7 Diagnostic Imaging Of The Low Back: Limitations And Pitfalls · Diagnostic Imaging Of The Low Back: Limitations And Pitfalls Samuel D. Hodge, Jr., Esquire Jack E. Hubbard, PhD,

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Diagnostic Imaging Of The Low Back: Limitations And Pitfalls

Samuel D. Hodge, Jr., EsquireJack E. Hubbard, PhD, MD

PHYSICIANS POSSESS AN ARRAY of powerful diagnostic tools to assist in the diagnosis of low back pain. From conventional x-rays to the highly sophisti-cated MRI, few back abnormalities escape detection. However, not every herniated disc is clinically signifi-cant and there can be legitimate pain complaints in the absence of an abnormality on the diagnostic im-age. This chapter explores these issues as well as the prevalence of low back pain in the general popula-tion, the anatomic construction of this body section including those changes that occur with the normal aging process, and the various types of imaging mo-dalities used in diagnosing low back problems.1

SCOPE OF LOW BACK PROBLEMS • The inci-dence of low back pain is a major economic problem. The medical literature reveals that at least 75 percent of the population will experience back pain at least once in their lifetime and 25 percent of these in-

dividuals will have recurrent discomfort within one year.2 Simply put, low back pain is the expense hu-man beings incur in going from a four-legged crea-ture to an upright position. And, it is quite expensive. It has recently been estimated that the cost of low back pain is more than $90 billion annually.3 This problem is second only to the common cold as the reason for office visits to doctors. Over the years, sur-gical options have dramatically increased, to relieve low back discomfort.4 Nevertheless, most back pain sufferers do quite well, with 60 percent of those in-dividuals recovering after only six weeks5 and 80 to 90 percent of all low back pain patients becoming asymptomatic by the twelfth week after onset of their symptoms.6 Implicit in these figures is the fact that a minority of people with chronic low back pain7 ac-count for the majority of the costs in treating this disorder.8 As the literature demonstrates, 70 percent

112 | Anatomy For Litigators

of the cost associated with low back pain is generated by only 20 percent of patients.9

Workers greatly influence these statistics.10

Approximately 2 percent of all individuals in the United States receive compensation for back injuries each year,11 and a mere 10 percent of these employees account for 70 to 80 percent of the costs associated with this malady.12 Only 4.5 to 8 percent of disability claims involving low back pain last longer than one year. Those claims that exceed one year account for 64.9 to 84.7 percent of all disability cases.13 In the vast number of instances, an episode of low back pain limits a worker’s regular activity for at least 30 days.14 Less than half of those workers who miss 26 weeks of employment never return to their jobs, and almost none return to work if off more than 104 weeks.15

Demographically, low back pain is the most com-mon reason for disability in those under 45 years of age.16

ANATOMY OF THE LOW BACK • Diagnostic ra-diology is the term used to describe that branch of medicine in which diagnostic tests, such as x-rays, CT-scans, and MRIs, are taken to ascertain if an ana-tomic abnormality in the lower part of the spine is present. In fact, the American Board of Radiology defines this phrase as “that branch of radiology which deals with the utilization of all modalities of radiant energy in medical diagnosis and therapeutic proce-dures utilizing radiologic guidance.”17 On the other hand, a radiologic study18 is a snapshot of the interior structures of the body. As such, it is useful to know the anatomy of the low back in order to better under-stand the utility and pitfalls of low back imaging.19

The regions of the spine are adeptly explained in Kostel v. Schwartz,20 as:

three main groups of vertebrae – the cervical vertebrae atop the spinal column, of which there are seven; the thoracic vertebrae, situated below the cervical vertebrae, of which there are twelve; and the lumbar vertebrae situated below

the ‘L’ are used respectively to designate cervical, tho-racic, and lumbar vertebrae. The sacrum is located at the base of the spinal column, and below it, the coccyx or ‘tailbone.’ The five sacral and four coccy-geal vertebrae are fused together and considered one bone.21

For purposes of this chapter, the low back22 is the termination point of the spine23 with attachment to the pelvis,24 an area known as the lumbosacral re-gion.25 For Example: See Figure 7-1.

Figure 7-1

Its major components are bones, joints, liga-ments, discs, muscles, and nerve roots. Unfortunately, any of these structures can be a pain generator, a fact that contributes to the difficulty in diagnosing the cause of an individual’s low back pain.26

Bones

The bones of the low back consist of five lum-bar vertebrae and a fused bone known as the sacrum. Bones themselves, however, are not pain-sensitive; it is the membrane covering these structures, the richly innervated periosteum,27 that causes discomfort from bone trauma, such as a fracture,28 or a nontraumatic cause, such as cancer.

The five lumbar vertebrae are stacked on top of each other like napkin rings and are labeled L1 to L5 consecutively; the L1 vertebra is located around the level of the navel. For Example: See Figure 7-2.

The Lower Back | 113

Figure 7-2

In addition to their role in supporting the weight of the upper body, they allow the low back to move, provide for muscle attachment to the spine, and protect the nerve roots that extend from the spi-nal cord through openings in the spine down into the legs. Their functions are reflected in the design and shape of these bones. For example, the massive, roughly kidney-shaped body of each vertebra is built to support the trunk as it bears the vertical weight. For Example: See Figure 3. Extending posteriorly from the vertebral body is a delicate arch consisting of an opening, known as the spinal canal or verte-bral foramen,29 which protects the nerve roots as they extend downward from the spinal cord.30 This arch, attached to the vertebral body by paired pedicles, ex-tends outward as the transverse processes,31 serves as the attachment for muscle, and completes the struc-ture as the lamina.32 The term pedicle may sound fa-miliar to many trial lawyers because of the various lawsuits involving pedicle screws. Because this bony part projects rearward, it is accessible to physicians for “pedicle fixation,” the placement of screws pass-ing through the pedicle and into the vertebral body.33

Figure 7-3

The vertebral arch terminates as the spinous process, which are the bony bumps underneath the skin of the back.34 Two sets of vertebral joints, the facets, interconnect each vertebra with the one above and below, allowing individuals to bend forward and back, or side to side. These facet joints are supplied by sensory nerve endings and are a source of pain.35 The other bony structure of the low back, the sacrum, is actually a series of fused vertebrae that ap-pear like an upside-down triangle when viewed from the front.36 In turn, the lumbar vertebrae sit on top of the sacrum. The termination point of the low back is the coccyx, or tailbone. This anatomic part consists of four bones.37 Pain in the coccyx is labeled “coccy-dynia.” The role of the sacrum is to connect the spine to the pelvis via the sacroiliac joint (SI joint), located on each side of the sacrum.38 For Example: See Figure 7-4.

Figure 7-4

Joints Joints allow the body to bend and turn. In the low back, the facets and sacroiliac joints provide that mobility.39 The two paired facet joints (also known as zygapophyseal joints) are the way that each ver-tebra interconnects with the vertebrae above and be-low it, which provide for movement. For Example: See Figure 7-5. These facets are fluid-filled struc-tures known as synovial joints, similar to the knuckle joints of the fingers. As explained in Auguste v. PTM Management Corp.,40 a synovial joint is “a joint in which the opposing body surfaces are covered with


a layer of cartilage within a joint cavity that contains synovial (or lubricating) fluid, lined with synovial membrane and reinforced by a fibrous capsule and ligaments so that some degree of free movement is possible.”41

Figure 7-5

Like the knuckles, the facets are supplied by sensory nerves, making them an important pain gen-erator; they have been identified as the cause of low back pain in 10 to 20 percent of patients.42 This fact has been acknowledged by the court when it said, “The facet joints are pain generators in the low back since they carry nerve endings in themselves.”43 The sacroiliac (SI) joint,44 connecting the sacrum to the pelvis, is not as mobile as the facets, allowing for only small movements. For Example: See Figure 7-4. Like the facets, the SI joint is pain-sensitive and another important pain generator in the low back, account-ing for 13 to 30 percent of pain in this area.45 Radiologists frequently use the term spondyloly-sis when describing an abnormality in the lower por-tion of the spine. As the court noted, spondylolysis is very similar to arthritis even though it is not called arthritis for a variety of reasons. In other words, the idea is the same, i.e., degenerative changes of the spine.46 To be more medically accurate, this word re-fers to a defect in the bony bridging piece between the upper and lower facet joints (pars interarticu-laris) resulting in the vertebra above sliding forward in relation to the vertebra below, a condition termed spondylolisthesis.47 This medical problem can be con-genital or traumatically induced and usually occurs at the L4-L5 levels.48

Ligaments Ligaments connect one bone to another and consist of fibrous bands of tissue.49 In the low back, they keep the vertebrae in place, providing stability to the spine. Like cables, some straplike ligaments extend up and down the length of the spine, called longitudinal ligaments.50 These structures are located in the front and back of the spine and are known as the anterior longitudinal ligament51 and posterior longitudinal ligament,52 respectively. For Example: See Figure 7-6.

Figure 7-6

The spine also has a series of short ligaments, the ligamentum flavum, that connect the laminae of the individual vertebrae together. As explained in Mousseau v. Schwartz, these strong ligaments lie just underneath the facet joints and are also known as the yellow ligaments because the tissue is yellow in color.53 Although ligaments are supplied by sensory nerves, it is unclear as to whether ligaments are a significant pain generator in the low back.54

Discs The intervertebral discs are probably the most misunderstood component of the low back.55 Placed between each vertebra, they serve as cushions for the spine, acting as shock absorbers for the microtraumas of daily life.56 Discs also allow the vertebrae to slide against one another, providing for a small degree of mobility. Like a jelly donut, a disc consists of an in-ner gelatinous core termed the nucleus pulposus and an outer firmer layer termed the annulus fibrosis.57 For Example: See Figure 7-7.


Figure 7-7

The nucleus pulposus has been discussed in a number of court cases because of the role it plays in herniated disc cases. For example, the term is de-scribed in Langford v. Employees Retirement System of Texas58 as “an elastic semi-fluid mass in the center of an intervertebral disc, being the persistent remains of the embryonic notochord. The nucleus pulposus, or portions of it, may rupture or prolapse into the spinal canal (herniation of nucleus pulposus) and this con-dition is a common cause of chronic sciatica.”59

The nucleus pulposus is 90 percent water by vol-ume during a person’s younger years, with elements of connective tissue accounting for the remaining 10 percent. Encasing the nucleus pulposus is the tough outer annulus fibrosis, which consists of criss-cross-ing fibers resembling a steel-belted radial tire.60 Only the outer portion of the annulus is supplied by nerve fibers for pain sensitivity.

