Determination of Causation of Intervertebral Disc Injuries Following Baltimore Auto Accidents

Determination of Causation of Intervertebral Disc Injuries Following Baltimore Auto Accidents

As a Baltimore Chiropractor that routinely treats patients involved in Baltimore auto accidents, I am often called upon to determine causation of injuries. That is, I need to determine do a reasonable degree of medical probability whether or not a patient’s symptoms are causally related to a Baltimore auto accident. In the state of Maryland, the threshold of certainty is 51%. In other words, based upon the patients history, physical examination and objective evaluations (x-ray, MRI, etc), I have to be 51-100% sure that the patient’s complaints (whiplash, headaches, neck pain, back pain, etc) are causally related to the Baltimore auto accident. Clinically I am not concerned about causation, as it is my duty to treat a patient’s symptoms. However, medico-legally the determination of causation is extremely important when assigning fault or financial culpability for an injury.

The issue of clinical causation comes up a lot in my clinical practice. Typically an injured patient claims that part or all of their complaints are causally related to their Baltimore auto accident while the adverse (at-fault) insurance company claims that my patient is either not injured or that their injuries predated the Baltimore auto accident.

Fortunately a well respected researcher, Michael Freeman PhD, combed the literature to determine the appropriate systematic guidelines to make such a determination. A link to his study can be found here.

Mr. Freeman determined that for a clinician to draw causality three criteria must be met:

1. Biological plausibility– There must be a possible link between an injury and a Baltimore auto accident. A Baltimore auto accident could plausibly cause an injury to the spine including the intervertebral discs, but it is not likely that it can cause cancer.

2. Temporal relationship– The outcome (injury) can not pre-date the auto accident (with the exception of pre-existing degenerated non-symptomatic disc injuries which are beyond the scope of this blog post) AND the outcome can not unreasonably post date the auto accident (It is not plausible to relate neck pain 6 months after an auto accident if it did not show up sooner).

3. A lack of a more likely or probable alternative explanation for the symptoms– A patient who is obese but has no signs of prior back pain can not have their obesity blamed for their back pain if the pain first presents following a Baltimore auto accident.

Mr. Freeman concludes that “when using these guidelines in a narrative report setting, the clinician can write that the essential causal elements of biologic plausibility, temporality, and lack of likely alternative explanation have been met for a give case…and that a particular symptomatic disk injury resulted from a particular motor vehicle crash, as a reasonable medical probability.”

Disk injuries are very common injuries following Baltimore auto accidents. It is imperative that any provider understand how to appropriately diagnose and causally relate these injuries, as it affects the ability to properly treat these injuries and bring about symptomatic relief for patients.

If you, or anyone you know was involved in a Baltimore auto accident and have suffered from intervertebral disc injuries, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

Dr. Gulitz

Seat Belt Induced Injuries in Baltimore Auto Accidents

Believe it or not, wearing a seat belt can actually cause injuries if you are involved in a Baltimore auto accident. Don’t get me wrong- this is not a license to unbuckle and drive without a seat belt harness. Seat belts were invented to prevent catastrophic injury and ejection from a vehicle and should be worn any time an occupant gets behind the wheel. Interestingly, the forces that restrain an occupant and prevent ejection can be the cause of other lesser seen injuries in the cases of Baltimore auto accidents.

One of the most important indicators to the possible presences of these seat belt injuries is what is referred to as “seat belt sign.” This is the presence of an abrasion (redness, scraping) located over the abdomen, pelvic region, neck, or breasts (or anywhere a seat belt is worn).

In children the presence of seat belt sign may indicate a SCIWORA injury. This stands for Spinal Cord Injury Without Radiographic Abnormality. Admittedly, I have never seen it in my 5 years of clinic practice to date. During the deceleration phase of the rear-end whiplash injury internal organs can sometimes get compressed between the seat belt and the spine causing organ damage and even dislocation of spinal segments. This can cause severe compression to the spinal cord that can be missed on standard radiographic (x-ray) examination. Presence of a seat belt sign in children should warrant further abdominal MRI in children and may prompt an MRI to rule out SCIWORA.

