplaintiff'sdoctorsfeelthereisaherniateddiscatL4-L5,true?

Q:Iwantyoutoassumethattheplaintiff'sneurologisthastestifiedbeforethisjuryunderoaththathe hasreviewedthesefilmsandthatthereisaherniateddiscatL4-L5.Iwantyoufurther,toassume,that thetreatingradiologistinthiscase--notsomeonewhowasretainedforthepurposesoflitigation--has putthesefilmsupbeforethisjuryandhaspointedoutthatthereis,infact,aherniateddiscatL4-L5.I takeityoudisagreewiththattestimony?

Q:Itakeityourpositionisthatbothofthesetreatingphysiciansarewrong?

ThisisagoodtimetogotoyourenlargementsoftheMRIfilmsthemselves.Itisimportanttocompare theactualfilmswithanatomicalmodelsofthespinesothejurycancomparenormalanatomywiththe MRIfilms.Throughyourcrossyoucandemonstratehowtherearetwoprimarytypesofcutstakenby MRIimaging:sagittalorlateralviews,whichshowthesideofthespinebutwithvariousslicesmoving

inwardtothemidlineofthespine;andaxialviews,whicharehorizontalslicestakenfromthehead downtowardthefeet.Thesagittalcutsareeasilycomparedtothefullanatomicalmodelofthespine, whiletheaxialcutsarebestcomparedwithsmallanatomicalmodelsthataretypicallyusedbydoctors toshowpatient'sexamplesofherniateddiscs.Theeasiestviewsforthejurytograsparethesagittal viewssoitisgoodtobeginthisaspectofthecrosswiththosecuts.Theyactuallylookvirtuallyidentical tothesideviewofthefullspinemodelwhentheyareheldsidebyside.Aftercomparingthemand pointingoutthevertebralbodies,discs,thecalsac,cerebrospinalfluid,gethimtoadmitataminimum thatbyanydefinition,thediscatL4-L5isinfactprotrudingoutofposition:

Q:Thereissomethingknownasaprotrudingdisc,true?

Q:Radiologistsdefinethoseinacertainway,right?

Q:Therearedifferingschoolsofthoughtregardingtypesofprotrudingdiscs,correct?

Q:Onetypeisabulgingdisc,true?

Q:Anothertypeisaherniateddisc?

Q:Andobviouslytherearevaryingdegreesofherniateddiscsaswell?

Q:Butaprotrudingdiscisdefinedaswhenthediscextendsoutpasttheendplateofthevertebralbody above,andthevertebralbodybelow,right?

Q:NowIamshowingyouplaintiff'sexhibit4inevidence,whichisanenlargementoftheoriginalsagittal viewoftheplaintiff'sMRI;you'dagreefirstofallthatthisis,infact,asagittalviewoftheplaintiff's spine,right?

Q:Itwastakenonemonthpost-accidentaccordingtothedateonthetopright-handcorner?

Q:Asamatteroffact,priortoyourtestimonyyouwentovertheseveryenlargementswithdefense counselearlierthismorning?

Q:You'dagreethatthisshowstheL4-L5disc?

Q:AndweknowthatfromcountingupfromthefirstsegmentofthesacrumwhichwouldbeS1,for sacralsegment1?

Q:SothenextlevelabovethatwouldbethediscatL5-S1,true?

Q:Whichisnormal,correct?

Q:ThenweseeL4-L5,true?

Q:Andyouwouldagreewithme,thatonthisview,ofplaintiff'sexhibit4inevidence,thatthedisc extendspastthevertebralendplateofL4above,andL5below[pointingitouttothejury]?

Q:Asamatteroffact,theseredmarksplacedontheexhibitbythetreatingradiologist,outlinethatvery extensionbythediscbeyondthevertebralendplatesaboveandbelow?

Q:Whichradiologicallyspeaking,meansaprotrudingdisc,right?

