📍 Thanks for joining me today on the Lawyer's np. I'm Linda, your very own nurse practitioner and legal consultant. This week we are continuing our deep dive into spinal injuries by focusing on radiculopathy. This episode is the missing piece that ties our last two discussions together. By the end of today, you'll see how to pull these clinical threads into a cohesive narrative, giving you the medical ammunition you need. To be better advocates for your clients and challenge those common defense narratives.

This show is for informational purposes only and is not medical or legal advice. See our show notes for the full professional disclosure. Over the last two weeks, we have talked about the cervical spine, focusing on the spinal nerves and their functions. We talked about how a simple soft tissue case. Can be a high value neck pain case.

When the patient's pain is persistent, you now know what medications to look for when reviewing neck pain cases and what those medications are doing to relieve pain. Last week we covered disc herniations.

You know that disc herniations don't always cause pain. People live with asymptomatic disc herniations every day, but low impact collisions can be the catalyst that causes a biochemical cascade leading to inflammation and chemical injury to localized nerves that is invisible on MRI.

This week, we are going to continue to grow your knowledge by discussing how the chemical burn contributes to your client's symptoms of radiculopathy. I am almost certain that you have come across the term radiculopathy in your client's charts, but after listening to the last two weeks episodes on the cervical spine and disc herniation, you're really starting to get a clear picture of the real impact it can have. By definition, radiculopathy is the result of compression or irritation of a spinal nerve root.

The compression or irritation results in pain, numbness, tingling, muscle wasting, and muscle weakness. Keep in mind that radiculopathy can either be caused by direct mechanical compression. By a fully herniated disc that would be easily seen on imaging, or it could be chemical irritation. And like we discussed last week, that is invisible on imaging.

Radiculopathy can be diagnosed with imaging studies or with in-office testing as long as it's accompanied by a really good history. What I mean when I say a good history, it's a thorough interview portion. The components of a good history from a nurse practitioner's perspective would include the onset of symptoms. When did your client first notice they were having symptoms?

Was it immediately after the accident? Was it two weeks after the accident? And what, if anything, brings the pain on. How long have the symptoms been present? This really tells the chart reviewer how important this was for the client to address. Just think about it. How many times have you looked in a chart and saw that your client took two months to talk about their neck pain that began immediately after the accident?

Now, if your client lives in a state where healthcare is saturated, and it took them two months to see their PCP. More defensible than someone who just didn't think to schedule an appointment.

What makes the pain worse or aggravating? Factors? This is super important for you to have. This gives you clear information about your client's limitations before attorneys are involved. It's almost as unbiased as it gets if laying flat makes the pain worse. If their sleep quality is likely severely impacted and that alone will bleed into other aspects of their lives.

How about if driving is now painful and they drive for a living? This can really impact their ability to care for themselves and their dependence financially. What makes the pain better or alleviating factors? This helps practitioners guide treatment for the client and helps anyone reading the chart. Really understand how severe the pain is.

Alleviating factors could be as simple as Tylenol with a salonpas, patch, and if you don't know what that is yet, wait until you're 40 or pregnant. To find out.

The quality of pain is important for the provider to note. Is it burning pain localized? Scattered? Does it radiate? Is it a stabbing pain? All of these descriptions help narrow down the cause of a client's discomfort. It is also very useful to have a pain rating scale noted in the chart. Most clinicians use a variation of the Wong Baker faces scale paired with a numeric scale.

So any scale that's used is helpful in determining the client's subjective pain level at the time of the appointment. This also helps guide therapy as a medication management. Take a quick moment to think about how many charts you have seen that don't include half of these items. I have reviewed enough charts for attorneys to know that these questions are skipped over by providers fairly frequently, but when you have a chart that has all the right elements, it is so refreshing because it provides solid groundwork for you to fight for your client.

