Real impact of degenerative changes.

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For this month’s study I want to talk about the difference between chronological age and physiological age.  Chronical age is how old we are.  Or how long ago was our birth.  Physiological age or biological age is a measure of how well our body is functioning and is often a more accurate indicator of overall health than our chronological age. 

There are many different factors to consider with physiological age including lifestyle, genetics and exposures in our environment.  These exposures can be toxins, injuries, difficult work environments, diet and all sorts of exposures. 

Assessment of physiological age is very important in health care.  A physical exam is done to assess the physiological age of a patient.  On an examination this is often done with blood work, imaging and a variety of other tests.

The question I have as a forensic chiropractor to you is, what does physiological age mean for a new injury?  How is physiological age assessed on new trauma patients?  The most common assessment of physiological age on trauma patient is imaging.  Imaging in the form of x-rays, CT scans, MRIs, and ultrasound can give us a lot of information about physiological age.  I have talked about this on prior podcasts that imaging can help paint a picture that helps time date an injury.  Imaging can also paint a picture of physiological age. 

One of the most common features seen on imaging is boney degenerative changes or osteoarthrosis or bone spurs.  We have talked about boney changes and wolff’s law.  These changes take a minimum of 6 months to be seen on imaging and likely take years to develop.  These degenerative changes take place when abnormal pressure is placed on the bone.  This is typically from too much movement in a joint, not enough movement in the joint or abnormal movement in a joint.  This is a very common finding on imaging and is often reported as normal for the patient’s age if they are older.  I would argue that this is never normal at any age, but a degenerative process that is often seen in Western Society. 

Another feature we see on imaging that shows an increase in phycological age is degenerative disc bulges.  I have talked about this on many prior podcasts.  There are many signs of degenerative discs including circumferential bulge, loss of disc space height, degenerative boney changes around the disc, loss of fluid or desiccation.  These changes to discs take time to develop and certainly show an increase in physiological age.  

When imaging shows degenerative bone and disc changes, we would say that they have an older physiological age.  These changes were not likely caused by new trauma, but likely show signs of prior problems.  For this reason, I have seen most insurance companies all too eager to say that if imaging shows degenerative changes that all findings are pre-existing and unrelated to the injury. 

I have talked a lot on prior podcasts about being able to look at imaging and assess for new trauma in a degenerative spine.  It is common that I will see a degenerative spine with new injuries on imaging.  For today’s study I want to cover what an increased physiological age means for degenerative cervical spines in hyperextension injuries.  The study is Spectrum of Imaging Findings in Hyperextension injuries of the neck published by Sameet Rao et al in Radiographics journal in 2005.

This study was a review of a 5-year database from 2 trauma centers with predominant hyperextension injuries seen.  They showed that quote “More severe injuries were observed in patients with underlying predisposing conditions” end quote.  They defined whiplash injuries as quote “noncontact hyperextension injuries to the neck are commonly referred to as whiplash injuries and result from an unrestrained neck motion during a rear-end collision” end quote.  

This study went on to show that CT scans are often used to assess for cervical fractures.  They went on to show multiple types of cervical spine fractures seen with hyperextension injuries.  Page 1248 in the journal covers a section titled Conditions predisposing to Injury.  They start this section by saying quote “Patients with underlying abnormalities of the cervical spine are at increased risk for significant injuries, even from relatively minor forces” end quote.  They did not say elderly patient have the increased risk for significant injuries even with relatively minor forces.  They reported that increased spinal physiological age increases the risk of significant injuries even with relatively minor forces. 

An increased physiological aged cervical spine would have a decrease in mobility that would quote “affect the lower cervical spine to a greater degree, resulting in more frequent injury to the cervioccranium and upper spine, with fractures of the axis being the most common” end quote.

The important concept is that degenerative changes lower the threshold for significant injuries even with low forces.  Although these changes often predate injuries degenerative changes often make the injuries much worse.   Today’s study went on to say that when CT scans or x-rays are negative, but the patient has neurological symptoms an MRI should be ordered.   These degenerative changes will make the cervical spine prone to all types of injuries.  It seems that this study supports the thought that physiological age is more important than chronological age when in a MVC or other trauma. 