In addition to the lap belt causing injury, the shoulder harness can injure an occupant as well, depending on where it contacts the neck of an occupant. This is also especially true when the webbing lays across a child/young adult’s neck rather than their chest. This is seen when the webbing is not adjusted to an occupants height appropriately. It can cause seat belt sign on the neck which can indicate damage to the vascular structures of the neck. Most notably, it can cause compression and tearing of the carotid and/or vertebral arteries. Careful evaluation may include doppler ultrasound to the affected structures or MRA evaluation. The discussion of MRA evaluation is beyond the scope of this blog post. Please contact me if you want more information.

Finally, women are especially susceptible to seat belt sign following a Baltimore auto accident as well. Due to the anatomy of their breasts, they can develop seat belt sign across their breasts. In some cases this can cause break down of fatty tissue in the breast region, known as traumatic fat necrosis. This can lead to a change in the shape and look of their breast tissue. There has been some research indicating that this can lead to breast cancer, although research in that category is not conclusive at this time. Additionally, women who have artificially augmented their bosoms can suffer from a traumatic capsulotomy where their augmented breasts begin to display asymmetry following a whiplash injury or where their breast implants actually get punctured as a result of a motor vehicle collision in Baltimore.

Once again, these seat belt signs are certainly not very common and even when present, do not necessarily indicate internal damage as described above. I always tell patients that they know their body better than I do and that if they suspect there may be internal damage that they should talk to their providers about having more thorough examinations be performed.

If you, or anyone you know, has suffered from an auto accident in Baltimore and have seat belt sign or other forms of whiplash, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

The preceding information was found in the book “Whiplash and Mild Traumatic Brain Injuries” by Dr. Arthur C. Croft (pages 202-203.)

Dr. Gulitz

Neck Exercises Following a Baltimore Auto Accident

As a chiropractor that routinely treats patients with neck pain following Baltimore auto accidents, it is not uncommon for me to treat patients with a combination of both joint and muscle pain and dysfunction. Traditionally Chiropractors have been thought of as providers that only engage in only passive therapies- that is treatment where a patient has the therapies done TO them, instead of by them. To some degree this is true. I offer patients electrical muscle stimulation, ultrasound, intersegmental traction, and even spinal manipulation which are all passive modalities. Research has shown that in addition to passive treatments, more active treatments such as muscle stretching and resistance exercises help patients to decrease pain, increase ranges of motion, and decrease healing time. More interestingly, the faster a patient resumes active therapies following their injury, the faster they heal.

At Mid-Atlantic Spinal Rehab & Chiropractic we offer both passive and active modalities to help our injured patients heal from whiplash following Baltimore Auto Accidents.

Assuming that a patient has an injury to the joints and muscles of their neck, lets take a look at a few exercises we would likely have them perform in the office. Keep in mind- no two patients are the same and some patients may require additional or different exercises depending on their specific condition and injury. These exercises are to be considered a guideline for neck stretching. Please contact me or another healthcare professional if you have questions before performing any of these stretches on your own.

1. Side Bending Stretch (Lateral Flexion). A link can be seen here. You lean your ear to your shoulder as far as you can. Make sure to repeat both sides and not push past perception of pain.

2. Turning Stretch (Rotational Stretch). A link can be seen here. You turn your chin towards your shoulders as far as you can. Make sure to repeat both sides and not push past perception of pain.

3. Chin out/Chin Back (Protraction/Retraction Stretch). A link can be seen here. You “jut” your chin forward and bring it back (think about making a “double chin”), paying particular attention to not extend your neck. Typically extension will bother your condition following whiplash, although this is not always the case.

4. Isometric Resistance Stretching. A link can be seen here. This is the addition of light resistance, either by utilizing a hand, a towel, or a small ball to engage muscles actively while restricting joint motion. These are considered a progression over the first three stretches we discussed and should be worked up to over time.

If you, or someone you know, has suffered whiplash and has neck pain as a result of a Baltimore Auto Accident, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help.

Dr. Gulitz

Measuring Activities of Daily Living following Baltimore Auto Accidents

As prolific readers of my blog, many of you know that I spend a fair amount of time discussing diagnosis and treatment of patients who have experienced headaches, neck pain, or back pain following Baltimore auto accidents. Appropriate diagnosis and treatment are paramount for the Baltimore auto accident patient since patients want to feel better as fast as possible following an injury.

One of the services I provide to my patients that many other local providers do not is an analysis of a patient’s activities of daily living. That is, I try and figure out what degree their pain and discomfort impacts their normal activities of daily living, or ADLs.

