Transcript: Identifying Hidden Value in Cervical Spine Cases

Hey guys, and welcome to the Lawyers NP I'm your host Linda Acker.

Before we dive in, it's probably good for you to know a bit about me. I've been in the medical field for about 16 years, and advocating for patients is second nature to me, but over the last two years, I've found a way to advocate for them long after their visit, helping those whose pain remain. It started when I began working with an amazing attorney who's a close friend of my husband.

I realized I loved the detective work, digging through charts to find those objective strengths and weaknesses to help attorneys fight for their clients. It allows me to teach the medical terms and the real life implications of a diagnosis to the one person who can help that person in a way I couldn't directly, their attorney. And what better way to reach more attorneys than with a new podcast? So let's get to it.

This show is for informational purposes only and is not medical or legal advice. See the show notes for the full professional disclosure.

So most attorneys look at the records for a client with neck pain and see standard soft tissue claim. But when you're reviewing medical chronologies, if you aren't looking past that negative x-ray or really looking at the medication lists and seeing the inconsistencies in the medical record, you're leaving money on the table and letting the defense win. Today we're breaking down the anatomy of a high value neck pain case.

Before we even get into what your client is feeling, we have to get a little bit of background. Let's start at the beginning. What are nerves and why do they matter? We know they help enable movement by sending signals from the brain through pathways that trigger different parts of our bodies to act in ways that we need them to. Our nerves impact so many aspects of our daily lives that we don't even think about.

Our voluntary movement, our five senses, breathing, digestion, how fast our heart beats, how we respond to internal and external stressors, and even down to our blood pressure. Nerves are behind it all. The brain and spinal cord are part of the central nervous system. The central nervous system is constantly processing the input that it receives from the peripheral nervous system. The peripheral nervous system is a complex network of nerves that sends signals from all over the body back to the spinal cord and brain for processing and decision making.

So let's focus in on the spine a little bit further. The cervical spine is made up of the first seven vertebrae in your C spine, so C one through C seven. Simple enough, your cervical spine provides support for the weight of your head, surrounds and protects your spinal cord, and helps with a wide range of head movements. Each vertebrae or bone in the spine is connected at the back by special joints called facet joints. They allow forward, backward, and twisting movements, the neck is able to perform. The spine is also surrounded by muscles, nerves, ligaments, and tendons, which is all very important when you're thinking about a whiplash case.

There are intervertebral discs that act like cushions between each vertebrae and absorb impact. The muscles of the neck includes things like the trapezius muscle and muscles above your shoulder blades, and a few others that help with movement of the cervical spine. There are also some key ligaments in like the anterior longitudinal ligament, posterior longitudinal ligament, and ligamentum flava that stabilize your C-spine.

There's one whole other layer to this. There are eight nerves that exit through the cervical spine, known as C one through C eight that mainly function to manage movement in your neck, shoulders, arms, and hands. These nerves provide sensation awareness, think about constant input from your body getting funneled through those nerves to give you constant information on what your body is doing in space all the time.

Cervical nerves, C1 through C3, help control movement. So forward, backward, and side to side movements. C3 is in charge of sensation on the sides of your face in the back of your head. C4 controls the shoulder shrug movement and the diaphragm. It also provides sensation for parts of the neck, shoulders, and upper arms. C5 controls the deltoid muscles of your shoulders and biceps, as well as providing sensation to the upper part of the arm, down to the level of your elbow. C6 controls the muscles of the wrist and bicep, as well as providing sensation to the thumb side of the forearm and hand. C7 controls your triceps and wrists as well as the sensation of the back of your arm and middle finger. That one controls your hands and gives sensation to the pinky side of your hand and forearm.

As you can see, your cervical spine does way more than you probably ever knew it did. So when there's damage to the cervical spine, you can see how much that can really impact a person and change their quality of life. All those muscles and nerves rely on the central nervous system to receive, process and guide movement.

So now that you know more than you probably ever wanted to know about the cervical spine, let's jump into a case study. Let's say you have a 56-year-old woman named Mary who walks into your office and tells you a heartbreaking story. She was at a red light , she was fully stopped and was rear-ended by a work truck. The initial event happened about eight months ago, but she's still experiencing significant pain in her neck that radiates down her right arm. The vehicle that struck her was traveling at about 20 to 25 miles per hour, and there was moderate damage to both vehicles.

At the time of the event, Mary felt shaken up but didn't wanna go to the hospital because she didn't really feel that bad. She did experience pain that evening, but was able to take Tylenol, apply some warm packs to her neck, and then she just went to bed.

The next morning was when all of her troubles began. She woke up with a stiff neck, a dull headache at the base of her skull, and heaviness in her right shoulder. She ended up in an urgent care office two days later. Her vitals were stable and within normal limits for her age. She has no significant medical or surgical history and has never had back pain or neck pain in the past.

