New Vs. Old disc damage and delayed symptoms

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Welcome back to the Forensic Chiropractor podcast.

There are lots of injuries I see when doing IMEs.  I have seen amputations, crush injuries, complex regional pain syndrome, severe brain injuries, meniscus tears, rotator cuff tears, labral tears, fractures, and a wide variety of other injuries.  Doing forensic works offers me an opportunity to see and work with injuries I would not typically see as a chiropractor.  A lot of these injuries that I just mentioned do not have a lot of fighting when it comes to causation.  When there is an amputation of a finger causation is rarely an issue.  A patient that fell 30 feet off of a roof and has fractures, punctured lungs and a TBI is typically not fighting causation. 

These types of injuries are not uncommon, but not the normal I see in my office.  Most of my patients were in motor vehicle collisions and have persistent symptoms.  There are lots of causes of spinal pain after a motor vehicle collision, but there are 2 that I spend a lot of time working on causation.  Disc damage and ligament damage are consistently seen as causes of persistent spinal pain after a motor vehicle collision.  Unfortunately, causation is often fought for both of these injuries. 

Today’s study addresses causation for disc herniations.  The study is Traumatic Lumbar Disc Herniation: A systemic case review and meta-analysis published by Li et al in the Brain and spine Journal in 2023.  The study starts by stating that often lumbar disc herniations are considered nontraumatic events and are typically caused by genetics in young patients and degenerative changes in older patients.  This study showed that trauma causing lumbar disc herniations goes back as far as the 1850s in the literature.

Today’s study reported that if there are no high-grade disc degeneration then a diagnosis of traumatic disc herniation should be considered following adequate trauma.  They do not elaborate of what disc degeneration is or what high-grade disc degeneration would be.  I have talked a lot about what disc degeneration looks like.  As a refresher disc degeneration looks like loss of disc space height, circumferential bulge, degenerative osseous changes surrounding the disc, disc desiccation, type 2 or 3 modic changes.  So today’s study is saying that if we have a traumatic event capable of causing damage and we do not have lots or high-grade degenerative findings we should consider the herniation new and causally related to the injury event. 

This study reviewed 12 other studies to come up with the results.  They defined a disc herniation as a pathological condition in which the intervertebral disc is injured due to trauma and causes the disc complex to extend into the spinal canal.  They showed that disc herniations often have neurological symptoms.  These symptoms are not depended on the size or location of the disc herniation.  This means that even small herniations can cause neurological symptoms and large ones can have less neurological symptoms.

It was shown that some patients do not have neurological symptoms initially, but can have a delay of up to 6 weeks after the initial injury.  That is one of the most powerful points this research article brings up.  I have seen lots of new disc herniations with no signs on initial examination, but are present 1 month later on the reexamination.  Although this is not uncommon the defense experts often say if the herniation was caused the collision the neurological symptoms would be present immediately.  What a powerful study to validate that the nerve deficits can take up to 6 weeks to be seen. 

Today’s study went on to show that herniated discs shrink over time and appear more degenerative.  This is another indication to assess with an MRI sooner vs. later.  Along with disc herniation this study showed we should also consider the following injuries: first spinal fractures at the same level, second instability due to disc space loss, third puncture of the dura, fourth severe spinal instability. 

This study reported that with medical legal cases it may be necessary to have the herniated disc sent for histological examination to assess the extent of degenerative changes.  They also reported that it is necessary to consider the possibility of developing chronic pain after disc herniations.  They concluded with quote “Radiologically, mild disc degeneration without spinal instability should be accepted for diagnosing traumatic lumbar disc herniation” end quote.  Again showing that with mild degenerative changes new appearing herniations with recent trauma should be considered traumatic. 

Real world

For today’s real world example I want to give a common time line I see in a motor vehicle collision.  Patient’s after the collision are often not feeling a lot of pain.  They have a lot of adrenaline and this has been shown to suppress or modulate the pain perception during emergencies.  If emergency responders show up at the collision they will often be told that the patient in the collision is doing okay with no pain.  Then the police report shows no injuries. 