Discs are usually designated according to the vertebra above and below them. Thus, the L3-4 disc is located between the third and fourth lumbar ver-tebrae. For Example: See Figure 2. Approximately 70 percent of all chronic low back pain is due to disc, facet, and sacroiliac joint sources.61

In a disc herniation (a.k.a. “slipped disc”), the gelatinous core oozes through a tear or defect in the annulus, just as that which occurs when a grape is squeezed so that the inner pulp extrudes through the skin of the grape.62 For Example: See Figure 7-8.

Figure 7-8

Discs almost always herniate posteriorly in the middle (central or midline disc) or to the left or right sides (lateral disc) and may trap the exiting nerve root. For Example: See Figure 7-9.

Figure 7-9

The plaintiff’s medical expert in Royal Indemnity Co. v. Jones63 discussed this phenomenon when he stated: when you part the membrane that keeps the

disc material between the vertebrae, the materi-al of the disc[] shoots through the break. When an intervertebral disc collapses, it can only col-lapse in one direction, the material has to go somewhere, and it can’t go laterally, because the ligaments on each side are too strong. It doesn’t break forward for the same reason, those liga-ments are intensely tough, and so it can only bulge backwards into the area where the spinal cord goes down. 64


When this type of entrapment happens, a dis-cectomy65 may be needed to remove the extruded nucleus pulposus, thereby decompressing the nerve root. In addition to causing pain by direct compres-sion on the nearby nerve roots, an extruded disc can also cause pain by releasing inflammatory proteins found within the nucleus pulposus that irritate sur-rounding tissues. It is important to note, however, that “the term herniated disc does not imply any knowledge of etiology, relation to symptoms, prog-nosis or need for treatment.”66

The cause of the disc abnormality in the low back is a frequent source of dispute in a compensa-tion setting. As one surgeon noted during the trial in Cleland v. Wilcox: 67

It is extremely difficult to determine all of the factors involved in the production of a protruded in-tervertebral disc. I would say that about 50% of the patients upon whom I have operated for protruding intervertebral disc had no history of a definite injury to the back as a causative agent for the production of the protruded disk.68

Nerve Roots The lower portion of the spinal cord ends around the L1 or L2 vertebral levels and is termed the conus medullaris.69 Extending from the spinal cord are paired sensory and motor nerve roots that hang down individually while continuing their path to the legs, located and protected within the spinal canal of the lumbar vertebrae.70 To some ancient anatomists, this bundle of nerve roots in the low back resembled a horse’s tail,71 so it became known as the cauda equi-na.72 Sensory nerves relay information such as pain, temperature, and touch from the legs upward toward the spinal cord on their way to the brain. A detailed discussion of the function of sensory nerves is con-tained in Thermographic Diagnostics, Inc., v. Allstate Ins. Co., where the court noted that sensory nerves emerge from the spine and travel to skin areas. For instance, the nerve that exits at L4 comes down the buttock, over the front of the thigh, and down into the big toe; from L5, the sensory nerve proceeds down the side of the buttock, and to the middle toes; and the S1 nerves come down the back of the thigh

into the little toe. These nerves, which allow one to feel sensations, are closely associated with the sympa-thetic nervous system over which one has no control, and as much as one third of every sensory nerve con-tains sympathetic nerve fibers. When this becomes irritated through trauma or otherwise, the sympa-thetic nerve fiber associated with that nerve causes vasoconstriction of the arterioles under the skin,73 resulting in a decrease in skin temperature. On the other hand, motor nerves carry signals from the spinal cord to the muscles of the legs, caus-ing the muscles to contract and the legs to move. Spinal stenosis is another term frequently used by radiologists when looking at films of the low back.74 Stenosis means narrowing, so this term refers to a disc protrusion or bony overgrowth that may reduce the diameter of the spinal canal75 so much that this im-portant opening in the vertebrae must be surgically enlarged to reduce pressure on the cauda equina.76 Foramen refers to a natural opening in bone. In the low back, the nerve roots exit from the spine through these openings, the intervertebral foramina, formed by the stacked vertebrae above and below the disc.77 When this opening becomes too narrow as a result of bony overgrowth, the exiting nerve roots may become compressed, requiring surgery to relieve the pressure on the nerve roots. This procedure is known as a foraminotomy. After exiting the spine in the low back, the nerve roots extend down the leg in a specific pattern, pro-viding sensory and motor function to that portion of the lower limb. By knowing this pattern, physicians often can diagnose which nerve roots are affected. For example, a herniated L5-S1 disc that is pressing on the S1 nerve root often causes shooting pain from the back, down the back of the thigh, calf, and into the outside of the foot. This pattern of pain is called sciatica78 and is often accompanied by numbness and tingling in the lower extremity. These sensory chang-es follow a dermatomal pattern; that is, each sensory nerve root follows a specific distribution into the extremity. By knowing the sensory pattern that the nerve root follows, a dermatome, the physician can determine which nerve root is affected, thereby iden-tifying which level of the lumbar spine is involved.79 A chart displaying the dermatomes of the body is a


useful defense tool in checking the claimant’s subjec-tive complaints because the distribution of pain for a specific disc abnormality should follow the known dermatomal pattern. Dermatomal charts may vary, however, depending on the source. Conversely, a plaintiff’s case is bolstered when the distribution of pain fits the dermatomal pattern and abnormality demonstrated on imaging of the low back. If the motor nerve roots are also affected, the in-dividual will experience weakness in specific muscle groups supplied by that nerve root. A myotome refers to a group of muscles supplied by a single nerve root. In an S1 compression, for example, the calf muscles may be weakened, causing difficulty when pushing down with the foot such as in attempting to stand on the toes. Reflex testing may also reveal an abnor-mality, such as a diminished ankle reflex, which is reflective of an S1 nerve root compression. Likewise, a diminished patella tendon reflex is indicative of a problem with the L4 nerve root.

Muscle

Muscle makes up about 40 percent of a per-son’s body weight and provides for movement. These structures can be a source of pain, as anyone knows who has experienced a “Charley horse.” Surprisingly, the muscles of the back are often overlooked sources of low back pain but are important pain generators.80 Back muscles vary in length and size and are found in multiple layers. In addition, muscles in the buttock can cause back pain and sometimes mimic a nerve root compression problem. This is illustrated by a muscle deep in the buttock, the piriformis muscle, which can go into such intense spasm that it irritates the underlying sciatic nerve,81 causing shooting pain down the leg in a pattern similar to an S1 nerve root compression.82 Muscle pain can be acute, such as a spasm from a back sprain, or chronic, resulting from myofascial trigger points.83 The latter are localized or focal re-gions of muscle that remain tight and knotted from an acute or repetitive injury causing persistent local-ized pain as well as radiating symptoms down the leg, mimicking a nerve root problem.84

THE AGING SPINE • As people age, certain predictable changes occur in the spine’s anatomic structures and relationships. Most of the time these changes are asymptomatic, that is, they do not cause low back pain. When a radiologist sees these changes on diagnostic imaging, the word “degenerative” is utilized. Unfortunately, this term may give the wrong impression to a patient, creating a mental image that the person’s back is falling apart or disintegrating. An interesting study highlights this point by examining word usage by radiologists in a number of consecu-tive lumbar x-ray reports.85 Of those reports, 74 per-cent included the presence of “degenerative changes” but only a fraction of them used the phrase “normal for age.” The authors concluded that identifying such changes as “degenerative” may lead patients to cata-strophizing about their health, but substitution of the term “normal aging” makes the result more palat-able.86 Bone loss is a complication of the aging process leading to osteoporosis. Although this condition oc-curs primarily in women, it can also develop in men. Bone loss can start around age 35 with a continuous decrease of 1 percent a year.87 In turn, bone loss can lead to a collapse of the vertebrae and cause a loss of height as people age.88 Individuals think of bone as solid, static structures, but bones do change as they adjust to the downward forces on the vertebral bodies as well as in the movements of the facet joints. Such repetitive movement over time results in the forma-tion of osteophytes or “bone spurs” at the top and bottom of a vertebral body. Bony buildup can also occur at the facet joints, leading to narrowing (steno-sis) of the intervertebral foramen, the place where the nerves exit the spine, or stenosis can occur within the spinal canal itself from bone deposits. Another result of aging is the degree of the disc’s composition. This change is caused because of a loss of water content and an increase in collagen. This normal aging process transforms the consistency of the disc’s center from a gelatinous material to a tougher crabmeat texture.89 The loss of a hydrostatic cushion results in decreased mobility and flexibil-ity of the spine. Fissures or tears may even develop over time in the outer portion of the disc, making it more likely that the liquid center will extrude out-ward leading to a spontaneous disc herniation. From


a litigation point of view, it is important to remember that the radiologic term “tear” is descriptive only and not meant to imply a traumatic cause.90 Research has shown that these types of changes can occur as early as the third decade of life.91 The rate that these disc changes happen depends on age, genetic factors,92 nutrition,93 amount of vertical loading on the ver-tebrae, and smoking.94 By the eighth decade of life, however, the nucleus has such a high fibrous content that it is difficult to differentiate it from the fibrous annulus.95 Repetitive stress on the disc can cause it to bulge and even force the liquid center to extrude and cause a disc herniation.96 Disc material can also herniate into the vertebral body above or below the disc, with reactive bone formation around the displaced disc. Radiologists call the resulting structures Schmorl’s node seen on imaging studies.97 These abnormalities are common findings, often reported by the radiolo-gist as incidental and without clinical significance.98 Degenerative changes in the disc are not painful in and of themselves, and a very high prevalence is seen in the asymptomatic population.99 The significance of this phenomenon was dis-cussed in Kennedy v. Allstate Insurance Company where the court commented that it is possible for a person with a herniated disc, degenerative disc dis-ease, or osteophyte formations to be asymptomatic before an accident and to have that trauma aggra-vate the pre-existing conditions, making the claimant symptomatic.100 That is why it is important for coun-sel to secure the claimant’s preaccident health records to see if they contain any reference to low back pain. If the answer is yes, a factual question arises as to whether the abnormity was truly asymptomatic. In this regard, the records of the family doctor are the best to secure because that is where people with low back pain usually seek help. The aging process also affects the ligaments of the spine, causing them to become lax as they lose their elastic components. As they continue to age, ligaments calcify and take on a bony appearance, con-tributing to decreased spinal mobility.101 Likewise, muscle mass decreases with age, contributing to a loss in mobility and endurance.102