Q:Whichyouknowalloftheplaintiff'sdoctorshaveconfirmed,true?

Iftheopposingradiologistdoesnotagreewithyourpointhere,itisaverygoodtimetorepublishthe markedenlargementtothejuryandaskourhypotheticalquestionregardingyourtreatingphysicians' opinionsthattheexhibitshowsaherniateddisc.

NeuralCompression

BothsagittalandaxialimagesofMRIstudiesmayshowcompressionofnervestructures,nerveroots, thethecalsacorspinalcorditself.Evenifyouropposingradiologistdoesnotconcedecompressionof theseneuralstructures,youcanstillwinonthisissue.Todoso,takehimoutsidehisareaofdaily practice,whiletechnicallystayingwithinhisareaofexpertise.Onewaytodothisistoincorporate clinicalfindingsintoyourcross.Ifyourclient'streatingphysicianfindsradiatingpain,muscleweakness andsensorylosswithinthedistributionofyourL4-L5disc,forcetheradiologisttoconcedethe"clinical correlation"withtheherniateddisc.

Q:Althoughyoudon'tgenerallytreatpatients,butreadfilms,youarefamiliarwiththeterm,"clinical correlation,"true?

Q:Andoftentimes,withpositivefindingsonMRIoranyotherradiologicalstudyforthatmatter,youwill actualsignoffthereporttotheclinician,"clinicalcorrelationadvised,"correct?

Q:Becauseyouknowthathowthepatientactuallyfeelsisanimportantfactorinmakingthediagnosis?

Q:Andyoucertainlywereinvolvedinresidencytraininginvolvingneurology,true?

Q:Asamatteroffacttobecomeaneuroradiologist,bydefinitionyouweretrainedinneurology,right?

Q:SoyouknowwithadischerniationatL4-L5,thatwillimplicateacertaindermatomepattern,true?

Q:ThatpatternwouldbewithinthedistributionoftheL5nerveroot,correct?

Q:Becauseaposteriordischerniationontherightside,toareasonabledegreeofmedicalcertainty, maycompressthedescendingL5nerveroot,whichtravelsfromthelowback,crossesoverthefrontof thetibiaorshinandtravelsintoeverytoebutthesmallone,true?

Q:Asamatteroffact,exhibit2inevidence,theNetterDermatomeChart,showsthiswell,true?

Q:Iwantyoutoassumethefollowingistrue,doctor:Assumethattheplaintiffhastoldthisjuryhehas constantpainradiatingfromhislowerbackdownhisrightlegacrosshisshinandintothetopofhisfoot causingpainandnumbnessinhisfourtoes.Youwouldagreewithmethatcertainlythatclinicalpicture isconsistentwitharight-sidedposteriordischerniationatL4-L5?

Q:Iwantyoutofurtherassumethathisorthopedistandhisneurologisthavetoldthisjuryunderoath thathehasdecreasedsensationinthatverydistributioncomingdownhisrighttibiaintoallofhistoes expecthispinkytoe.Youwouldagreethatcertainlythatclinicalpictureisconsistentwitharight-sided discherniation?

Q:Andifthatweren'tenough,doctor,assumebothcliniciansfounddecreasedmusclestrengthofthe greattoeextensor.Youwouldagreethatthisisjustanotherclinicalfindingconsistentwitharight-sided discherniationatL4-L5?

Q:IfyouputalltheseclinicalfindingstogetherwiththeseMRI's,youhaveaseverelyinjuredman,don't you?

Conclusion

Withtheproperpreparationandtechniqueyoucanmaketheradiologist'stestimonyaseffectiveasif shewereyourownwitness.Bymakingenlargementsoftheradiologicalstudies,youcandemonstrate thecorrectnessofyourcasedirectlytothejury.Ifthestudiesareclearandunequivocal,don'thide themfromthefinderoffact.Insteadusetheopposingexperttounderscoretheseriousnessofyour case.

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