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The Spine at Trial: Practical Medicolegal Concepts about the Spine

CHAPTER 1: What Holds Up Your Body?

Adult Anatomy and Biomechanics of the Spine

The Spine or Vertebral Column

The Vertebrae

The Vertebral Bodies

Arches

Pedicles

Facets

Laminae

The Spinous Process

The Transverse Process

The Cervical Spine (The Neck)

The Thoracic Vertebrae

The Lumbar Vertebrae

The Sacrum

The Coccyx

Discs, Ligaments, and Muscles

The Intervertebral Discs

Ligaments

Muscles

The Spinal Canal

The Spinal Cord and Nerves

The Lateral Foramina

The Blood Supply of the Brain and Spinal Cord: The Pipelines of the Neck

Circulation to the Brain

Circulation to the Spinal Cord

Some Biomechanics Concepts: How the Spine Moves and Tolerates the Load

The Three-Joint Complex

Biomechanics of the Cervical Spine

Biomechanics of the Thoracic Spine

Biomechanics of the Lumbar Spine

Spinal Stability

The Three-Column Principle

Checklist for Evaluating Instabilityin Every Region of the Spine

Surgical Procedures and Instability

Differences in Surgical Procedures between the Cervical Spine and Lumbar Spine

CHAPTER 2: The Baby's Spine Develops, Grows, and Ages

Developmental Anatomy

Underlying Principles and Vocabulary

Week-by-Week Development

Testing and Treating the Unborn Baby

Concepts about Teratology

Development of the Skeletal System

Ossification Centers

A Typical Vertebral Ossification

Developmental Anatomy

Typical Cases

Children in Car Wrecks

CHAPTER 3: The Aftermath of the Tornado

Healing and Repair of Injuries

The Dynamic of Wounding

Tissue: The Specialized Cells

The Process of Healing and Repair

Coagulation

Inflammation

SWELLING (EDEMA) _ PAIN _ HEAT _ REDNESS

Granulation

Scar Formation

General Modifying Factors in Wound Healing

Healing of Specific Tissues

Fasciae

Ligaments

Tendons

Muscles

Cartilage (Joints, Discs)

INTERVERTEBRAL DISC

Bones

Brain,

Spinal Cord, and Nerves

The Wonder of Healing

CHAPTER 4: The Bionic Eye

What Lawyers Should Know about Imaging Procedures and Neuromuscular Tests

The X-Ray (Roentgen Rays)

Cervical Spine X-Ray Views

CERVICAL LATERAL (CROSS-TABLE LATERAL) RADIOGRAPHS _ CERVICAL ANTEROPOSTERIOR (AP) X-RAY PROJECTIONS _ CERVICAL OPEN-MOUTH X-RAY VIEWS _ CERVICAL OBLIQUE X-RAY VIEWS

Thoracic Spine X-Rays

Lumbar Spine X-Rays

LUMBAR AP OR PA X-RAY VIEWS _ LUMBAR LATERAL VIEWS _ LUMBAR OBLIQUE VIEWS

Bone Scans, Radionuclide Imaging, or Nuclear Diagnostic Testing

Myelograms

Discograms

Computerized Axial Tomography (CT) Scans

Common MRI Concepts

Electrical Neuromuscular Tests

Nerve Conduction Velocity Studies

Electromyograms

Somato Sensory Evoked Potentials (SSEP)

Conclusion

CHAPTER 5 The Twisted and Broken Spine

Fracture and Dislocation of the Vertebral Column

Spinal Injuries to Unborn Babies

Neck Injuries in Children

Occipito-Atlantal (Occiput-Atlas [C1]) Injuries

Medical Information

Legal Application

Atlas Injuries (Jefferson Fractures: When the Atlas Is Crushed)

Medical Information

Legal Application

Atlanto-axial Injuries (Injuries at the Top of the Spine)