Once a solid history has been completed, a thorough physical exam should be done to evaluate the source of the pain. I have a list of in-office testing that can be done for neck pain with a brief description of how the test is performed. If you want it, go ahead and email me for the PDF, it's a really helpful tool that I use with my attorney clients so they have a clear picture of what's happening in the provider's office at the time of their client's visit. Once the physical exam portion is done, imaging is usually ordered if it wasn't done already.

Imaging studies can be helpful with, x-rays showing narrowing within the spinal column. Fractures or structural changes. Cts offer more detailed pictures with three dimensional images, and of course there are MRIs. These show soft tissue damage that may be leading to compression of the nerve or spinal cord injury.

Beyond imaging, there are EMGs or electromyography. These measure electrical impulses in the muscles that can show if the nerve is functioning as it should. This can help differentiate whether or not nerve compression is contributing to the client's symptoms or if a disease process is contributing to their symptoms.

Now, I have heard this question from my attorney clients more than a few times, so let's talk about it. If the MRI is negative, can you actually prove my client has radiculopathy?

The short answer is yes. Diagnosing Radiculopathy goes beyond just an MRI, the client's symptoms, physical exam findings, and electrodiagnostic results when combined are enough to not only diagnose this condition, but can help determine long-term prognosis.

Electrodiagnostic studies can be done, but these have limited use in distinguishing noncompressive causes of radiculopathy if they don't include multiple myotomes or dermatomes. Electromyography is helpful because it provides objective information that can show changes in the nerve that are often missed on an in-office exam.

There is something that I almost never see in physical exams or even when I attend defense medical exams. I don't see this happening, but it's bilateral limb circumference measurements. This is a huge miss for most providers, so make sure you look for this when you're reviewing chart notes for your radiculopathy clients ensure the provider assessed for muscle wasting on the affected side obtained a comprehensive history of injury.

Ensure the provider assessed for muscle wasting on the affected side. Obtain a comprehensive history of the injury and ensure the progression of symptoms have been well documented. I can't tell you how many notes are missing physical exam assessments that include measuring the affected muscle or even bilateral strength testing.

Not having these items to compare over time can hurt your case, but having the objective measurements can really make your case. Imagine having one provider measure the circumference of the client's bicep the first day. Your client complains of neck pain and every visit after. As symptoms fail to improve, you get an objective measurement every six to eight weeks. Can map out the deterioration of the muscle group to prove there is an actual cervical issue. You get an objective measurement every six to eight weeks and can map out the deterioration of the muscle group to prove there is an actual cervical issue.

Okay. I know I have ranted about the value of physical therapy and occupational therapy notes before, but this is something many of those providers will put in their notes at the beginning assessment and any follow-up assessments after to ensure the client is progressing. Be sure to get elbow deep in those charts when you have them. In summary, in-office testing for radiculopathy when combined with the patient's history and physical exam findings.

Can support the diagnosis of radiculopathy despite having a negative MRI. If you want the full list of in-office testing, that can be done to help diagnose cervical radiculopathy when the MRI is negative. Email me for the list of in-office physical exam testing you should be looking for in those charts .

Another question I'm asked pretty often is if the patient did not report radiating pain until two weeks after the injury, doesn't that suggest an intervening cause?

This one is not as cut and dry as most of you would like it to be, but I will say there are ways to prove that the delay was due to inflammatory processes, which can take time to fully present. A delay of two weeks is often seen in the clinical setting as the time required for secondary inflammation or chemical inflammation to develop after a trauma.

We want to ensure that the chart notes exclude other peripheral nerve disease as possible diagnoses, or that they have at least been listed in the differential diagnosis. Because these conditions can mimic the symptoms of radiculopathy. There's also a specific form of degeneration that can occur and can take up to six weeks to appear.

So if you're seeing that in your chart notes, reach out, I'd love to explore that with you further. All in all, there is a period where the injury has occurred, but the clinical and electrodiagnostic evidence has not yet fully matured. The client's symptoms have appeared after two weeks because it took that long for the inflammation to reach the point of impacting the nerves directly.