IMAGING PROCEDURES • It is necessary to discuss the interpretation of diagnostic modalities of the low back before considering the advantages and limitations of the different imaging modalities. Most people perceive radiology reports as objective evidence of an abnormality, and this may be an in-correct assumption. This mistake is compounded because the courts frequently rely on them to deter-mine the validity of a compensation claim and most physicians rely on radiologic reports to make a diag-nosis and to develop a treatment plan. It is important to remember, however, that although the image may be objective, the report, or the interpretation of that study, is subjective. Most reports are generated by a radiologist, who analyzes the films and decides on what the studies show: are they normal or abnormal and why. By way of background, radiologists are physicians who spe-cialize in diagnosing and treating medical problems using medical imaging techniques, such as x-rays, computed tomography (CT) scans, and magnetic resonance imaging (MRI).103 Following graduation from medical school, this medical specialist must complete a residency of at least 4 years of postgraduate work in such subjects as radiation safety and protection, radiation effects on the human body, and appropriate performance and interpretation of quality radiologic and medical im-aging examinations. These physicians often complete a fellowship of 1 or 2 additional years of specialized training in a particular radiologic subspecialty, such as nuclear medicine, breast imaging, or cardiovascu-lar radiology.104

In writing their reports, radiologists’ conclu-sions are set forth in the impressions section of the report. What is not so well known is that imaging interpretation can vary between radiologists (in-terobserver variability) as well as by the same radi-ologist on different days (intraobserver variability). Surprisingly, some studies demonstrate that in 20 to 30percent of the cases, radiologists not only dis-agree among themselves about what is seen, but also change their opinion in reading the same films at dif-ferent times.105 Although image quality has dramatically im-proved over the years, interobserver variability per-


sists and is due to differences in visual observation, perception of any abnormality, and threshold of concern about perceived abnormalities.106 Four rea-sons have been advanced for this phenomenon: dif-ferences in the criteria used for determining abnor-malities, ambiguous or unclear images, differences in interpreter and reporting style, and overlooking an abnormality.107 In a compensation context, defense counsel should consider having the films reviewed by a radiologist to see if the original diagnosis remains consistent when reviewed by another expert. For example, in a blinded study of lumbar CT scans, neuroradiologists were in agreement only 11.5 percent of the time when reviewing the same sets of images from asymptomatic patients.108 Agreement, however, was achieved 60 percent of the time among neuroradioloigsts in a blinded study of MRI scans from asymptomatic patients.109 In examining “vari-ability” in the reading of lumbar x-rays, another study found significant interpretation differences by physicians within the same specialty.110 When the same scans were reviewed by different specialists (i.e., by a general orthopedic surgeon, spine surgeon, or radiologist), the interobserver variability was much higher.111 Part of the problem relates to the differenc-es in terminology used by radiologists. One author who analyzed the problem of variability in describ-ing abnormalities of the lumbar disc – bulging, her-niation, ruptured, protrusion, or extrusion – suggests that “for the purpose of compensation, a nomencla-ture based on clinical rather than imaging findings would probably be the best solution.”112

The following is an overview of the more com-mon imaging procedures available to physicians in diagnosing the cause of low back pain.

Lumbar X-Ray X-rays have been a time-honored method of looking into the body since their discovery by Wilhelm Roentgen in 1895. This method is based upon the fact that x-rays, a form of electromagnetic radiation, penetrate an object based on the density of that object. An x-ray image is made when the person is placed between the x-ray tube and photographic plate or, more recently, a digital intensifying screen as the image receptor. The denser body parts cast an im-

age resembling a shadow by blocking the x-ray beam; x-rays go through less dense tissues and are not seen on the screen.113 Thus, bone and calcium deposits are evident on lumbar x-rays, but less dense structures, such as nerves, discs, and muscle, are not imaged. Consequently, bone pathology, including a fracture or subluxation, can be diagnosed with x-ray, but the test cannot visualize a herniated disc. It is common for physicians to order x-rays at the time of the initial evaluation of the patient with low back pain. However, routine x-rays of the low back in people with acute lumbar pain may be of limited clinical utility114 because 75 percent of such studies provide no useful information.115 In fact, lum-bar x-rays may not be necessary for the first episode of low back pain that has been present for less than 7 weeks, except in the face of certain medical/physical findings.116 On the other hand, plain radiographs are important in the evaluation of failed back syndrome, i.e,. persistent back pain despite surgery.117

Myelogram A myelogram is a type of x-ray in which radio-contrast dye is injected into the fluid space around the cauda equina and spinal cord and x-rays are taken of that segment of the spine.118 This technique allows for the visualization of the nerves to the lower back and spinal cord by outlining them with dye. In turn, a herniated disc or spinal cord pathology can be in-ferred if there is a distortion of the dye, but the discs and nerves are not directly viewed. Before the advent of CT and MRI scans, the myelogram was the only way to image the interior of the spinal canal. However, a myelogram has the disadvantage of being unable to provide a cross-sec-tion image of the spine, and the test can be painful as well as lead to complications because it is an invasive procedure.119 Currently, myelograms are performed infrequently and are limited to those situations in which the test is combined with a CT scan when other imaging techniques are inconclusive.120

Discogram Discography, developed about 60 years ago, is a controversial procedure designed to identify pain arising from a specific intervertebral disc.121 In this


two-part test, a contrast agent is introduced into the nucleus pulposus, the gelatinous interior of the disc. An x-ray or CT scan is then performed to determine if an abnormality exists such as a rip in the outer edge of the disc. The controversy stems from the second part of the procedure, in which the patient is asked if the injection reproduces that person’s back pain. If the answer is yes, the patient is described as hav-ing concordant pain and the offending disc is thereby identified. As the court noted in Dupree v. Insurance Company of North America,122 “a discogram is a con-troversial and questionable procedure because it relies upon the subjective reaction of a patient to pressure applied to the spine in order to determine whether pain is produced.” The procedure is unique in that it is the only method of identifying pain originating from a spe-cific intervertebral disc.123 Discography, however, is an invasive procedure whose complications include disc infection, abscess formation, acute disc hernia-tion, and blood vessel injection.124 The clinical utility of discography has been questioned in medical and legal circles.125 For in-stance, one court noted that the discogram is “some-what controversial among orthopedic surgeons” and some physicians who perform the procedure find it lacking in reliability. The decision also found that there is disagreement about what constitutes a posi-tive test result. In the matter of Falcon Inland, Inc.126 The medical literature reveals a wide variation in the sensitivity, specificity, and positive predictive value of the procedure.127 This variability is due to several factors, including proper execution of the technique itself, the nature of the discs, and symptom inter-pretation.128 Critics also point to the incidence of false-positive results, particularly in those patients with psychological or secondary gain issues. For ex-ample, lumbar discograms were performed on pa-tients but without a history of low back discomfort. Nevertheless, the authors reported that 70 percent of the asymptomatic patients tested had a significant pain response from the injection.129 Further, they found a strong correlation between positive findings on psychological testing and a false-positive disco-gram; 80 percent of patients with pending legal cases and/or who were receiving disability payments had positive pain responses with discography. Proponents

of discography advocate the use of the procedure in preparation for surgery, pointing out that it is helpful to identify which disc requires surgery.130 This controversy has lead one investigator to conclude that discography should be performed with high selectivity and be limited to those patients where “the degree of symptoms dictate surgical consider-ation, when there is a high index of suspicion for disc origin of pain, and when other imaging procedures have been equivocal or negative.”131 Others, however, found “no practical purpose in discography using an evidenced-based approach regarding the diagnosis and proper treatment” of low back pain132 and that the “therapeutic utility (of discography) has not been established.”133 One report134 even concludes that al-though discography combined with CT scanning is accurate in detecting degenerative disc disease, “its ability to improve surgical outcomes has yet to be proven.” Counsel need to be mindful of these issues when handling a case involving this diagnostic proce-dure.

CT Scan Computed tomography (CT) scanning is a quantum advance in the application of x-ray technol-ogy to the evaluation of the anatomy of the body.135

Invented by Sir Godfrey Hounsfield in 1972, CT scanning involves multiple x-ray “slices” through the body (tomography) that are then fed into a comput-er for analysis.136 These slices are made in the axial plane, i.e., horizontal cuts from head to toe. This procedure is conducted while the individ-ual lies on a movable table within a large opening in the scanner much like a donut with a hole in the center. An x-ray tube then circles around the body at a 360-degree angle, taking hundreds of images through the same plane. These images are fed into a computer that reconstructs this information as a slice through the interior of the body. The patient table is then advanced a short distance and another “slice” is taken, and so on. Because minute differences in density are de-tected by this method, CT scanning can image high-ly dense structures such as bone as well as low-density tissues such as discs and nerves. By taking multiple “cuts,” CT scans effectively slice through the body at


different levels. To use a loaf of bread as an example, an x-ray is only able to image through one plane such as the top, bottom, or side of the loaf. The CT scan, however, can cut the bread into slices and allow the viewer to see from the crust into the interior of the loaf. Further, advances in computer software allow physicians to construct a three-dimensional image of the body region. CT scanning can also be combined with a myelogram or discogram to enhance imaging of the spine.137

MRI Scan Magnetic resonance imaging (MRI) is an ex-traordinary imaging advancement that goes beyond CT scanning. First used for medical imaging in 1977 and approved by the FDA in 1986, the physics of the MRI does not use x-rays but rather an interaction of a powerful magnetic field and radio waves.138 The protons in the nuclei of the hydrogen atoms of the body act as tiny magnets. When stimulated by a powerful magnetic field generated by the MRI scanner, about one half of the protons line up in the direction of the magnetic field and the balance do so in the opposite direction. When these excited nuclei are exposed to radio waves, they change direction, re-sulting in the emission of signals that are detected, analyzed, and displayed as an image of the body. Like CT scanning, two- and three-dimensional slices of the body provide exquisite views of the body’s inte-rior. Unlike CT scanning, MRI images can be made through any plane of the body and reveal more detail for soft tissues. The CT scan, however, remains best suited for visualizing bony structures and detecting the presence of fresh blood owing to the iron in he-moglobin. This is why the CT scan remains the test of choice in detecting brain trauma and other causes of bleeding, whereas MRI is best suited for revealing soft tissue damage such as a herniated disc or torn ligament. A major limitation in the use of MRI is the in-ability to scan patients with electronic devices such as a pacemaker or spinal cord stimulator as well as the presence of ferrous metallic fragments such as a bul-let, shrapnel, or metallic particles in the eye prevalent in those who work or are exposed to metal.

