In this article I will focus on X-ray testing and MRI testing.
Given the standard of care in treating post-traumatic injuries, most injured people will have some sort of X-ray testing. While we all know what an X-ray test looks like, it is important to understand the purpose of an X-ray test when representing an injured person. X-ray testing can detect dense materials such as bone or metal, which show up white on X-rays. X-ray testing can also detect fat and muscle, which show up gray on X-ray films. Soft tissue cannot be detected on X-ray testing. As a result, the plaintiff’s attorney needs to be aware that, generally speaking, many of his or her client’s injuries will not show up on the X-ray because they are limited to detecting fractures, infections, arthritis, osteoporosis and bone cancer.
One common finding in a post-traumatic setting that the plaintiff’s attorney will encounter is straightening of the normal cervical lordosis or straightening of the normal lumbar lordosis. The cervical lordosis is the normal curvature of the neck and the lumbar lordosis is the normal curvature of the lower back. Many times after an injury, X-ray reports will indicate that the patient had straightening of the normal lordosis. This is objective evidence of muscle spasm and, in turn, objective evidence of a traumatic insult to that portion of the body.
Many times the defense expert will attempt to minimize the effect of this abnormal finding by claiming it could be merely be due to patient positioning. The plaintiff’s attorney should not accept this response and should be prepared to cross-examine the defense expert taking this position.
Here is an example of a way to attack this position:
“Doctor, isn’t it true that in the emergency room the plaintiff underwent a cervical spine X-ray which demonstrated straightening of the normal cervical lordosis?”
“Can we agree this is objective evidence of muscle spasm in the neck immediately after the accident?”
“Not necessarily, it could have been due to patient positioning.”
“Well, doctor, you would agree that the radiology tech who performed this study was employed at a major university hospital and presumably performs hundreds, if not thousands of these tests per year, correct?”
“Can we agree that the tech probably understood the importance of proper positioning in the test?”
“Then wouldn’t you agree that it was more likely due to muscle spasm than improper patient positioning on the X-ray table?”
“More likely, yes.”
Unlike X-ray testing, in almost all personal injury cases, MRI testing can be critical to determining the nature and extent of a post-traumatic injury. MRI stands for magnetic reasonance imaging and, except for observations during surgery, it is generally considered the gold standard for detecting many types of post-traumatic injuries.
Similar to X-ray testing, MRI testing can also detect fractures, infections, arthritis, osteoporosis and bone cancer. However, more importantly, MRI testing can detect injuries to the soft tissue. Although soft tissue can be more inclusive, for our purposes, soft tissue is ligaments (tissues connecting bones), menisci (tissues absorbing shock between bones), tendons (tissues connecting muscle to the bone) and intervertebral discs (gelatinous substance between the vertebrae in the spine that allows for slight movement of the vertebrae and holds the vertebrae together).
The plaintiff’s attorney needs to know what to look for when reading MRI reports. For instance, the plaintiff’s attorney may know that his client has an injury to his shoulder and that the client has undergone a shoulder MRI. The radiologist interpreting the film will not say that the patient has a rotator cuff tear. Rather, the radiologist will examine the four tendons that compose the rotator cuff — the supraspinatus tendon, the infraspinatus tendon, the teres minor tendon and the subscapularis tendon. In a post-traumatic setting, in a common report the radiologist will indicate that he or she recognizes a complete or partial tear of the supraspinatus tendon. If the radiologist forms this impression, this is a rotator cuff tear. If any of the tendons of the rotator cuff are torn it is considered a rotator cuff tear. From a statistical standpoint, in a post-traumatic setting it will almost always be the supraspinatus tendon that is torn in a trauma. This is a biomechanical argument that is best saved for another article.
The plaintiff’s attorney must also understand the terminology with respect to the intervertebral discs in the spine. Generally speaking, a serious post-traumatic injury to the spine involves something called a herniated disc. A true herniated disc is where the nucleus pulposus escapes its outer housing, the annulus fibrosis and encroaches into the surrounding space in the spine.
Just because a disc has been herniated does not necessarily mean it will have clinical significance to the patient. When reading these reports it is important for the attorney to note whether or not the disc is impinging or touching the adjacent nerve roots or the spinal cord. This could signal a very large injury and a very significant case. In any event, it is not necessarily true that a disc needs to impinge or touch the adjacent nerve root or of the spinal cord for it to have a significant effect on the injured party. Over time the experienced plaintiff’s practitioner will develop an effective line of questioning to address all potential types of herniated discs.
In the next article, I plan on addressing additional types of diagnostic testing including EMG/NVC testing and discograms. •