I understand that the patients I treat in this office are not just “my patients”- they are also bosses, employees, brothers, sisters, husbands and wives. They have responsibilities to themselves and their families outside of my office. Pain is more than a physical thing when it impacts other areas of life. While I understand that often times neck and back pain are not “life threatening” this pain is often “quality of life threatening” when a mother has too much back pain to lift up her child without back pain, or when a father has too much back pain which prevents him from going to work and earning money for his family.

In my office we discuss not only the pain a patient is feeling, but also the impact that that pain has on their activities of daily living. There are three main areas of ADLs that we discuss and one other area, that while important, most patients do not usually openly discuss with me:

1. General Activities– sitting, standing, bending, lifting, walking, lying down, sleeping, and driving.

2. Duties Under Duress– working, housework, dressing, personal hygiene, and child care

3. Enjoyment Activities– using the computer, watching television, reading, exercising, (other personal enjoyments).

*4. Loss of Consortium- If couples are unable to be intimate and engage in a sexual relationship due to pain.

Most times when a patient feels better with the Baltimore auto accident treatment provided in this office they are able to resume their ADLs and are able to be discharged from treatment without ADL impairment. Sometimes, however, that is not the case and a patient is released with residual pain and residual impact on ADLs. While unfortunate, the documentation allows me to effectively communicate this disruption in their lives to their personal injury attorney so that they can be compensated for these problems and the disruption that it has caused to them personally.

If you, or someone you know, has suffered from a Baltimore auto accident and require treatment, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

Dr. Gulitz

More On Disc Herniations Resulting from Baltimore Auto Accidents

In the last blog post I mentioned the prevalence of disc herniations in the asymptomatic population. We discussed that despite prevailing thought that approximately 50% of the population has an asymptomatic (painless) herniated discs, we discovered that the true number is probably closer to 20%. The other 80 percent of population that has herniated discs get to be this way due to the gradual breakdown of the discs, usually initiated by a series of micro traumas, and can also result from overt traumatic events such as falls, and motor vehicle collisions (Baltimore Auto Accidents).

So now that we know how prevalent these injuries are, what exactly IS a herniated disc? I am sure we have all heard about “slipped” “prolapsed” “blown out” “ruptured discs” and “shredded” discs, but what does it all mean?

Fortunately the American Society of Neuroradiology and the North American Spine Society have come together to release terms that all doctors and laypeople can use to discuss disc pathology in order to better understand what is going on.

1. Disc Bulges– A common term denoting less than 3 mm of extension beyond the normal disc margin. There can be symmetrical bulging or asymmetrical bulging (right sided vs. left). These are not considered herniated discs.

2. Disc Protrusions- A type of disc herniation where the distance of protrusion is less than the width of the base.

3. Disc Extrusions- A type of disc herniation where the distance of protrusion exceeds the width of the base.

3b. Sequestered Disc Fragments– These are a specific type of disc herniation where the extruded disc fragment has penetrated the outer annular fibers and has broken loose.

A visual of the different type of disc injuries can be seen here.

An important thing to consider as a Chiropractor that treats patients involved in Baltimore auto accidents resulting in disc bulges, disc protrusions and disc extrusions is that everyone is different. That is, just ordering an MRI and having an MRI report does not tell me how to best help a symptomatic patient. Typically, I concern myself with the degree, if any, there is neurological compression in the spine. That is, typically the bigger disc injuries (disc extrusions) cause more neurological findings such as numbness, tingling, or weakness, and need to be treated more cautiously. Provided that there are no signs of stenosis or lower motor neuron lesions, it is typically safe to perform Chiropractic spinal manipulation/mobilization to the affected spinal levels. As always, patient preference is taken into account and patients that are fearful of being adjusted will instead be focused on corrective therapeutic exercises and spinal mobilization, similar to what they would do if they were being treated by a physical therapist.

Most patients with disc bulges and protrusions respond favorably to chiropractic care. Those that do not respond to care are referred to an orthopedic spinal specialist for a second opinion and future treatment recommendations. Although every case is unique, as a general rule, most bulges and protrusions do well with chiropractic care, while most extruded discs with and without sequestered fragments are typically not as responsive to care and are referred out to a specialist quickly.

If you, or someone you know has suffered from a disc bulge, disc protrusion, and/or disc extrusion as a result of a Baltimore auto accident and are in need of treatment, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

Dr. Gulitz