IMAGING – PAIN DISCONNECT • Medical im-aging of the low back becomes problematic when the radiologic pictures do not fit the clinical picture. This imaging-pain disconnect occurs through a wide spec-trum, including those situations of abnormal imag-ing with no pain to normal images with low back pain. Counsel must be aware of these disconnects be-cause an abnormality, such as a herniated disc on an MRI, may not be clinically significant.

Abnormal Images and No Back Pain The job of doctors and lawyers would be rather easy if one could point to an abnormality on an x-ray or scan and unequivocally state that the pathology is the cause of the pain. The problem is that frequently radiographic abnormalities occur in the spine with-out concomitant back pain. No imaging procedure is immune to this conundrum. Simply put, many im-aging abnormalities are the result of the asymptom-atic aging process discussed previously. For example, a study involving x-rays of the low back of 1172 healthy young adults without low back pain discovered significant abnormalities in 58 per-cent of those imaged.139 Similarly, a study of military parachute instructors who experienced tremendous vertical forces on their spine revealed no correlation between the severity of radiographic changes and ei-ther the prevalence or severity of low back pain.140 As for myelograms, 24 percent of lumbar my-elograms from individuals with no back pain had sig-nificant abnormalities.141 Even CT scans are not im-mune from these statistics. For instance, 24 percent of a study population who had no low back pain was found to have significant abnormalities of the lumbar spine.142 MRI scans provide exquisite detail of the in-side of the body, and a number of studies involving lumbar MRI scans of subjects without low back pain are reported in the medical literature. For example, a study of asymptomatic subjects published in the New England Journal of Medicine revealed that 52 percent of the subjects had a lumbar disc bulge of at least one level, 27 percent had a disc protrusion, and one per-cent had a disc extrusion.143 Another study of asymp-tomatic subjects revealed an astounding 76 percent incidence of disc herniations,144 whereas a different


study of subjects without a history of back or leg pain revealed that a third of the subjects had substantial abnormalities.145 In the same study of those less than 60 years old, 20 percent had a herniated lumbar disc; and in the group older than 60, 36 percent had a herniated disc and 21 percent had spinal stenosis. A study of women between 16 and 80 years of age without low back pain demonstrated degenerative disc disease in over a third of those between 21 and 40 years of age.146 By age 70, however, 80 percent of the subjects were found to have significant disc ab-normalities. In another age-related study of asymp-tomatic patients, 31 percent of the subjects scanned were found to have a disc or spinal canal abnormal-ity.147 With follow-up scans taken seven years later, there was no correlation between the duration/sever-ity of developed low back pain and the degree of pa-thology seen on the original scans. Another study of asymptomatic adolescent tennis players demonstrat-ed that only 15 percent of these athletes had normal lumbar MRI scans.148 As for discograms, researchers examined the lumbar spine of healthy, asymptomatic people and found that the test was abnormal 17 per-cent of the time in this population.149 Thus, the medical literature demonstrates that no matter which imaging technique is utilized, sig-nificant pathology occurs in the low back region of individuals without a current or past history of low back pain. Therefore, the question is, “What sepa-rates individuals with dramatic morphologic findings who have no symptoms from individuals with identi-cal alterations who do?”150 An abnormality found on an imaging study should not be considered diagnos-tic “unless it conforms to the clinical syndrome.”151 That is, an abnormality found on imaging must cor-respond to the clinical presentation and findings to be medically relevant.

Normal Images and Low Back Pain The converse of this structure-symptom conun-drum is also true. Although modern medical imag-ing provides detailed anatomic views of the low back, some back pain generators cannot be seen on diag-nostic imaging. Muscular pain, for example, is not detected with any imaging finding. If a severe muscle spasm is present, that may be inferred by changes in the normal curvature of the lumbar spine on a

plain x-ray.152 However, the far majority of muscular causes, such as myofascial trigger points, are without radiologic findings.153 Even the cause of pain arising from the facet joints connecting the vertebrae is not seen with normal imaging of the low back.154 The di-agnosis of facet joint pain is made on clinical grounds and confirmed by medial branch blocks whereby the nerves to the suspected facets are anesthetized.155 A positive response occurs if the procedure significantly reduces the low back pain, even if the relief is only temporary. Similarly, sacroiliac (SI) joint pain can be present despite normal imaging and can be con-firmed with a block of the nerves to the joint.156

Psychosocial Factors Unfortunately, significant complaints of pain with disability and without a clear identifiable cause occur as a result of a preponderance of psychosocial issues. Any discussion of low back pain must, there-fore, include a consideration of psychological and so-cial issues surrounding this problem.157 These factors are yet another reason why it can be difficult to make a direct connection between an imaging abnormality and a patient’s complaints of pain and why “a purely anatomic pathologic approach to diagnosis is not ad-equate to characterize the patient who has low back pain.”158 Depression has long been associated with chronic pain and resultant disability, although the debate is often over which is the cause and which is the effect. This relationship was addressed in one research study that concluded both statements are true, thereby suggesting a depression-pain syndrome in which these two phenomena are biologically linked.159 Disability from back pain is also linked to many different factors, including job dissatisfaction; labor-management stresses; family and work dynam-ics; alcoholism; as well as relationships with family, friends, and colleagues.160 Disability from chronic low back pain has been advanced as a complex psycho-socioeconomic phenomenon.161 Therefore, psychosocial issues sur-rounding back pain have been afforded a greater weight than radiologic findings. For instance, a study found that predictors of low back pain disability, job dissatisfaction, and psychological aspects of work


were more powerful predictors of disability than the MRI scan results.162 Litigation and compensation issues are yet ad-ditional factors that contribute to low back pain and disability. For example, in a surgical outcome study of patients with low back pain, it was shown that work-ers’ compensation and litigation issues are strongly associated with poor surgical outcomes.163 In fact, the majority of patients with failed back syndrome – poor clinical outcomes following low back surgery – are involved with lawsuits, claiming total disability from any form of work.164 Needless to say, compen-sation may act as a “powerful disincentive and bar-rier to recovery because of factors such as secondary gain.”165

USING IMAGING IN LOW BACK PAIN LITIGATION • Despite these stumbling blocks, medical imaging does have a role in a claims setting when appropriately utilized. In fact, the number of cases in which diagnostic imaging of the low back has been utilized is too numerous to count, and such imaging arises in every conceivable context. The key, however, to the successful utilization of these tests in court is the clinical correlation with the patient’s history and medical records.

Clinical Correlation Not even the highly sophisticated MRI can determine what caused a herniated lumbar disc that is so graphically revealed by the imaging study. However, when that MRI scan matches the clinical setting, it provides powerful support for a case. The following is an example. A worker without a history of back problems lifts a heavy package and develops immediate and severe low back pain shooting down the back of his right leg. On examination, his physi-cian finds an S1 sensory nerve distribution, dimin-ished reflex, and muscle weakness. An MRI reveals a herniated disc at the L5-S1 level lateral to the right, thereby compressing the S1 nerve root on that side. In this situation, there is a very high probability that the herniated disc resulted from the work-related in-cident and the symptoms and findings are caused by the herniated disc. However, in a different scenario, a coemployee at the same plant with a history of inter-

mittent back problems lifts a heavy tool causing in-tense, diffuse low back pain with spotty tingling into the left leg that does not follow a clear dermatomal pattern. His MRI reveals bulging discs at L2-3 and L3-4 and a herniated disc lateral to the right at L4-5. What can be said about these abnormal MRI find-ings with respect to confirming the employee’s symp-toms and whether the abnormalities are related to the work injury? Not much. It is impossible to state with a reasonable degree of medical certainty that any of the disc bulges are causing the employee’s pain or were even caused by the lifting injury, and certainly the herniated disc on the right is not causing the tin-gling in the worker’s left leg. Likewise, findings on x-rays performed of the low back of an injured worker within a few days of injury that show bone spurs and other chronic abnormalities are meaningless because these changes take months or years to develop.

Medical Records Reviewing a claimant’s medical records and im-aging studies can be a treasure trove for either defense or plaintiff counsel.166 If a preaccident imaging study shows pathologic changes, counsel for the claimant should readily concede this finding but argue that the abnormality was quiescent until the injury. To determine the accuracy of this argument, however, the medical records may be reviewed for evidence of prior back problems and symptoms. The family doc-tor – or primary care physician – is usually the first person a patient visits for a medical problem and pos-sesses some of the best records to obtain. Prior com-plaints of back pain may appear in these records, and the file should also contain reports from orthopedic surgeons, neurologists, chiropractors, physical thera-pists, and imaging studies. Blood tests should not be overlooked because they may demonstrate pre-exist-ing rheumatoid problems, diabetes, or Lyme disease as well. These conditions can mimic or be similar to the symptoms of low back pain and radiculopathy. Other important documents to secure include health insurance and pharmacy records. Health insurance documents, such as Blue Cross records, should be examined because they provide a list of diagnostic codes and names of treating physicians. Pharmacy re-cords set forth medications prescribed and the name of the physician who ordered the drug. By reviewing


this information, the defense may quickly ascertain if a pre-existing back problem existed that the claimant has failed to disclose. It should also be standard practice for lawyers involved in low back litigation to ascertain if there was any imaging of the back prior to the injury. If yes, the pre- and postincident images should be compared side-by-side by a radiologist looking for changes. Obviously, the lack of an appreciable dif-ference between these two studies renders any abnor-mality meaningless as it pertains to the claim. Still, any changes in the pre- and postaccident studies may have no trauma-related significance but may merely reflect progressive, expected age-related changes such as spur formation or desiccation (diminished water content) of the discs. If the postaccident scan, how-ever, shows significant changes in pathology, such as nerve compression that fits the clinical picture and was not on the preaccident study, the scan supports the case.