Another great question I am often asked by my attorney clients is, does a successful epidural injection mean the injury is healed or just masked? Epidurals are a tool for symptom control. They're not a cure for the underlying structural injury. We learned in the last couple of episodes that patients with cervical spine pain see their symptoms resolved with conservative treatment. That includes physical therapy, occupational therapy, and medication management.

Epidural steroid injections can be used as a follow-up option for those who still feel pain after their initial efforts have not been successful. We talked a bit about how imaging can show a herniated disc with no pain and how it can show no herniation in a patient with pain. Steroid injections help reduce localized inflammation, but if there is a structural issue seen on an MRI that's contributing to the pain and it's not just inflammation, the injection won't fix the structural issue.

Pain may improve because the inflammation is reduced, but the structural defect is still there. Essentially, a successful injection, can heal the acute inflammatory process that is contributing to the radiating pain, but it does not necessarily heal the mechanical injury like a tear in the disc or a bone spur. Instead, it manages the symptoms to a point where your client may no longer require more invasive interventions like surgery. That was a long way of saying that injections are categorized alongside physical therapy as part of managing the condition, and This is often used by pain management specialists to reduce inflammation related radiculitis. So inflammation around the nerve root pain reduction with an epidural injection is not a cure. It's just a way to manage symptoms.

Okay. Now my favorite question that I'm asked isn't it true that most adults over 40 have some level of degenerative disc disease that could cause these exact symptoms?

Well, yeah. They absolutely could have had disc degeneration before their accident, but it likely was not causing pain. Before the accident last week, we talked about how the disc is sensitized. How the accident is the catalyst to push the disc over the edge and become compromised, causing pain due to the chemical spills and inflammation. Remember, just because the imaging shows a problem doesn't mean that the problem is the cause of the patient's pain.

Abnormal imaging results can happen in healthy people, so having an EMG or NCS can help determine if the abnormality is a contributing factor for your client's pain. This is where the physical exam and history of presenting illness becomes so important. If you're lucky and your client has been going to the same primary doctor for at least two years, there's a good chance you can look back and see that there were no back pain issues noted. But I would bet that most of your clients have not had the same primary doctor and have no prior documentation that supports the fact that their back pain began after their accident.

If that is the case, not to worry. Their most recent assessment after the accident can be helpful as long as it has all the factors that we talked about earlier, like onset of symptoms, aggravating factors, alleviating factors, et cetera.

Now let's move into a case study so we can tie it all together. Bill is a 42-year-old who is right hand dominant. He's a software engineer and is in your office because he was in a collision 12 months ago, but still suffers from chronic burning neck pain that radiates into his right pinky finger. He's got this persistent right hand weakness and heaviness because of it.

He was involved in a high velocity rear end motor vehicle accident about 12 months ago. He was seen in the emergency department immediately after his injury and diagnosed with a sprain or a strain. Had cervical spine x-rays done and was cleared from the trauma team. He was told to take over the counter Motrin or Tylenol and to follow up with his primary doctor the following week. He saw his primary doctor a week later and was managed conservatively.

His doctor ordered physical therapy, ibuprofen, 800 milligrams, and a follow-up in eight weeks. Since then, bill has bounced around from doctor to doctor because he's moved a few times for work. He has mentioned the pain to his other doctors but doesn't have the records with him. He's not seen a pain specialist but did have physical therapy after the accident for his neck injury.

The PT notes mention the radicular symptoms evolving and recommending follow-up with his doctor, but he moved before he could get a referral to his spinal surgeon. He has been taking gabapentin for the pain and it helps to reduce his symptoms. He feels like it helps, but finds that it's causing him to be more sleepy.