Medical Information

Legal Application

Odontoid Fractures: The Broken Tooth of the Spine

Medical Information

Legal Application

Injuries of the Axis (C2): The Hangman's Fracture

Medical Information

Legal Application

OTHER WAYS TO SUFFER HANGMAN'S FRACTURE

Injuries of the Neck below C2

Medical Information

Legal Application

LATE INSTABILITY

Conclusion on Injuries of the Neck Below C2

Thoracolumbar Trauma in Children

Clinical Presentation

COMPRESSION FRACTURE _ SEAT-BELT INJURY _ FRACTURESAND DISLOCATIONS _ BURST FRACTURES

Thoracic Fractures in Adults

Thoracolumbar Junction

Fracture of the Lumbar Spine

Injuries to the Spinal Cord

Medical Information

Legal Application

CHAPTER 6 The Wrecked Back

Soft-Tissue Injuries of the Neck and Lower Back

Soft-Tissue Injuries of the Neck

Neck Pain

Headache

Dizziness

Temporomandibular Joint Disorders Following Whiplash

Dysphagia and Dysphonia after Whiplash

Imaging Procedures in Soft-Tissue Injuries of the Neck

HYPEREXTENSION INJURIES IN WHIPLASH _ HYPERFLEXION INJURIES

Low Back Pain Following Whiplash

Injury of Degenerated Discs

The Future of the Patient Who Suffers Whiplash Injury

Soft-Tissue Injuries in the Lumbosacral Spine

Backache

Facets

Leg Pain

Additional Diagnostic Procedures

Compensation Neurosis

In Soft-Tissue Neck Injuries

EMOTIONAL SUFFERING CAN ALSO INCREASE PAIN PERCEPTION

In Soft-Tissue Lumbar Spine Injuries

CHAPTER 7 Jelly Doughnuts of the Spine

What Lawyers Should Know about Discs

General Concepts

Commonly Asked Questions

What Is This "Diffuse Bulging"That Radiologists Describe?

What Else Do We Need to Know about Disc Deterioration?

What Happens to Facet Joints in Disc Degeneration?

Is This Back Then Stable?

What Happens to the Disc When It Loses Water?

Do Discs Degenerate to the Same Extent, at the Same Rate?

How Does This Affect Back Movement?

Is Natural Degeneration Painful?

How Many Lawyers Limit Their Clients to Those Who Are Eighteen Years Old with Normal Discs?

If One Herniated Disc Indicates a Bad Trauma, Do Three or Four Discs Favor a Worse One?

So What Does it Matter If a Disc Herniates?

Do the Discs Keep Changing over the Years?

How Does Herniation Affect an Already Degenerated Disc?

Do Discs Degenerate in a Particular Direction? Does Direction Affect Symptoms? What Is Displacement?

How Much Do We Need to Know about Involved Muscles?

What Is the Difference between Displacement and Location?

How Should We Respond If Symptoms Are Not Consistentwith the Radiology Reports?

What Should the Physical Exam Involve? What Should We Look For?

Does Mobility Reflect the Symptoms?

Does the Size of the Spinal Canal Play a Role in Symptom Development?

What Does Soft Disc Herniation Mean?

Degenerated Herniated Cervical Discs

General Concepts

Symptoms Specific to the Level

C2-C3 = C3 NERVE RADICULOPATHY _ C3-C4 = C4 NERVE RADICULOPATHY _ C4-C5 = C5 NERVE RADICULOPATHY _ C5-C6 = C6 NERVE RADICULOPATHY _ C6-C7 = C7 NERVE RADICULOPATHY _ C7-T1 = C8 NERVE RADICULOPATHY

Controversies Concerning Sleep and Cervical Herniations

Diagnosing Degenerated Herniated Cervical Discs

THE PATIENT'S HISTORY _ THE PATIENT'S PHYSICAL EXAMINATION

Recommended Tests and Diagnostic Procedures

ABOUT CT SCAN _ ABOUT DISCOGRAPHY _ ABOUT COMBINED MYELOGRAPHY/CT SCAN _ ABOUT MRI

Treatment of Degenerated Herniated Cervical Discs

MEDICAL TREATMENT _ SURGICAL TREATMENT _ WHEN IS THE POSTERIOR APPROACH USED?