As soon as the patient leaves the scene, they call their insurance company.  They are often way more worried about their vehicle than their health.  It takes a few hours for the adrenaline to wear off.  Hours to days later the patient starts to realize they are in pain.  They then go to the emergency room.  IN the emergency room they have lots of CT scans done.  The CT scans are used to assess for fractures and bleeding.  Often in the emergency room patient will complain of neck pain, back pain, extremity pain headaches and a variety of other complaints.  CT scans of the spine and extremities are ordered and no fractures or bleeding is seen.  The physician often gives 1-3 diagnosis codes and this is typically a diagnosis code for a motor vehicle collision and a strain.  I rarely see diagnoses that match the patients’ complaints.  When reading emergency room notes I rarely see a headache diagnosis given even though it is one of the patient’s main complaints. 

The patient then goes home and thinks they have no injuries.  They typically report to me that they thought they would just start to feel better since the emergency room physician said they didn’t really have anything wrong.  They then wait a couple weeks without doing any care.  They realize that they are not getting better and get concerned.  They typically reach out to a person injury attorney at this point.  The attorney typically says that if they have symptoms they need to get into to a doctor. 

They go home and research doctors and after a couple days call my office.  They get in on their next day off and that’s 4 days after they call.  When they walk into my office it has been around 1 months since their motor vehicle collision.  We do an exam and realize they have high likelihood of having a disc herniation with radiculopathy.  I order an MRI and they get this done in next 1-2 weeks. 

The MRI confirms my clinical findings and they have a disc herniation with radiculopathy.  There is no nerve root compression and we start care in my office.  After 3 months of care, they are released from care with minimal pain or neurological findings.  I write a report explaining that the patient never had prior symptoms.  The onset of symptoms came on after the collision.  The MRI shows all signs of the disc herniation appearing new.  The herniation is focal with no loss of disc space height, no degenerative osseous changes, increased signal in the herniation with no disc desiccation.  I given the patient an impairment rating with future care explanation.  It feels like the care was wrapped up neatly and ready for an attorney to get a fair settlement for the injuries. 

The insurance company fights to give any value for the injury for one specific reason.  They have hired a IME doctor that states that they disc herniation would have caused pain and neurological symptoms immediately.  Since it took around 1 month for the symptoms to show up in the medical records then there is no way the collision caused the disc herniation.  I see this exact opinion lots from defense IME experts most of which are orthopedic surgeons. 

This seems to stall out a lot of negotiations and I’m sure lowering settlement offers all the time.  I find int interesting that they defense doctor rarely gives opinions of the facts of the specific case, but states that if the injury occurred it would have caused pain and neurological symptoms immediately.  They rarely given an opinion about the MRI. Rarely is there any disputing my report of the MRI that shows clearly a new injury.  They are not showing degenerative disc bulges with loss of disc space height, degenerative osseous changes, disc desiccation and other old findings.  They just hang their hat on when symptoms would have started. 

Today’s study is crucial for everyone to understand.  Today’s study showed that neurological deficits can take up to 6 weeks to show up after the initial injury.  Today’s study showed that if imaging shows mild degenerative changes with no prior symptoms and a mechanism of injury that we should accept the injury as the cause of the disc herniation.                

I covered similar findings in my 5^th podcast.  This was a study by Del Grande et al titled Imaging the intervertebral disk age-related changes, herniations and radicular pain.  Their study showed that you need disc herniation with nerve abutment or compression and inflammation to have radiculopathy.  This means that without an inflammatory response radiculopathy or extremity pain from a disc herniation is not likely. 

This correlates with today’s study.  We often have disc herniations at the time of the injury, but the radicular or nerve symptoms can take days or weeks to show up.  This should end the discussion about if the herniation was new the symptoms would have been there immediately.  This is not true.  Pain is often masked by adrenaline after the injury.  The neurological symptoms can take up to 6 weeks to show up. 

Thanks for listening.