So when he's at work, he can't focus because of this. He only takes the gabapentin when he's not working, leaving him in pain the entire time he has to work. Over the last 12 months, he's felt localized pain in his neck that's transitioned into radicular symptoms, nerve root involvement. He now notices that he's not as strong as he used to be. His right arm feels weaker than his left. Remember, he's right hand dominant, so it should be stronger than his left.

And lately he's been dropping items when he holds them in his right hand. About six months after his accident. He had an MRI done. It was normal, so he stopped pursuing treatment because he felt like no one believed he was still hurt. While the MRI was negative, the physical exam. His current doctor did provided amazing objective evidence of a permanent injury. His new doctor is gonna get a gold star for his physical exam, and you see this in the chart notes. Sperling's test positive cervical distraction, positive deep tendon reflexes, abnormal on muscle inspection. The doctor noted atrophy or wasting.

As a legal pearl, muscle wasting is an objective finding. Bill cannot fake the physical loss of muscle mass. This indicates chronic long-term nerve compression that has led to denervation. In this case, the MRI showed no significant disc herniation. MRIs are usually taken while the patient is lying flat and still. But pain often occurs during movement.

During compression of the spinal column, the accident may have caused a micro tear in the disc while the disc hasn't slipped. Inflammatory biomarkers leaked onto the nerve root, causing burning and inflammation without a visible mass. On the MRI, bill has failed conservative therapy. And has a gap in his medical records with a negative MRI.

Good thing the current provider did all those in-office exam maneuvers because that provider can now diagnose radiculopathy and that provider can get your client to the right specialist for electro conductive testing. When you're reviewing cases like this, be sure to consider the reasons for your client's gaps in care.

Bill wasn't intentionally skipping appointments. He had to move for work to earn a living and support himself. This can make a huge difference in how you think about advocating for your client. Getting back to the case study, remember Bill reported taking Gabapentin. And while Gabapentin provided him with a reduction in the burning sensation, he was likely feeling the side effect of somnolence or sleepiness created a loss of enjoyment of life and loss of earning capacity.

He couldn't safely perform his duties as a software engineer while he was medicated. Having to choose between pain and earning a living is tough for anyone. Just think of that impact. When you have your client, just think of the impact that alone will have on your client's professional and personal life.

As we wrap up this episode, I want you to remember one critical takeaway. A negative MRI does not mean a lack of injury. If your client is presenting with classic symptoms of radiculopathy.

Look past the imaging report and dive back into the provider's physical exam notes, documentation of specific clinical markers like dermatome, sensory deficits, reflex changes, or provocative testing is often where the proof of injury lives. Before we conclude , I wanna give you some key medical legal terms for cervical spine litigation. Let's do a rapid fire review of some of the terms that are essential for your discovery and demand letters. When you are searching for expert support or drafting motions.

Remember these high value phrases, biochemical mediators of discogenic pain. Use this to pivot away from physics-based, no impact defenses. Cervical radiculopathy versus brachial plexopathy.

This is crucial for a accurately localizing nerve injury. Acute annular tear in low velocity impact. This challenges the degenerative changes narrative. Chemical radiculitis without foraminal stenosis. Explaining why your client has 10 out of 10 pain, even with a small bulge post. Post-traumatic cervical spondylosis acceleration.

This is the medical term for your eggshell plaintiff argument. Mastering these specific terms allows you to speak the language of the clinicians, and more importantly, effectively cross examine defense experts who rely on outdated biochemical models. Don't let a normal MRI report serve as the final word. When the patient's clinical presentation tells a completely different story.

📍 I hope that this episode combined with the last two, has given you the confidence to advocate more effectively for those clients who are falling through the diagnostic cracks.

And remember, you don't have to navigate those voluminous complex medical records alone.

If you need a partner to help distill that data into a clear, compelling narrative, I'm here to lend a hand. Be sure to visit my website, clear advantage lnc.com. Send me an email so we can connect.

Thanks for listening, and until next time, stay medical legal ready.

My Client has Radiculopathy symptoms, but the MRI is negative—now what?