CONCLUSIONS • Despite the amazing advances in diagnostic imaging, this branch of medicine is still not an exact science. Many considerations account for the limitations and pitfalls of diagnostic imaging of the low back. These include the subjective inter-pretations of the findings by the radiologist, the in-herent shortfalls of the different imaging modalities, the normal degenerative changes that occur in the low back with aging, the causes of low back pain in the absence of a radiologic correlate, and the psycho-socioeconomic influences in a claims setting.

Counsel for clients with low back pain should never blindly rely on the results of a diagnostic image to prove a low back injury or disability and must be aware of the shortcomings and pitfalls of the test re-sults. It is also useful to have a medical expert explain the science behind the test in order to demystify the procedure. On the other hand, defense counsel should not be intimidated by a positive test result on a radiologic study. The radiologist’s opinion is merely one piece of the puzzle that must be correlated with the patient’s clinical history. Because of the large number of asymptomatic people with abnormal ra-diologic findings, an abnormal MRI or x-ray does not always provide objective proof of a claim. This is am-ply demonstrated by the medical articles referenced in this chapter. In fact, because of the overwhelm-ing number of people who experience low back pain, the odds favor the defense in finding a pre-existing problem that may not have been disclosed, thereby making the case turn on the credibility of the claim-ant and not on the results of a diagnostic test. On the other hand, positive imaging studies that correlate with the patient’s clinical picture may supply power-ful evidence in support of the claim. Nevertheless, one must remain cognizant of the fact that it is the function of the physician to identify the cause of a patient’s back pain in the context of the clinical his-tory, physical findings, and imaging studies. And, in the courtroom, it is the task of the fact-finder to ac-cept or reject that doctor’s conclusions.


PRACTICE CHECKLIST FOR

Diagnostic Imaging Of The Low Back: Limitations And Pitfalls

• The incidence of low back pain is a major economic problem, not only for the affected individuals, but also for the United States as a whole.• A radiologic study is a snapshot of the interior structures of the body.• The low back is the termination point of the spine with attachment to the pelvis, an area known as the lum-bosacral region. Its major components are bones, joints, ligaments, discs, muscles, and nerve roots. • The bones of the low back consist of five lumbar vertebrae and a fused bone known as the sacrum. Bones, however, are not pain-sensitive; it is the membrane covering these structures, the richly innervated periosteum, that causes discomfort.• The bones in the low back are the lumbar vertebrae, which are stacked on top of each other like napkin rings. In addition to their role in supporting the weight of the upper body, they allow the low back to move, provide for muscle attachment to the spine, and protect the nerve roots, which extend from the spinal cord through openings in the spine on their journey down into the legs.• Joints allow the body to bend and turn. In the low back, the facets and sacroiliac joints provide that mobility. The two paired facet joints are the way that each vertebra interconnects with the vertebrae above and below it, thereby providing for movement. • Ligaments connect one bone to another and consist of fibrous bands of tissue. In the low back, they keep the vertebrae in place, providing stability to the spine. • Like cables, some strap-like ligaments extend up and down the length of the spine and are called the longitu-dinal ligaments. These structures are located in the front and back of the spine and are known as the anterior longitudinal ligament and posterior longitudinal ligament, respectively.• The spine also has a series of short ligaments, the ligamentum flavum, that connect the laminae of the indi-vidual vertebrae together.

RESEARCH TOOLS

West Key NumbersDeficit in Medical Knowledge not Sufficient to Prove Medical Malpractice Key Cite: 198H Health 198Hk820.Factors for a Jury to Consider in Spinal Surgery Medical Malpractice Key Cite: 198H Health 198Hk820.Failure to Detect a Disease is not Necessarily Malpractice Key Cite: 198H Health 198Hk637.Proving Causation in Medical Malpractice Cases Key Cite: 198H Health 198Hk822(3).

American JurisprudenceKenneth W. Biedzynski, et al. Expert and Opinion Evidence, 31A Am. Jur. 2d Expert and Opinion Evidence § 9, May 2009, Thompson Reuters/West.


Katherine Delsack, et al, Use of Cat Scans in Litigation, 8 Am. Jur. Proof of Facts 3d 145, August 2009, Thompson Reuters/West.Laura Hunter Dietz, et al., Sufficiency and Weight of Evidence, 2 Am. Jur. 2d Administrative Law § 358, May 2009, Thompson Reuters/West.Robert E. Hair, et al., Lumbar Spine Injuries, 38 Am. Jur. Proof of Facts 2d 285, July 2009, Thompson Reuters/West.Mary Leary, Obtaining Workers’ Compensation for Back Injuries, 79 Am. Jur. Trials 231, August 2009.Daniel Penofsky, Diagnostic Radiology Malpractice Litigation, 75 Am. Jur. Trials 55, August 2009, Thompson Reuters/West.

Causes of ActionJosh Friedman, Cause of Action to Recover Damages Under Americans With Disabilities Act (42 U.S.C.A. §§12101 Et Seq.) for Employment Discrimination for Having a Record of a Disability or Being Regarded as Disabled, 16 Causes of Action 2d 153 (2008).James Lockhart, Cause of Action for Medical Malpractice Based on Loss of Chance of Cure, 4 Causes of Action 2d 1 (2008).Jonathan Purver, Cause of Action against Motor Vehicle Operator for Negligence in Backing Vehicle, 7 Causes of Action 2d 917 (2008).Stephanie Schaeffer, Cause of Action Under the Family and Medical Leave Act ( 29 U.S.C.A. §§ 2601 to 2654) for Unlawful Termination, 14 Causes of Action 2d 85 (2008).Jay Zitter, Cause of Action Against Retail Store for Injury Caused by Hazardous Display or Shelving of Merchandise, 38 Causes of Action 2d 641 (2008).

Law Reviews and Other PeriodicalsDiagnostic Imaging and Back Pain, 18 NO. 5 Workers’ Compensation Monthly 21, May 1998.Gawienowski and McGhee, Oh My Aching Back: Establishing Presumptively Disabling Low Back Impairments in Social Security Disability Determinations, 59 J. Mo. B. 133 (May-June, 2003).Ginsberg, Beyond the View Box: The Radiologist’s Duty to Communicate Findings, 35 J. Marshall L. Rev. 359 (Spring 2002).Jay Himmelstein & Gunnar Anderson, Low Back Pain: Risk Evaluation and Preplacement Screening, 3 Occupational Med.: St. Art Reviews 255 (1988).Samuel Hodge, Jr., A Litigation Primer on Diagnostic Imaging, 16 No. 5 Prac. Litigator 7, September 2005, American Law Institute. Lee Russ, et al., Diagnostic Techniques–Imaging Procedures, 7 Attorneys Medical Advisor § 71:9, 2009 Thomson Reuters.Richard Senelick, Of Law and Medicine, 60 Defense Counsel Journal 287 (April 1993). Sharona Hoffman, First, Do No Harm: Why Doctors Are Not Omnipotent Under the American With Disabilities Act, 14 Hofstra Lab. L. J. 151 (Fall 1996).

(Endnotes)

1 Portions of this article have been published in Show Me the Pain–Pitfalls and Limitations of Diagnostic Imaging of the Low Back, Journal of Law and Medicine, Winter 2009. These excerpts have been reprinted with permission.2 Loeser, Low back pain in: Bonica’s Management of Pain, 3rd ed. John D Loeser, ed. Philadelphia: Lippincott, Williams & Wilkins;


