In a developing body of testimony, many doctors and therapists treating our injured clients seem to us to be articulating a comprehensive medical basis for long-term back and neck symptoms. The following is our understanding of the analysis we are hearing through medical-legal testimony about some of the reasons for persistent musculoskeletal conditions in our clients. Comments and clarifications from our readers would be appreciated to increase our understanding.
Thirty years ago, when I began practicing personal injury law, conventional wisdom in the medical community was that soft tissue injuries should heal completely within 2 to 4 months. Doubts were often raised when injured clients continued to complain of pain beyond 2 to 4 months. Something other than organic injury was often assumed to be going on.
Many practitioners held to this conventional wisdom. Some doctors were at a loss to explain medically the long term pain of their patients, many of whom they considered to be good, credible people.
Better understanding of ligaments and their role provided some answers. Since ligaments do not get a rich blood supply they take longer to heal than muscles. Also, they sometimes do not heal as completely if stretched or torn. This phenomenon can produce long-lasting debilitating symptoms.
Thus, pain which extends beyond the time normally anticipated for muscle recovery may be attributed to injury to ligaments. The ligaments include the ligaments which maintain the stability of the spine or SI joint. (See “Doctors’ Testimony Key…,” lead article in Volume 15 of the State of Jefferson MEDICAL-LEGAL JOURNAL). Traumatic injury to a facet joint capsule, a structure which, as you know, has a large ligamentous component, is yet another cause of persistent symptoms.
Another source of pain which appears to us to be increasingly better understood comes from internally deranged disks. In a recent deposition, a local orthopedic surgeon opined that most (about 90%) injured (strained/sprained, torn) disks get better, albeit slowly and sometimes incompletely. The other 10% or so have lasting symptoms. Trauma, then, often produces injury to a disk. The accompanying muscle spasm can be a reaction to the injured and painful disk, rather than due solely to an injured muscle. The muscles are reacting to the disk injury, the trauma to the annulus.
Historically, extremity pain associated with a spine injury was only explained if there was a pinched nerve causing radicular pain. Now many spine specialists recognize that a compressed nerve is not necessary for there to be limb pain. You can have referred pain from an injured disc, rather than radicular pain. Much as a heart attack causes referred pain to the arms, you can have referred pain from the vertebral joints to the arms or legs. However, the primary injury may be to the disk itself. While there may be referred pain in the limbs, the symptoms may be primarily back or neck pain. The extremity pain can result from chemical irritation of the nerve caused by the injured disk.
The renting of the tissues in a disk may also reduce the disk space height through a loss of hydration and cause foraminal stenosis, a reduction in the size of the hole where the nerve comes out. In this way, an injury may result in a condition often attributed to foraminal bone spurs. The bone spurs may indeed be present, but the main reason for the stenosis is often now thought to be the loss of height due to the disk injury.
As I have heard it explained through testimony, another significant aspect of the disk is that its outer aspect is richly innervated, whereas the inside of the disk has no nerve endings. So, one may have internal tears in the disk and not be aware of them. Then an injury suddenly extends the tears to the outer aspect bringing the onset of symptoms.
One of our clients suffered with neck pain and right-sided focal headaches located behind his eye after a traumatic injury. His primary complaint was his headache, which he described as feeling like someone was sticking a knife behind his right eye. He had been hit by a forklift and thrown about twenty feet and landed on his shoulder. His headaches persisted long after his shoulder pain was gone and physical therapy had concluded. Medications did not seem to help.
A pain specialist was called in who diagnosed facet joint mediated pain. The injury trauma to the facet joint disrupted the capsule around the joint. The headache pain was found to originate from the injured C2-3 joint capsule. The C2-3 nerve and the branch going up the occiput (the third occipital nerve) was irritated and this lead to his headaches.
The diagnosis was obtained by the use of precisely administered injections blocking the nerves that innervate the C2-3 joint and blocking the joint itself. When the patient reported a significant decrease in pain level on the visual analog scale (VAS) after the injection, the doctor knew that the source of the pain had been isolated.
The pain was treated by means of a radio frequency injection procedure. Instead of standard spinal needles, cannulae were used which were attached to a radio frequency generator which heated the four-millimeter active tip of the needle. The needles were placed in the same precise manner as those doing the nerve block, except the purpose this time was to cauterize and transect the nerve to achieve longer lasting, if not permanent, pain relief. If complete and permanent relief do not occur, it may be for two reasons: 1) the nerve branch may be thicker than the probe, making only partial lesion possible; or, 2) the nerve may regenerate after 8 to 12 months and the pain will recur.
The point of explaining this diagnosis and pain treatment procedure is to underscore the reality of historically unrecognized long-lasting, if not permanent, pain syndromes resulting from spinal injuries.
Our hope is that with these medical developments, your patients may obtain more effective diagnosis and treatment for the painful results of their injuries. Also, we hope that our clients may secure compensation, settlements and judgments commensurate with the full extent and effects of their injuries, because their symptoms can now be explained anatomically. Finally, we hope people suffering the painful aftermath of their injuries will no longer endure the added insult of being told there is nothing medically wrong.
This article was prepared by Dennis H. Black