I am sure insurance companies will continue to argue that any pre-existing degenerative changes seen on imaging is proof that there is no new injury and that everything is pre-existing.  I am also sure that some providers will argue that all of the symptoms are from the new injury and the pre-existing degenerative changes are incidental findings.  The evidence shows a little of both of these arguments.  Quote “Patients with underlying abnormalities of the cervical spine are at increased risk for significant injuries, even from relatively minor forces” end quote.  However, this doesn’t mean that significant injuries occurred.  It means that they have an increased risk for these significant injuries.  As seen in this study these significant injuries are not always osseous and an MRI can be helpful assessing new damage.  We should also assess ligament damage as they are at a higher risk for ligament damage.  Once again, each patient is unique and we must asses what happened and not what could not couldn’t happen to them. 

Real World

For the real-world example today’s article made me think of a patient I worked with a few years ago.  She had 2 separate MVCs that needed an apportionment.  This patient had pre-existing problems and was fortunate to have an MRI before either MVCs and one after each MVC.  The attorney knew this case would be complicated given the pre-existing degenerative changes and prior problems. 

The patient’s MRI showed moderate degenerative boney changes and mild to moderate degenerative disc bulges.  During treatment the insurance company already started disputing care as unrelated to knew trauma and was all pre-existing.  To me this is a classic example of it doesn’t matter what could happen to a patient, but what did happen.  The insurance company was completely inaccurate saying that because there were mild to moderate degenerative changes that all of the patient’s problems were unrelated to the MVC.  It also doesn’t matter that the evidence shows that pre-existing degenerative changes make future injuries more likely. 

The interesting thing about this patient is that she was chronologically young.  She was in her 20’s, but had a significantly higher physiological age.  Her physiological age would have placed her much older.  The first MVC she was in did not cause that much damage to the vehicle, and the insurance company reported that there is no way she could have been hurt in this MVC.  We have and can discuss evidence to show that low damage and low speed collisions can cause damage, but the insurance company now had 2 reasons to argue she was not likely hurt in the first collision.  She had pre-existing problems with degenerative changes on imaging and low damage collision. 

The MRI taken prior to the first MVC did not show a disc herniation at C3-4.  The MRI after the first MVC did dhow a herniation at C3-4.  This herniation did not appear brand new in every way.  There were mild degenerative osseous changes around the disc.  There was no loss of disc space height and the herniation was focal.    For causation the most important was likely the prior MRI taken less than 6 months prior to the MVC did not show the herniation.   The insurance company argued that this new herniation was typical wear and tear of her degenerative spine.  I used today’s article to show that the prior degenerative changes would make her more prone to injury with a MVC.  I quoted straight from the article quote “Patients with underlying abnormalities of the cervical spine are at increased risk for significant injuries, even from relatively minor forces” end quote. 

As we were nearing the end of care and preparing to write a report for the attorney, she was in another MVC.  This second MVC was also minimal damage to her vehicle and was low speed.  She again had radicular complaints and another MRI was ordered.  This new MRI showed a C6-7 herniation that was not present on either of the 2 prior MRIs.  The new insurance company was convinced that all symptoms were related to prior injury and the prior MVC.  There is certainly a lot of evidence to support prior issues and there were significant problems with her first MVC. 

Once again, I was able to show that although her cervical spine had moderate degenerative osseous changes at the C6-7 level the prior MRI a few months before did not show a focal herniation at C6-7.  The C6-7 herniation did not show loss of disc space height.  Once again, I had to explain to this insurance company that quote “Patients with underlying abnormalities of the cervical spine are at increased risk for significant injuries, even from relatively minor forces” end quote.    I had to explain that indeed the MRI did show that she had a new significant injury in the cervical spine that was related to her second MVC.

Once care was finished, I had to write a report for her attorney that covered causation for pre-existing, the first MVC and the second MVC.  Causation was easy as far as disc damage went.  The damage to ligaments and facets was harder to show with objective evidence.  After working on causation, I had to write an apportionment of her current condition to the 3 causations (pre-existing, first MVC and second MVC).  The apportionment is difficult to come up with an idea of what percentage of her current condition is responsible.  In my opinion this is often based more on opinion than facts.  It is hard to know how much of her current symptoms and impairment rating are related to the either of the MVC and the prior problems. 

The attorney was able to get good settlements from both of the car insurance companies for her injuries.  Not only is it important to understand how to time date injuries with imaging, but it is important to understand that pre-existing degenerative changes do lower the threshold for injury even with relatively minor forces.