2001; 76:1508-1509.; See also Hair & Pollen, Lumbar Spine Injuries, 38 Am. Jur. Proof of Facts 2d 285.3 Shen, Samartzis, Andeerson, Nonsurgical management of acute and chronic low back pain, J Am Acad Orthop Surg. 2006:14:477-487. 4 Loeser, supra fn 2.5 Lurie, Evidence-based management of chronic low back pain, Adv Pain Management. 2008: 1:141-146.6 Spengler, Gigos, Martin et al., Back injuries in industry: a retrospective study, overview and cost analysis, Spine. 1986; 11:241-245.7 Chronic low back pain has been described by one court as consistent pain which last for at least three months. Barre v. Bonds, 763 So.2d 60 (La. App. 4 Cir. 2000).8 Shen, supra fn 3.9 Engel, Korff, Katon, Back pain in primary care: predictors of high health-care costs, Pain. 1996; 65:197-204.10 Low back pain in the work environment is not limited to modern society. Rather, there is evidence of low back discomfort in an occupational setting thousand of years ago. The first reported case occurred around 2780 B.C. when a doctor in Egypt treating construction workers at the pyramid of Sakkara documented a “sprain of a vertebra,” Senelick, Of Law and Medicine, 60 Defense Counsel J. 287 (April 1993). 11 Anderson, Epidemiological features of chronic low back pain, Lancet. 1999; 354:581-585. Although many physicians have re-searched the phenomena of back injury and low back pain in an occupational setting, the understanding of the etiology and preven-tion of low back pain is weak and frequently speculative. Hoffman, First, Do No Harm: Why Doctors Are Not Omnipotent Under the American With Disabilities Act, 14 Hofstra Lab. L. J. 151 (Fall 1996).12 Engel, supra fn 9.; Abenheim, Suissa, Importance and economic burden of occupational back pain: a study of 2500 cases representa-tive of Quebec, J Occup Med. 1987; 29:670-674. See also Senelick, supra fn 10. As the author noted in his discussion of the causes of low back pain in workers, 35 percent have a sedentary job, whereas 47 percent are physical laborers. About 2 percent of the workforce will incur a compensable back injury each year. 90 percent of low back pain, however, resolves in one to three months without permanent residuals. Seventy to 80 percent of these patients may suffer a recurrence, but their pain usually resolves within three months. The treatment and economic problems come from the 5 to 10 percent of patients who have chronic and persistent symptoms.13 Hashemi, Webster, Clancy, Trends in disability duration and cost of workers’ compensation low back pain claims (1988-1996); J Occup Environ Med. 1998; 40:1110-1119.14 Bigos, and Muller, Primary Care Approach to Acute and Chronic Back Problems: Definitions and Care, Bonica’s Management of Pain 3rd ed., John Loeser, ed.; Philadelphia: Lippincott Williams and Wilkins; 2001; 76A:1509-1528.15 Loeser, supra fn 2.16 Cunningham, Kelsey, Epidemiology of Musculoskeletal Impairments and Associated Disability, Am J Pub. Health. 1984; 74:574. For a discussion of obtaining workers’ compensation benefits because of low back pain, See Leary, Obtaining Workers’ Compensation for Back Injuries, 79 Am. Jur. Trials 231. For an analysis of low back pain as creating an impairment for Social Security Disability benefits, See Gawienowski & McGhee, Oh My Aching Back: Establishing Presumptively Disabling Low Back Impairments in Social Security Disability Determinations, 59 J. Mo. B. 133, (May-June 2003).17 The American Board of Radiology, Diagnostic Radiology available at http://www.theabr.org/ diagnostic.htm (last visited Oct. 26, 2010). See also Ginsberg, Beyond the View Box: The Radiologist’s Duty to Communicate Findings, 35 J. Marshall L. Rev. 359 (Spring 2002).18 For an explanation of diagnostic imaging, See Hodge, A Litigation Primer on Diagnostic Imaging, 16 The Practical Lawyer 5, 7-22 (Sept. 2005).19 For a detailed discussion of the anatomy of the low back, See Hodge, Anatomy for Litigators, ALI-ABA ed. (2007).20 756 N.W.2d 363 (S.D. 2008).21 Id. at 392. See also Westbrook v. Astrue (2007 WL 5110314, E.D. Mo. 2007); and Gellerman v. Jefferson Pilot Financial Ins. Co., 376 F.Supp.2d 724 (S.D. Tex. 2005).22 An analysis on how to defend the back injury claim is contained in Hodge, Defending the Back Injury Claim, 13 The Practical Litigator 5, 7-16 (2002).23 The spine is explained in Celeste v. Progressive Silk Finishing Co., 72 N.J.Super. 125, 178 A.2d 74 (A.D. 1962) as “a supporting structure for the entire body. . . made up of several bones, layer on layer, just like a brick with cement in between each brick.” 24 The bones that constitute the hip are the pelvis bone and the femur. Southern Pac. Co. v. Martin, 98 Tex. 322, 83 S.W. 675 (1904).

128 | Anatomy For Litigators25 The American Medical Association’s Guides to the Evaluation of Permanent Impairment recognizes two methods to evaluate a spinal impairment. The “Diagnosis-Related Estimates Model” or DRE, pertains to people who have sustained traumatic injuries. The sec-ond is the “Range of Motion Model.” The DRE method divides the main spine into three areas, the cervicothoracic, thoracolumbar, and lumbosacral regions. The lumbosacral spine is assigned a 75 percent value for total body function. This differs from the Range of Motion model which separates the spine into the cervical, thoracic, lumbar and sacral regions. With that model, the lumbosacral spine is involved with 90 percent of total body function. Verdijo v. Skyline Painting, 2000 WL 970676 (Del. Super. 2000).26 The West key number for cases involving back injuries and damages is 115K127.34.27 This definition was recognized as early as 1896 in Bryant v. Omaha & C. B. Railway & Bridge Co., 98 Iowa 483, 67 N.W. 392 (1896) where the court noted that the periosteum is the covering of bone. 28 For a discussion of fractures and the anatomy of bone See Hodge, supra fn 19, ch. 3.29 A foramen is “[a]n aperture or perforation through a bone or a membranous structure.” Wilson v. 21st Century Ins. Co., 42 Cal.4th 713, 171 P.3d 1082 (2007). A foraminotomy, therefore, is “a surgical operation for the enlargement of an intervertebral foramen. It is done to relieve pressure on the root of a spinal nerve, a nerve passing through an intervertebral foramen.” J.E. Schmidt, Attorney’s Dictionary of Medicine and Word Finder F-100, Matthew Bender, 1992; Wagner v. Georgetown University Medical Center, 768 A.2d 546 (D.C. 2001).30 The spinal cord has been described as a “cable” of nerves in the spinal column. Aetna Life Ins. Co. v. Evins, 199 So.2d 238 (Miss. 1967). For a discussion of spinal cord injuries, See Hair and Polin, Spinal Cord Injuries, 37 Am. Jur. Proof of Facts 2d 291 (July 2008).31 The transverse processes are protruding portions with one on each side of the vertebra. C. R. Winn Drilling Co. v. Industrial Commission, 32 Ill.2d 144, 203 N.E.2d 904 (1965).32 A “laminectomy” (removal of a part of the lamina) is a common back surgery in which a part of this bone is removed. The pro-cedure is performed to gain access to the spinal cord or nerve roots that are encased in bone and the operation allows at surgeon to remove a herniated disc, to free up nerve root compression caused by degenerative changes or to access a spinal tumor. Hodge, supra fn 19, at ch. 5.33 Maestas v. Sofamor Danek Group, Inc., 1999 WL 74212 (Tenn. App. 1999). For examples of pedicle screw cases, See Coffua v. Martin, 57 Mass. App. Ct. 1116, 786 N.E.2d 43 (2003); King v. Danek Medical, Inc., 37 S. W.3d 429 (Tenn. Ct. App.,2000); Blazoski v. Cook, 346 N.J. Super. 256, 787 A.2d 910 (A.D. 2002); and Atlantic Mut. Ins. Co. v. American Academy of Orthopaedic Surgeons, 315 Ill. App. 3d 552, 734 N.E. 2d 50 (1 Dist. 2000).34 There are a number of reported cases in which the spinous process has been fractured as the result of trauma. For example, in Pierson v. Deaven, 1998 WL 731582 (Del. Super.), a physician testified as to the significance of such an abnormality and noted that the spinous process fracture “did not alter the stability of the spine as far as protecting the nerve roots enclosed within the vertebrae. Rather, the fractures affect the spine by altering the attachment of the muscles that attach to the processes.” 35 Terebush v. Hoffman, 2009 WL 29904 (N.J. Super. A.D. 2009).36 Hodge, supra fn 19, ch. 5. The sacrum was defined in Brown v. Chater, 96 F.3d 1450 (C.A.7 Wis, 1996) as the triangular bone just below the lumbar vertebrae.37 Mueller v. St. Louis Public Service Co., 44 S.W.2d 875 (Mo. App. 1932).38 The sacroiliac joint and its relationship to trauma was discussed by the court a number of years ago in Horn v. Yellow Cab Co, 88 Cal. App. 678, 263 P. 1025 (1 Dist. 1928). As was noted, it “is the point of junction of the sacrum, which is a portion of the lower spine, with two of the bones of the pelvis. It is not a movable joint, but consists of flat surfaces held together by ligaments. A slip of the segments of the sacroiliac joint is caused by a wrench or twist severe enough to tear the ligaments, and when this occurs there is necessarily a painful injury to a cluster of nerves centering in the sacral plexus, two of them being the sciatic nerves extending down the back of the thigh and which are eventually distributed in the lower leg and the foot. The immediate effect of such an injury is to prevent the patient from stooping or turning, or from lifting any weight or performing any kind of work calling into play the muscles attending the spine.”39 Hodge, supra fn 19, ch. 5.40 22 Misc.3d 1102(A), 2008 WL 5431384 (N.Y. Supp. 2008).41 Id. at fn 6.42 Swenson, Differential Diagnosis: A reasonable clinical approach, Neurologic Clinics, Lower Back Pain. 1999; 17:43-63.


