While vehicular trauma frequently results in a whiplash associated disorder (WAD), usually involving the neck (cervical region), other associated complaints include headaches and lower back (lumbar region) pain.
Causation
The question that is asked most frequently when seeking my expert opinion is whether or not the findings on x-ray or MRI are the direct result of the motor vehicle accident. When making a determination as to causation of these x-ray or imaging findings I am able to rely on the vast medical literature describing both the natural history of a whiplash associated disorder (WAD) and the normal x-ray and imaging findings in the general population.
Whiplash Associated Disorder
Whiplash associated disorders (WAD’s) have been extensively studied and many reports have been published in the North American, Japanese and especially in the Scandinavian literature about this problem. In a 2015 article published in the American Journal of Neuroradiology Brinjikii, et al published a systematic literature review of imaging features of spinal degeneration in asymptomatic populations. In this review the authors found that the imaging findings of spinal degeneration were present in a high population of asymptomatic individuals. The incidence of these findings on imaging studies (CT or MRI) increased with age. They noted that many of these degenerative features were part of the normal aging process and not associated with pain. As an example, degenerative disc changes were found in 37% of asymptomatic 20-year-olds. In 80-year-old individuals the incidence of degenerative disc change was 96%. Disc protrusions were present in 29% of 20-year-oldindividuals and in 43% of 80-year-old individuals. Annular fissures (small linear tears) were present in 19% of 20-year-old individuals and in 29% of 80-year-old individuals. Matsumoto, et al in an article in the European Spine Journal noted tandem age-related lumbar (lower back) and cervical (neck) disc changes in 78.7% of asymptomatic volunteers with a mean age of 48 years.
Diagnostic Test Results and Motor Vehicle Accidents
Considering the extensive literature documenting age-related changes in the cervical and lumbar intervertebral discs, the difficulty in relating these changes to a recent or remote motor vehicle accident is apparent. Absent any pre-existing x-ray or imaging studies for comparison, the determination is often made by correlating the injured individual’s symptoms and physical findings with the findings on x-ray or imaging studies.
Assessing Causation After One Year
It becomes increasingly difficult in assessing the findings on x-ray or imaging studies longer than one year following the motor vehicle accident. It has been well documented in the literature that whiplash associated disorders (WAD’s) often remain symptomatic for years following the vehicular trauma. Radanov, et al in an article published in 1995 in Medicine (Baltimore) found that 18% of the 117 individuals experiencing a whiplash injury remained symptomatic at 2 years following the motor vehicle accident. Miettenen, et al studied whiplash associated disorders in Finland and published an article in Clin Exp Rheumatol in 2002. At 1 year following the injury 10% of those questioned were still symptomatic and 10% had been out of the workplace for over 1 month. The most common complaints were neck pain, headache or upper extremity symptoms.
Clinical Case Studies
Case Number 1
A.E. is a 43year-old man who was involved in a three vehicle motor vehicle accident on February 7, 2015. He was driving a pickup truck which sustained minor front end damage in the accident. He was seen in the emergency department of a local hospital three days following the accident complaining of lower back pain. X-rays revealed degenerative end plate changes involving L4 and L5. A CT scan was ordered that day and revealed a two millimeter disc bulge at L4/L5 and a broad based disc protrusion at L5/S1. There was no indentation of the thecal sac (the membrane surrounding the spinal cord). He was discharged from the emergency department with prescriptions for an anti-inflammatory medication and a non-narcotic pain medication. He was seen in follow-up by a local chiropractor. He was seen numerous times for chiropractic adjustments and various modalities. He demonstrated virtually no improvement in his complaints of lower back pain. On March 30, 2015 an MRI was performed which revealed the L4/L5 and L5/S1 disc bulges and degenerative facet joint changes.
I first saw A.E. on June 17, 2015 for an independent medical evaluation (IME). He continued to complain of lower back pain. He did not complain of any lower extremity pain, numbness or weakness. On physical examination he exhibited tenderness and muscular tightness in the lower lumbar region (lower back). All physical tests for nerve root compromise (radiculopathy) were negative including straight leg raising, sensation and motor function. I reviewed his X-rays and imaging studies.
I was asked to opine as to the causation of this individual’s remaining lower back pain and the etiology of the changes found on X-Ray, CT scan and MRI. I concluded that A.E. had experienced a whiplash associated disorder (WAD) which caused a myofascial strain injury to the soft tissues in the lower lumbar region. I noted that the remaining pain and tightness in the lower back was not unusual at approximately four months following the vehicular trauma described in the police report. I concluded that the X-rays and imaging studies revealed chronic degenerative changes which were not inconsistent with changes normally seen in a significant percentage of asymptomatic 43year-old individuals. There was no evidence of acute spinal injury on any of the studies. I was asked to evaluate the various medical bills and comment as to the appropriateness of these charges. I found the charges to be excessive to a significant degree.