Legal Application

Herniated Thoracic Discs

General Concepts

Diagnosing Herniated Thoracic Discs

THE PATIENT'S HISTORY _ THE PATIENT'S PHYSICAL EXAMINATION _ RECOMMENDED TESTS OR DIAGNOSTIC PROCEDURES

Treatment of Herniated Thoracic Discs

MEDICAL TREATMENT _ SURGICAL TREATMENT

Herniated Lumbar Discs

General Concepts

ANTERIOR HERNIATION OF LUMBAR DISCS _ MIDLINE HERNIATION OF LUMBAR DISCS _ POSTERIOR HERNIATION OF LUMBAR DISCS _ L3-L4 = L4 NERVE RADICULOPATHY _ L4-L5 = L5 NERVE RADICULOPATHY _ L5-S1 = S1 NERVE RADICULOPATHY

Diagnosing Herniated Lumbar Discs

THE PATIENT'S HISTORY _ THE PATIENT'S PHYSICAL EXAMINATION _ SYMPTOMS _ DIAGNOSTIC TESTS AND PROCEDURES

Treatment of Herniated Lumbar Discs

MEDICAL TREATMENT _ SURGICAL TREATMENT

The Operative Report

Deposition-Basic Concepts

Prognosis in Patients with Herniated Discs

CHAPTER 8 Spondylolysis and Spondylolisthesis

An Easy Way to Understand These Conditions

Spondylolysis

Description

Causes

Symptoms

Diagnosis

Treatment

Spondylolisthesis

Description

Causes

ISTHMIC SPONDYLOLISTHESIS _ TRAUMATIC SPONDYLOLISTHESIS _ POSTSURGICAL SPONDYLOLISTHESIS _ CONGENITAL SPONDYLOLISTHESIS _ DEGENERATIVE SPONDYLOLISTHESIS _ PATHOLOGICAL PONDYLOLISTHESIS Symptoms

Diagnosis

Treatment

CHAPTER 9 Understanding Impairment Evaluations

AMA Guides to the Evaluation of Permanent Impairment, 4th Edition Made Easier to Use