43 Terebush v. Hoffman, 2009 WL 29904, (N.J. Super. A.D. 2009). Physicians administer facet injections as a common way of providing pain relief to this area of the spine. The procedure is also diagnostic in that it helps ascertain if the pain is coming from a specific joint or is related to some other type of abnormality. 44 The sacroiliac joint refers to the bones of the sacrum and ilium. The sacrum is the portion of the vertebra, which forms part of the pelvis. In turn, the ilium bone is a broad, flaring portion of the hip bone. Clover v. Astrue, 2008 WL 3890497 (E.D. Mo. 2008).45 Schwarzer, Aprill, Bogduk, The sacroiliac joint in chronic low back pain, Spine. 1995; 20:31-37. 46 Kalra v. Garcia, 2007 WL 2032906 (N.J. Super. A.D. 2007).47 Malm v. Beerbower, 2006 WL 689100 (Cal. App. 1 Dist. 2006). See also Clover v. Astrue, supra fn 45.48 Foreman v. Automatic Systems, Inc., 272 S.W.3d 560 (Tenn. 2008), and Willet v. Holter, 122 Wash. App. 1068, 2004 WL 1775572 (Wash. App. Div. 2, 2004), are examples of litigation dealing with this condition.49 See Thompson v. Lockert, 34 N.C. App. 1, 237 S.E.2d 259 (1977) in which a ligament is described as tissue that connects the bones and joints, and is made out of a cartilage or fibrous material. 50 Hodge, supra fn 19, ch. 5.51 The anterior longitudinal ligament runs down the front of the spine, is approximately one millimeter in thickness and crosses into the posterior longitudinal ligament. Thompson, supra fn 50.52 The posterior longitudinal ligament runs the length of the back portion of the spine and helps prevent the disc from herniating backwards by holding it in place. On rare occasions, this ligament can thicken or harden thereby turning it into bone, a process called ossification, which condition can lead to paralysis. Ellison v. Abu-Assal, 2005 WL 3387742 (Cal. App. 4 Dist. 2005).53 756 N.W.2d 345 (S.D. 2008). A related term involving the low back is ligamentum flavum hypertrophy, a degenerative condition that occurs over a substantial period of time that can narrow the spinal canal, causing spinal stenosis, and resulting in radiculopathy. Larimore v. Employees Retirement System of Texas, 208 S.W.3d 511 (Tex. App.- Austin, 2006).54 Czerniecki, Goldstein, General considerations of pain in the low back, hips, and lower extremities, Bonica’s Management of Pain, 3rd ed. John D Loeser, ed. Philadelphia: Lippincott, Williams & Wilkins; 2001; 75:1475-1507.55 The court in Royal Indem. Co. v. Jones, 201 S.W.2d 129 (Tex. Civ. App. 1947) offered the following explanation of an interverte-bral disc. “Intervertebral substance is defined in Webster’s New International Dictionary as, ‘the tissue uniting the bodies of continu-ous vertebrae. In man it forms disks of varying thickness, closely adherent to the surface of the bones, and composed of concentric lamina of fibrous tissue and fibro cartilage with a soft pulpy substance in the center. . . The disks serve as cushions protecting against shocks and allowing slight movements of the bones.’”56 Hodge, supra fn 19, ch. 5.57 As noted in Hart v. I. L. Van Zandt, 399 S.W.2d 791, (Texas 1966). “Each intervertebral disk is composed of two parts: (1) the outer part, known as the annulus fibrosis, is a cartilaginous material that holds the disk in place, and (2) the inner part, known as the nucleus pulposus, is a soft substance that protrudes through the annulus fibrosis when the disk is ruptured.”58 73 S.W.3d 560 (Tex. App. 2002).59 Id. at fn 9.60 Hodge, supra, fn 43, ch. 5.61 Swenson, supra fn 43.62 See White v. John B. Kelly, Inc., 174 Pa. Super. 262, 101 A.2d 395 (1953).63 201 S.W.2d 129, (Tex. Civ. App. 1947).64 Id. 65 A discectomy is a common surgical procedure involving the removal of herniated disc material that presses on a nerve root or the spinal cord. Kostel v. Schwartz, 756 N.W.2d 363 (S.D. 2008). The difference between a discectomy and a laminectomy was explained in Louisiana Workers’ Compensation Corp. v. Louisiana Workers’ Compensation Second Injury Bd., 5 So.3d 211 (La. App. 1 Cir. 2008), in the following way, “A laminectomy is the excision of the posterior arch of a vertebra. . . A discectomy is the excision of an intervertebral disk.”66 Modic, Ross, Lumbar degenerative disk disease, Radiology. 2007; 245:43-61.67 273 Or. 883, 543 P.2d 1032 (Or. 1975).68 Id.69 See VECO Alaska, Inc. v. State, Dept. of Labor, Div. of Workers’ Compensation, Second Injury Fund, 189 P.3d 983 (Alaska 2008).


70 Hodge, supra fn 19, ch. 5.71 The spinal cord runs the length of the back from the brain to approximately the first lumbar vertebra. Below that area, the nerves flare out into the cauda equina. Funke v. Fieldman, 212 Kan. 524, 512 P.2d 539 (1973).72 A complication of back surgery is cauda equina syndrome, damage to the nerve roots that extend down from the bottom of the spinal cord. Jones v. Minster, 261 Ill.App.3d 1056, 635 N.E.2d 123 (2 Dist.1994). Cauda equina syndrome has been the subject of a number of medical malpractice lawsuits. See for example, White v. Vanderbilt University, 21 S.W.3d 215 (Tenn. Ct. App. 1999); Harsin v. Eastern Oregon Community Medical Center, Inc., 86 Or. App. 589, 739 P.2d 1093 (1987); Kling v. DiSclafani, 983 So.2d 648 (Fla. App. 5 Dist. 2008); and Cook v. Rankin, 259 Wis.2d 933, 657 N.W.2d 440 (Wis. App. 2002). 73 219 N.J. Super. 208, 530 A.2d 56 (N.J. Super. L. 1987).74 Spinal stenosis is a problem in which the spinal canal is narrowed so that compression takes place in the cord and nerves. Raugust v. Diamond Intern. Corp., 107 Idaho 724, 692 P.2d 368 (1984); and Nelson v. Semitool, Inc., 252 Mont. 286, 829 P.2d 1 (1992).75 The spinal canal consists of “three structures: the dura, the arachnoid in the middle, and the pia matter. It is a closed, pressurized system in which cerebrospinal fluid (CSF) circulates, cleansing and nourishing the spinal canal and the brain and the other elements of the central nervous system. Shelnitz v. Greenberg, 200 Conn. 58, 509 A.2d 1023 (1986).76 Raugust v. Diamond International Corporation, 107 Idaho 724, 692 P.2d 368 (1984). It is important to remember that the mere existence of spinal stenosis should not give rise to money damages because the condition is frequently congenital in origin. For instance, in finding that a slip-and-fall was not the cause of a police officer’s discomfort, the court noted that the officer’s condition is the result of his congenital spinal stenosis. This condition, which is present from birth, is characterized by a spinal canal that is narrowed more than normal and does not allow for swelling of the sac around the cord thereby resulted in the person’s experiencing pain. Haynie v. District of Columbia Police and Firefighters’ Retirement and Relief Board, 640 A.2d 188 (D.C. 1994).77 Each vertebra contains a hole or foramen roughly in the center of the bone. When these vertebra are stacked, one on the top of another, the openings form a continuous canal so that the spinal cord can run its length through the spine. Karthauser v. U.S,. 841 F.2d 1129 (C.A.9 Wash.1988).78 The court in Parke County Residential Care Center v. Norman, 899 N.E.2d 754 (Ind. App. 2008), explained sciatica as “a symptom of a problem with the sciatic nerve, a large nerve that runs from the lower back down the back of each leg.”79 As noted in materials published by the Association of Trial Lawyers of America, “complaints of pain, such as low back pain, fol-lows a distinct anatomical path which will help a doctor diagnose a problem at a particular disk level.” Cheng, Direct Examination of the Plaintiff’s Medical Expert, ATLA Winter Convention Reference Materials Advocacy Track: The Trial of Damages in a Muscle Sprain Case, ATLA-CLE 113 (Winter 2001).80 Swenson, supra fn 43; Travell, Simons, Background and Principles, Myofascial Pain and Dysfunction, The Trigger Point Manual, Baltimore: Williams & Wilkins; 1983; 2:5-44. 81 A related medical problem involving this muscle is piriformis muscle syndrome, a condition in which this muscle in the buttocks region compresses the sciatic nerve thereby causing pain in pain in the buttock, lower back, and leg. Pickett v. Industrial Com’n of Ariz., 2008 WL 4638932 (Ariz. App. Div. 2, 2008); WJLA-TV v. Levin, 264 Va. 140, 564 S.E.2d 383 (Va. 2002); and Smidt v. Telecommunications, Inc., 710 N.W.2d 258 (Iowa App. 2005).82 For example, See Hatfield v. Haynes Publications, Inc., 2008 WL 4072046 (Tenn. Workers Comp. Panel, 2008); Pickett v. Industrial Com’n of Ariz., 2008 WL 4638932 (Ariz. App. Div. 2, 2008); Doughty v. American Nat. Property and Cas. Co., 2006 WL 3105693 (La. App. 1 Cir. 2006); and Smidt v. Telecommunications, Inc., supra fn 83.83 Trigger points are used in a litigation setting to justify awards of compensation. For instance, in Larrabee v. State of New York, 216 A.D.2d 772, 628 N.Y.S.2d 447 (3 Dept. 1995), the court found that trigger points were “objectively ascertained and quantified.” But See Raygoza v. IBP, Inc., 86 P.3d 1026, 2004 WL 720233 (Kan. App.2004).84 Id.85 Thompson P, Carr E, Content analysis of practitioner-requested lumbar spine x-ray reports, Br. J Rad. 2007; 80:866-871.86 Id.87 Hansson, Roos, Age changes in the bone mineral of the lumbar spine in normal women, Calcified Tissue Intnl. 1986; 38:249-251.88 Twomey, Taylor, Age changes in lumbar intervertebral disks, Acta Orthop Scand. 1985; 56:496-499.89 Bigos, supra fn 14.90 Modic, supra fn 67.91 Swenson, supra fn 43.


92 See Miller v. Choo Choo Partners, L.P., 73 S.W.3d 897 (Tenn. Ct. App. 2001); Waldie v. Conrad, 2000 WL 1419 (Ohio App. 5 Dist. 1999); and Keel v. Saturn Corp., 1999 WL 85521(Tenn., Sp. Workers’ Comp. 1999). 93 Herring v. Poirrier, 797 So.2d 797 (Miss. 2000).94 Czerniecki, supra fn 55.; Modic, supra fn 67. For cases discussing the relationship of smoking and herniated discs, See Lagestee v. Days Inn Management Co., 303 Ill. App. 3d 935, 709 N.E.2d 270 (1 Dist.1999); KG Const., Inc. v. Sherman, 120 P.3d 145 (Wyo. 2005); and Boring v. Treasurer of Mo., Custodian of the Second Injury Fund, 947 S.W.2d 483 (Mo. App. E.D. 1997).95 Wagner, Sether, Yu, et al., Age changes in the lumbar intervertebral disk studied with magnetic resonance and cryomicrotomy, Clin. Anat. 2005; 1:93-103.96 Swenson, supra fn 43.97 Finneson, Anatomy of the low back, Low Back Pain, 2nd ed, Bernard E. Finneson, ed. Philadelphia: JB Lippincott; 1980; 1:1-25. 98 Modic, supra fn 67.; In City of Pittsburgh, Civil Service Commission v. Weger, 95 Pa. Cmwlth. 302, 505 A.2d 398 (1986), an issue was presented concerning the significance of a Schmorl’s node in a job applicant’s back and whether this condition disqualifies that person from becoming a police officer. In rejecting the individual’s job application because the Schmorl’s node indicated a “back injury risk,” the court stated, “Conditions which are included in the term ‘other gross abnormalities’ have been interpreted by the Commission’s staff physicians to include . . . the presence of two or more Schmorl’s node. . . The Commission’s medical expert . . . testified that the interpretation had been adopted as an amalgamation of various opinions outlined in medical literature as well as input from various specialists. . . More than one study indicated that the presence of the nodes alone indicated a weakened condi-tion of connective tissue in the spine which was probably genetically acquired. . . The presence of two or more Schmorl’s node was the generally accepted industrial standard for disqualification from a job that was considered to be arduous as opposed to merely physically taxing.”99 Id.100 807 So. 2d 946 (La. App. 5 Cir. 2002).101 Id.102 Bigos, supra fn 14.103 healthcommunities.com, About Radiology, available at http://radiology.healthcommunities.com/aboutradiology/index.shtml (last visited Oct. 25, 2010).104 Id.105 Alpert, Hillman, Quality and variability in diagnostic radiology, J Am Coll Radiol. 2004; 1:127-132; Jaffee, Why an image? Invest. Radiol. 1984; 19:248-249.106 Id.107 Deyo, McNiesh, Cone, Observer variability in the interpretation of lumbar spine radiographs, Arthritis and Rheumatism. 1985: 28:1066-1070.108 Wiesel, Tsourmas, Feffer et al., A study of computer-assisted tomography; The incidence of positive CAT scans in an asymptomatic group of patients, Spine. 1984; 9:549-551.109 Boden, Davis, Dina, et al., Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects, J Bone Joint Surg. 1990; 72A:403-408.110 Costa J, Paolaggi JB, Spira A. Reliability of interpretation of plain lumbar spine radiographs in benign mechanical low back pain Spine. 1991; 16:426-428.111 Madan, Rai, Harlow, Interobserver error in interpretation of the radiographs for degeneration of the lumbar spine, Iowa Orthop J. 2003; 23:51-56.112 Milette, The proper terminology for reporting lumbar intervertebral disk disorders, AJNR. 1997; 18:1859-1866.113 See Hodge, supra fn 19, ch. 2.114 Goddard, Gholkar, Diagnostic and therapeutic radiology of the spine: an overview, Imaging. 2002; 14:355-373.115 Scavone, Latshaw, Rohrar, Use of lumbar spine films; statistical evaluation at a university teaching hospital, JAMA. 1981; 246:1105-1108.116 Simmons, Guyer, et al., Radiographic assessments for patients with low back pain, Spine. 1995; 20: 1839-1841.117 Onesti, Failed back syndrome, Neurologist. 2004; 10:259-264.