She takes daily supplements like calcium and a multivitamin, but has no other medical conditions. She's active, usually walks three miles a day and works full-time in real estate. Her exam findings are significant for a limited range of motion in her neck for when rotating from left to right, tenderness over her right trapezius muscle, equal strength bilaterally, and she is neurologically intact.

Her provider ordered an x-ray that was done and read in office. The x-ray looked normal and didn't have any fractures. She was sent home with a diagnosis of whiplash. She received a prescription for Naproxen 500 milligrams and Flexeril 10 milligrams as needed, and told to follow up with her primary care if pain does not improve in a week.

So let's take a moment to think about why it took Mary some time to really feel her pain. Mary likely experienced an acute stress response at the time of her accident. What happens when you have an acute stress response?

The body does this amazing thing that helps you survive the moment of stress. When your body is exposed to a large stressor, the body releases a series of hormones that can increase heart rate and release adrenaline effectively numbing any pain you may have, so you can survive the moment and get to safety.

Once those hormones and the adrenaline wear off. It could be minutes, could be hours, depending on how much was released and how quickly the body is able to process and excrete or store the compounds. That's when the pain begins. I mean, this is a truly amazing system that impacts the entire body.

The person experiences increased heart rate, stronger heartbeats, widening of the heart to accommodate more volume and your cardiovascular system even redirects blood to large muscle groups so you can be ready to fight or flee. Just doing a little dive into the medications that typically are prescribed for acute pain or musculoskeletal injuries.

I know Ibuprofen is one of the mainstays of treatment as a provider, if the patient is healthy and young enough, because it does have a slew of side effects. But, ibuprofen is honestly one of my favorite medications for healthy adults and children. It works as a nonsteroidal anti-inflammatory to reduce inflammation without a prescription needed and is great to use in those who have had an event that causes acute localized swelling or inflammation, but don't need the prescription strength of a steroid to reduce the inflammation.

Flexeril is frequently prescribed as well. It's also known as cyclobenzaprine. It's used for the management of muscle spasms and is part of a group of drugs called cyclical antidepressants that help reduce muscle overactivity. This medication is currently FDA, approved as secondary treatment for muscle spasms when combined with rest and physical therapy. Good for short term use, nothing long term.

Other medications that you may see prescribed for your client include things like prednisone. If you see this think of aggressive inflammation, the provider is likely trying to reduce their inflammation rapidly because it is that out of control. This changes the case from a mild injury to something a bit more severe. Prednisone works as an anti-inflammatory by inhibiting an enzyme that releases pro-inflammatory mediators that lead to a cascade of inflammation. Gabapentin is another medication that you probably see very frequently in medical records.

If you see gabapentin, but no diagnosis of radiculopathy, the provider likely forgot to add it. Gabapentin works by treating nerve related pain, so paresthesias like pins and needles in the extremities. When you see this medication and the client says it helps, but there's no diagnosis of radiculopathy. It likely just hasn't been officially diagnosed yet, although it is being managed as such.

Tramadol, that's the next go-to when Ibuprofen and Tylenol fail. Tramadol steps up and helps relieve pain. It's a dual acting pain relieving medication that actually changes how the brain sees pain.

Celebrex. That's another one you may see, but it's not often prescribed. It's also a non-steroidal anti-inflammatory, kinda like ibuprofen, but it has lower risk of causing stomach bleeds. It helps like every other NSAID or non-steroidal anti-inflammatory by reducing inflammation, swelling, stiffness, and joint pain.

Naproxen that's another one that's pretty frequently prescribed. It's a low cost NSAID that reduces hormones that contribute to inflammation.

Okay, back to Mary. Her imaging was done in the urgent care and it was read by the treating physician, not a radiologist. Remember that many urgent cares send their images out to be reviewed by radiologists at a later time, the initial reading should be followed up by a final report. Be sure you are securing that final report when you're collecting the medical records.

Let's talk a little bit about why x-rays are only so good. We all know x-rays are the mainstay for diagnosing things like fractures, but they don't really catch soft tissue damage. Think ligaments, sprains, and strains. They provide really quick results but only show dense bony tissue. X-rays are really cool machines that send radiation to specific parts of the body that are then absorbed and passed through to an x-ray detector. Bones and tumors absorb the radiation very well, giving them that bright white color we're familiar with.

Muscles, fat and organs are not able to absorb the beam as well, so they look like 50 shades of gray. Alright, that was a lame joke, but you get the picture. White is bone, shades of gray are soft tissue, including ligament.

Now that we know what X-rays are capable of, when Mary follows up with her primary doctor, depending on where she's feeling the pain, it directs care. If Mary says she has point tenderness over her vertebrae, there's a good chance she has a fracture that was not visible on the initial x-ray. Why was the fracture potentially missed? That's an easy one.