Case Number 2
J.R.P. is a 73year-old female who was involved in a motor vehicle accident on July 24, 2013. She was the restrained passenger in a car which was struck on the passenger side by another vehicle. She was complaining of back pain. The physical examination was unremarkable. X-Rays revealed degenerative changes at L4/L5. Facet arthrosis (degenerative change) was noted at L5/S1.
She was referred to me from the emergency department. When a medical history was obtained she stated that she had been experiencing lower back pain intermittently for several years. She had undergone a series of epidural steroid injections which had provided relief several years earlier. On physical examination she exhibited lower lumbar tenderness and tightness. The neurological examination was entirely normal. I reviewed the X-rays. I referred J.R.P. for a lumbar spine MRI. This study showed degenerative changes including central canal and foraminal stenosis which was most severe at L4/L5 and L5/S1. No acute disc changes or vertebral compression was found. I prescribed physical therapy and a non-steroidal anti-inflammatory medication (NSAID) along with a lumbar support brace.
J.R.P. engaged a local law firm. She continued to complain of lower back pain. I was deposed as the treating physician in April 2014. I was asked to provide my opinion as to the cause of her continued lower back pain. I stated that she had sustained a whiplash associated disorder (WAD) and that it was not unusual for someone to remain symptomatic nine months following vehicular trauma of the type that she sustained. I was asked to opine as to the etiology of the changes found on the MRI scan. I stated that these changes were degenerative in nature and were consistent with her clinical history of long standing lower back pain. I concluded that there was nothing on the MRI which represented evidence of a more recent spinal injury.
Case Number 3
R.W. Is a 52-year-old mechanic who was self-employed. He stated that he was lifting an engine part when he felt a sharp pain in the lower back in March of 2012. He was seen at a local minor emergency center. X-rays were obtained which showed disc space narrowing at L3/L4, L4/L5 and L5/S1. Anterior osteophytes (bone spurs) were noted. He was referred to a local orthopedic and spine surgery practice. An MRI was ordered. This showed moderate to severe central, lateral recess and foraminal stenosis at the three levels noted. Disc bulges were noted, but there was no effacement or displacement of the thecal sac or lumbar nerve roots. Substantial facet arthrosis was noted. On physical examination he was noted to have tenderness in the lower lumbar region along with “muscle spasms”. He was prescribed a Medrol Dosepak and was referred to physical therapy. After six weeks of physical therapy he was not significantly improved. He underwent a three level lumbar decompression and instrumented 360° fusion from L3 to the sacrum in June of 2012.
R.W. was referred to me for an independent medical evaluation in October of 2012. On physical examination he had well healed surgical scars. He stated that he had not experienced lower extremity pain, numbness or weakness following the occupational injury. He stated that his back pain was continuing to slowly improve. On physical examination he still exhibited tenderness in the lower lumbar region. Neurologically he was intact. Straight leg raising, motor function testing and sensory testing were all intact.
I reviewed his preoperative and postoperative x-rays. The preoperative x-rays showed disc space narrowing at the three levels noted above. Degenerative changes were noted. The MRI findings reflected these degenerative changes causing varying degrees of stenosis. No significant acute changes were noted. On the postoperative x-rays the surgical hardware was intact and the alignment was good. Consolidation of the bone graft material was observed.
I was asked to review the medical bills which he had incurred up to that point. These totaled over $95,000, which consisted mostly of the costs related to the surgical procedure.
I was asked to opine as to the underlying cause of the claimant’s need for a three level 360° lumbar fusion. I stated that the post injury x-rays at the minor emergency center revealed degenerative changes long standing in nature. The MRI showed central, lateral recess and foraminal stenosis which was long-standing. The claimant had not complained of any acute lower extremity symptoms prior to the surgery. I concluded that he had experienced an acute lumbosacral strain of a musculotendinous nature at the time of the initial injury. I further concluded that the lumbar decompression and fusion, if indicated at all, was not required as a result of the injury lifting the engine part.
I was asked about apportionment of the medical charges. I stated that the cost of the emergency center visit, two orthopedic clinic visits, a Medrol Dosepak, x-rays, a lumbar MRI and 18 physical therapy visits would be attributable to the injury. I opined that the remaining medical bills were unrelated to the occupational injury and were incurred as a result of long-standing degenerative changes in the lumbar spine.
Conclusion
Given the extensive literature devoted to this issue, the orthopedic expert should assess every piece of evidence available for a given case in order to arrive at a reasonable determination as to causation of the positive findings on x-ray, CT scan or MRI.
About the Author
Neal Small, M.D. has been in the private practice of orthopedic surgery for over 35 years. Dr. Small has performed over 15,000 orthopedic surgical procedures. Dr. Small’s areas of clinical expertise include issues involving the knee, shoulder and spine. Dr. Small is a past president of the Arthroscopy Association of North America (AANA). Dr. Small has performed hundreds of independent medical examinations (IME’s) and thousands of medical file reviews as an expert. Dr. Small has provided expert testimony in numerous depositions and courtroom appearances. He is frequently asked to opine on causation of orthopedic conditions after motor vehicle accidents.