Familiarity with the Guides

Overall View of Assessment

Medical Impairment Evaluation

Nature of the Injury

Range of Motion

Range of Motion for the Cervical Spine

Range of Motion for the Thoracic Spine

Range of Motion for the Lumbosacral Spine

Nerve Damage

Nerves of the Upper Extremity

Nerves of the Lower Extremity

Multiple Regions' Injuries of the Spine

Causalgia and Reflex Sympathetic Dystrophy

Injury Evaluation Examples

Evaluation of a Cervical Spine Injury

Evaluation of a Thoracic Spine Injury

Evaluation of a Lumbar Spine Injury

CHAPTER 10 The Frightening Greek and Latin Words of Medicine

Terminology

Definitions as Used in This Book

LIST OF FIGURES

1-1 Anatomical Positions and Terms

1-2 The Vertebral Column

1-3 Padlock Analogy for a Vertebra

1-4 Analogy of a Vertebra to a Man with Clasped Hands

1-5 Pedicle Screw Procedure

1-6 Spinal Nerves in a Vertebra Cross Section

1-7 Nerves

1-8 The Atlas and the Axis

1-9 The Cervical Spine

1-10 Front Views of the Cervical Spine Showing the Unicate Process

1-11 Luschka Joint Comparison

1-12 Lumbar Vertebrae

1-13 MRIs of the Lumbar or Lumbosacral Spine

1-14 The Sacrum and the Coccyx

1-15 Cheeseburger Analogy for the Vertebral Bodies

1-16 Cervical, Thoracic, and Lumbar Ligaments

1-17 Spinal Cord and Nerves

1-18 Spinal Cord Cross Section

1-19 The Lateral Foramina

1-20 Blood Vessels

1-21 Tricycle Analogy of the Three Joint Complex

1-22 The Spine as a Three Column Structure

2-1 Spina Bifida with Myelomeningocele

2-2 Encephalocele

2-3 Hydrocephalus

2-4 Spermatogenesis and Zygote

2-5 Fallopian Tubes, Ovaries, Uterus, and Vagina

2-6 Fertilization

2-7 The Fertilized Ovum

2-8 Syncytiotrophoblast

2-9 Endoderm, Mesoderm, and Ectoderm

2-10 The Placenta

2-11 The Ectoderm Forming the Spinal Cord and the Nerve Sructure

2-12 Ossification Centers

2-13 Three Spinal Curvatures

4-1 AP X-Rays of Vertebrae

4-2 Cervical X-Rays, Lateral, and Oblique Views 1

4-3 Bone Scans

4-4 Myelograms

4-5 Cisterna Magna Puncture

4-6 Injecting Dye for a Discogram

4-7 Axial View of a Lumbar CT Scan after a Discogram

4-8 CT Scans

4-9 Various MRIs of the Cervical Spine

4-10 Various MRIs of the Thoracic Spine

5-1 Jefferson Fracture of the Atlas

5-2 Posterior Arch Fractures of the Atlas

5-3 Fractures of the Anterior and the Posterior Arches of the Atlas

5-4 Fractures of the Odontoid Process of the Axis

5-5 How to Show How the Odontoid Process and the Atlas Relate

5-6 How to Show How the Relationship of the Odontoid Process to the Atlas, the Transverse Ligament, and the Spinal Cord

5-7 How the Distance between the Atlas and the Odontoid Process is Measured

5-8 Hangman's Fracture

5-9 CT Scans

5-10 X-Rays taken after Spinal Instrumentation Surgery

5-11 A Burst Compression Fracture

5-12 Burst Compression Fracture

5-13 The Four Types of Partial, Incomplete Spinal Cord Injuries

6-1 Hemorrhage in Soft Tissue

6-2 Prevertebral Space

6-3 How Angular Displacement of the Cervical Spine Is Measured

7-1 Bulging Discs

7-2 Models of Osteophytes

7-3 Films of Osteophytes

7-4 Cervical Spine Osteophytes

7-5 Disc Hydration

7-6 Discogram of Contained Disc

7-7 Degenerated Disc Disease, Anterior Herniation and Lumbar Spondylosis

7-8 Herniated Discs

7-9 Neurological Examination

7-10 Herniated Lumbar Discs

7-11 Lumbar Spine Examination

7-12 Las?gue's Sign

8-1 Spinal Segments Showing a Spondylolytic Line of Fracture or Dissolution

8-2 Isthmic Spondylolisthesis

8-3 The Four Grades of Displacement in Isthmic Spondylolisthesis

8-4 Degenerative Spondyloisthesis

9-1 Cutaneous Innervation of Upper Extremity and Related Peripheral Nerves and Roots

9-2 Sensory Nerves of the Lower Extremity and Their Roots of Origin

9-3 Motor Innervation of the Lower Extremity

LIST OF TABLES

2-1 Major Structures Derived from Primary Germ Layers

2-2 Development of the Embryo

2-3 Development of the Fetus

2-4 Progression of Growth and Development of the Vertebral Column after Birth

4-1 Echo Times and Repetition in Different Imaging Techniques

6-1 Researchers' Data Concerning Factors Contributing to Recovery from Whiplash Injury

9-1 Station and Gait Impairment Criteria

9-2 Relationship of the Impairment of Upper Extremity to Impairment of the Whole Person

9-3 Knee Impairments

9-4 Impairment Estimates for Amputations

9-5 Impairment Estimates for Certain Lower Extremity Impairments

9-6 Combined Values Chart

9-7 Lower Limb Impairment from Gait Derangement

9-8 Whole-Person Impairment Percents Due to Specific Spine Disorders

9-9 Impairment from Limb Length Discrepancy

9-10 The Pelvis

9-11 Hip Motion Impairments

9-12 Classification for Determining Impairment of the Upper Extremity Due to Loss of Power and Motor Deficits Resulting from Peripheral Nerve Disorders Based on Individual Muscle Rating

9-13 Maximum Upper Extremity Impairment Due to Unilateral Sensory or Motor Deficits of Individual Spinal Nerves or to Combined Deficits

9-14 Maximum Upper Extremity Impairments Due to Unilateral Sensory or Motor Deficits or Combined Deficits of the Major Peripheral Nerves

9-15 Impairments from Nerve Deficits

9-16 Classification for Upper Extremity Impairment Due to Pain or Sensory Deficit

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