If the fracture is not out of place and it's very subtle, think hairline, it just isn't easy to see on imaging within the first 24 to 48 hours. Once the body begins to repair the area and there are signs of inflammation or increased gray areas, or osteoclastic activity, think more white, fuzzy, dense areas, a few days post-accident, it's much easier to see the fracture on x-ray.

This is why follow up is so important if the pain is persistent, be sure to watch out for missing documentation in the physical exam. Make sure that you're looking at every detail in the physical exam.

Look for documentation that says what the skin around the sore sites look like. Did the provider put down that the skin was normal coloring? Was it bruised? Was it purple? Was it green? Detail is key.

When you're looking at these documents, those little things often get missed, but can really help paint a clear picture of what the client is going through. Bruising near the site of pain can indicate tissue tear or fractures.

Was range of motion tested, active and passive? Did the provider touch the area? What's also known as palpation, this often gets missed. Was flexion and extension restriction noted by the provider? Where does this put Mary?

Without a diagnosed fracture or radicular symptoms at her visit, it's usually appropriate to begin with conservative therapy. Conservative therapy usually starts out with NSAIDs and Tylenol, short course of oral steroids, if there's any suspicion of inflammation.

Avoiding activities that increase pain or paresthesias, if there are any. A short duration of neck immobilization. Some alternative therapies may include acupuncture, physical therapy, or cervical traction. Think medieval times, horses pulling in opposite directions.

You may see medications like Gabapentin or Pregabalin, cyclobenzaprine and others. Any combination of these can be tried over six to eight weeks before the provider reevaluates. Your client reevaluation should occur within six to eight weeks to determine if symptoms are improving or worsening.

The evaluation should include testing for motor weakness and muscle wasting, advanced imaging like neuroimaging. Studies of the spine and electrodiagnostic studies should be ordered, if not previously completed.

We, as providers, want to make sure that our original diagnosis was the correct one. We are looking for progression of disease that may be causing the client's symptoms to worsen, for those who have significant pain after the six to eight week period, but have no signs of neurological deficit. Epidural glucocorticoids can be injected using guided fluoroscopy by interventionalists in attempts to avoid surgery.

For those with significant radiculopathy that's confirmed on advanced imaging like an MRI with progressive motor deficits, surgery is suggested if pain persists. Remember, a negative x-ray doesn't mean that everything is fine. It means the bone is just not out of place. If your client is having difficulty holding their head up without significant localized pain, it's time for advanced imaging and further follow up.

If the pain is persistent and or out of proportion to the way the person looks and what the imaging is saying, additional imaging is usually required to confirm there's no fracture. If your client has failed, conservative treatments continues to express significant pain when a specific area is touched or pushed, additional imaging is likely the next step to ensure there's no fracture. You aren't looking at a standard whiplash case. You're likely looking at an occult injury that requires advanced imaging to prove.

Most attorneys let the defense win here because the x-ray's negative. I help you find the why behind the pain so you can justify the damages. If you're tired of leaving money on the table, visit my website, clear advantage lnc.com. Link in the bio to get your free red flag back pain tip sheet. as an attorney, you'd never tell a client to Google legal advice. You value specialization. So why treat the medical side of your practice any differently?

Just a quick note on physical and occupational therapy. Can I just say I absolutely love their documentation? They are so focused and thorough. They notice acute changes, note them and update the doctors so quickly. They work through muscle issues, find barriers to care, document changes to the client's quality of life, goals of care, to get them back to prior levels of function.

Recommended advanced referrals. They document the why when treatments stall. These therapists are with your client two to four times a week for an hour, that is worth its weight in gold. They are constantly assessing your client, and in my personal experience, have really made the case for many of my attorney clients. Seriously, they really know their stuff and make amazing recommendations when the clients are able to participate routinely.

So if you have been skipping these documents because, I get it, they document a lot. Change your practice. Don't skip it. Grab some popcorn and get in those records because the things that unfold in those notes really help make or break your case or, Hey, I'm here to help if you just don't have the time or resources to really get into those documents. Alright, that's all for today. Thanks for tuning in. Visit my website, clear advantage lnc.com. Link in the bio to get your free red flag back pain tip sheet.

📍 Email me with the title, Red Flag Back Pain. Don't let valuable clinical evidence stay hidden in the charts. Maximize your case value by letting me do what I do best so you can focus on the win. Until next time, stay medical legal ready. https://clearadvantagelnc.com/contact-legal-nurse-consultant

The information provided in this podcast, The Lawyer's NP, and any associated materials—including our e-books and templates—is for educational and informational purposes only. While we strive to provide the most accurate and current data available at the time of release, science and law are constantly evolving. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment, nor does it constitute legal advice or the establishment of an expert-witness relationship. For Attorneys: Always consult with a qualified medical expert regarding the specific facts of your case. For the General Public: Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have heard on this show. Reliance on any information provided by Linda Acker, FNP, or Clear Advantage LNC is solely at your own risk.