What would you do?
A patient has been in your care for six weeks after a low-speed motor vehicle collision (MVC). They are still experiencing unresolved neck and shoulder blade pain since the MVC two months prior. Since their initial visit, they have had some pain relief (<25%) and progressive improvements in range of motion. The patient, and their lawyer, are concerned about a more serious spinal injury sustained from the motor vehicle accident. An MRI and prior X-rays results clear the patient of severe structural pathology. The lawyer is now concerned as these imaging results highlight a common medicolegal issue: The injured plaintiff’s ongoing pain lacks documentation of a specific anatomical source of pain.
What strategy can you use to help inform the courts on the causation of ongoing spinal pain when the X-ray and MRI are clean? Learn how Dr. Steele navigates patient care, long term expectations, and lawyer expectations after a traumatic injury without structural abnormalities.
Our patients may end up in litigation after an auto accident due to pain associated with a neck injury. Successful cases must establish causation between the accident and neck pain reliant on documenting a specific tissue injury. Simple strains and sprains do not warrant long-term care in the eyes of the courts. “It is therefore important to be able to establish neck pain from facet joint injury in individuals with tests that are both reliable and valid as these can provide evidence of injury for the courts in order for them to be able to make a determination on causality.” (1)
Cervical facet joints can be stretched or compressed during hyperflexion/hyperextension injuries. There is evidence that injuries to facet capsules can be the source of ongoing pain in the absence of tissue failure. Persistent afferentation from these structures after an accident may cause dorsal horn activation and resultant central sensitization. (2,3) Pain associated with the facet joint irritation often follows a predictable pattern:
- Unilateral neck and shoulder pain
- Pain upon cervical rotation and extension
- Radiation may occur segmentally in specific patterns
- Discomfort rarely extends past the shoulder
Findings by Lawson et al. (2020) may shift your attention to diagnostic injections in identifying a spinal structure resulting in ongoing pain if facet joint irritation is suspected.
- Individuals can end up in litigation after an MVC due to the prolonged symptoms associated with neck injury. Litigation of neck injuries in MVC is costly to both the courts, clients, insurers, lawyers, and medical professionals. In a medicolegal setting, it is important to establish general causation between an injury and neck pain, and a specific causation with the individual, where a clinician determines a diagnosis which can then help determine a specific cause. (1)
- One solution to document the source of pain is facet joint injections. This procedure directly connects anatomical spinal injury to the ongoing physiological pain. Given the basic-science evidence that injury to cervical facet joint can become an ongoing source of pain, it is important to be able to objectively diagnose pain emanating from the cervical facet joints in individuals who are suffering from persistent neck pain post-MVC. (1)
- Medial branch blocks are well established in medical literature to objectively document ongoing post-traumatic cervical pain, and is scientifically reliable in courts. (1)
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- Lawson GE, Nolet PS, Little AR, Bhattacharyya A, Wang V, Lawson CA, Ko GD. Medial Branch Blocks for Diagnosis of Facet Joint Pain Etiology and Use in Chronic Pain Litigation. International Journal of Environmental Research and Public Health. 2020 Jan;17(21):7932. Link
- Siegmund, G.P.; Winkelstein, B.A.; Ivancic, P.C.; Svensson, M.Y.; Vasavada, A. The Anatomy and biomechanics of acute and chronic whiplash injury. Traffic Inj. Prev. 2009, 10, 101–112.
- Curatolo, M.; Bogduk, N.; Ivancic, P.C.; McLean, S.A.; Siegmund, G.P.; Winkelstein, B.A. The role of tissue damage in whiplash-associated disorders. Spine 2011, 36, S309–S315.
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