118 As noted in Rockwood v. Singh, 258 Ill.App.3d 555, 630 N.E.2d 873 Ill.App. 1 (Dist. 1993), “A myleogram is similar to an x-ray; however, an . . . dye is injected into the patient’s spine, allowing the physician to see the dye in the x-ray.”119 For instance, a patient died after suffering an allergic reaction to the dye used in a lumbar myleogram. Elizabethtown Sportswear v. Stice, 720 S.W.2d 732 (Ky. App. 1986). See also Johnson v. City of New Orleans Police Dept., 4 So.3d 114 (La. App. 4 Cir. 2009). The court refused to establish a link between the development of headaches and the administering of a myleogram in Beverly v. Boardwalk Const.,771 So.2d 741 (La. App. 3 Cir. 2000). For an opposite result, See Shelnitz v. Greenberg 200 Conn. 58, 509 A.2d 1023 (Conn. 1986); Cooper v. Ross & Roberts, Inc., 1986 WL 4564 (Del. Super.1986).120 Nevertheless, in a case in which an injured worker sought disability benefits for a lower back injury, the claimant’s doctor testified that a myleogram is significantly more sensitive than an MRI scan. Hokes Bluff Welding and Fabrication v. Cox, 2008 WL 4757149 (Ala. Civ. App. 2008). In another matter pertaining to an injured worker, a doctor stated that he would order a myleogram prior to any surgical consideration. Warren v. Action Oil Recovery, 944 So.2d 615 (La. App. 1 Cir. 2006).121 As noted in Michel v. W.C.A.B. (U.S. Steel Corp.), 966 A.2d 643 (Pa. Cmwlth. 2009), the use of discograms and their interpreta-tion is controversial. Some physicians believe strongly in them, and others do not.122 646 So.2d 461 (La. Ct. App.1994).123 Peh, Provocative discography: current status, Biomed Imaging Intervent J. 2005;1:1-7.124 Smuck, Yoon, Colwell, Intravascular injection of contrast during lumbar discography: a previously unreported complication, Pain Med. 2008; 9:1030-1034.125 See Hodge, supra fn 19, ch. 2.126 1999 W.L. 600373 (E.D. La. 1999).127 Swenson, supra fn 43., Silber, Anderson, Vaccaro, et al., Pre-operative discography: appropriate indications and clinical interpretation, UPOJ. 2001; 14:79-82.128 Wichman, Discography: over 50 years of controversy, Wisc Med J. 2007; 106:27-29.129 Carragee, Tanner, Khurana, et al., The rates of false-positive lumbar discography in selected patients without low back symptoms, Spine. 2000; 25:1373-1380.130 Peh, supra fn 125.131 Swenson, supra fn 43.132 Wichman, supra fn 130.133 Bogduk, Karasek, Precision diagnosis and treatment of back and neck pain, Continuum. 2005; 11:94-126.134 Cohen, Larkin, Barna, et al., Lumbar discography: A comprehensive review of outcome studies, diagnostic accuracy and principles, Reg Anesth Pain Med. 2005; 30:163-183.135 For an article discussing the uses of Ct scans in litigation, See Delsack and Piazza, Use of Cat Scans In Litigation, 8 Am. Jur. Proof of Facts 3d 145 (Dec. 2008).136 See Hodge, supra fn 19, ch. 2.137 A CT scan of the lumbar spine is an accepted diagnostic use. As noted in Corley v. State, Dept. of Health & Hospitals, 749 So.2d 926 (La. App. 2 Cir. 1999), a lumbar CT scan will “either indicate or rule out a number of possible causes for low back pain, such as a ruptured disc, a pinched nerve, bone spurs, a tumor or infection.”138 See Hodge, supra fn 19, ch. 2.139 Korber & Bloch, The “normal” spine, Med J. Aust. 1984; 140:70-72.140 Bar-Dayan, Weisbort, Bar-Dayan, et al., Degenerative disease in lumbar spine of military parachuting instructors, J R Army Med Corps. 2003; 149:260-264.141 Hitselberger, Witten, Abnormal myelograms in asymptomatic patients, J. Neurosurg. 1968; 28:204-206.142 Wiesel, supra fn 110.143 Jensen, Brant-Zawadszki, Obuchowski, et al., Magnetic resonance imaging of the lumbar spine in people without back pain, NEJM. 1994; 331:69-73. This article was cited in Stevens v. Homiak Transport, Inc., 21 A.D.3d 300, 800 N.Y.S.2d 157 (1 Dept. 2005); and Pierce v. Louisiana Maintenance Service, Inc., 668 So.2d 1232 (La. App. 5 Cir. 1996).144 Boos, Rieder, Schade, et al., The diagnostic accuracy of magnetic resonance imaging, work perception, and psychosocial factors in iden-tifying symptomatic disc herniations, Spine. 1995; 20:2613-2625.145 Boden, supra fn 111.


146 Powell, Wilson, Szypryt, et al., Prevalence of lumbar disc degeneration observed by magnetic resonance in symptomless women, Lancet. 1986; 2:1366-1367.147 Borenstein, O’Mara, Boden, et al., The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymp-tomatic subjects, J Bone Joint Surg. 2001; 83:1306-1311.148 Alyas, Turner, Connell, MRI findings in the lumbar spines of asymptomatic, adolescent, elite tennis players, Br J Sports Med. 2007; 41:836-841.149 Walsh, et al., Lumbar Discography in Normal Subjects: A Controlled Prospective Study, J of Bone and Joint Surg. Aug. 1990; 72:1081.150 Modic, supra fn 67.151 Frymoyer, Back pain and sciatica, NEJM. 1988; 318:291-300.152 A straightening of the lordotic curve in the low back may be indicative of muscle spasm. Royal Indem. Co. v. Smith, 456 S.W.2d 218 (Tex. Civ. App. 1970).153 Travell, supra fn 82. This book has been cited in court on a number of occasions. For instance, See Coats v. Hickman, 11 S.W.3d 798 (Mo. App. W.D. 1999).154 Czerniecki, supra fn 55.155 Bogduk, supra fn 135.156 Czerniecki, supra fn 55.157 For sample court cases in which psychological factors played a role in back pain, See Purolator Courier v. Chancey, 40 Ark.App. 1, 841 S.W.2d 159 (1992); Allen v. Care Focus Durham, 673 S.E.2d 166 (N.C. App.2009); In re Pickens, 134 P.3d 1231 (Wyo.2006).; Walton v. State ex rel. Wyoming Workers’ Safety and Compensation Div., 153 P.3d 932 (Wyo. 2007).; and McGaughey v. City of New Orleans, 695 So.2d 1109 (La. App. 4 Cir. 1997).158 Swenson, supra fn 43.159 See Katon, Sullivan, Depression and chronic medical illness, J Clin Psychiatry. 1990; 51(suppl.):3-14.160 Bigos, supra fn 14.; Swenson, supra fn 43., Frymoyer, supra fn 153.; Gatchel, Gardea, Psychosocial issues; their importance in pre-dicting disability, response to treatment, and search for compensation, Neurologic Clin. 1999; 17:149-166.161 Gatchel, Polatin, Mayer, The dominant role of psychosocial risk factors in the development of chronic low back pain disability, Spine. 1995; 20:2702-2709.162 Boos, Semmer, Elfering, et al., Natural history of individuals with asymptomatic disc abnormalities in magnetic resonance imaging: Predictors of low back pain-related medical consultation and work incapacity, Spine. 2000; 25:1467-1541.163 Vaccaro, Ring, Scuderi, et al., Predictors of outcome in patients with chronic back pain and low-grade spondylolisthesis, Spine. 22(17):(1997).164 Onesti, supra fn 119.165 Vaccaro, supra fn 165.166 See Hodge, Unraveling the Mystery of Medical Records, 52 The Practical Lawyer 1, 45 – 62 (Spring 2006).

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7 Diagnostic Imaging Of The Low Back: Limitations And Pitfalls · Diagnostic Imaging Of The Low Back: Limitations And Pitfalls Samuel D. Hodge, Jr., Esquire Jack E. Hubbard, PhD,