[Unknown Member]

Read the case like you would read it normally.  How else would you want defend yourself? 

[landk_304]

Quote from Alpha Angle

Do you tailor your reports in that manner? Do you try to read cases as acute or chronic based upon your best guess? Are you ok calling a lot of cases Age Indeterminate and moving on?

 
Don’t put yourself at legal risk. Read it the same way you’d read any random ER study. Unless I’m sure, it’s age-indeterminate. No guessing.

[ruszja]

I can adjust wording to increase the degree of joy of my referrer, I cannot adjust the substance of what I say if its not supported by the image in front of me.
 
I was on the witness stand for an assault case many years ago. The defense was trying to somehow squeeze out of me that this could have been a ‘chronic’ injury. It was really dumb, something to the effect that ‘I certainly wouldn’t be able to rule out that the victims femur had been broken a few minutes before the incident that was subject to the trial’. I said something to the effect of: ‘I dont believe the victim would have been physically able to climb onto the bed of your clients pickup had his femur already been broken at that point.’ Now the defense attorney could have objected to my fact witness ‘speculation’, but I guess he knew that he asked for the speculation and it would have been dumb to object. I even gave some free expert witness testimony for the DA when I opined that being flung off the back of a pickup would be a sufficient trauma to cause the injury. After the witness testimony concluded, the idiot who was on trial decided that pleading guilty was the better course of action.
 
But yeah, in lawyer medicine acute vs. chronic can make the difference between a kid being taken from his parents or a large settlement getting paid on a personal injury claim or not. So if you see its a PI or medicolegal case, make your language very precise and descriptive.

[gustavobarraza_207]

The age of onset of the findings demonstrated on this exam can not be determined with certainty without the availability of previous exams
 
feel free to get a second opinion

[alex.nieto_484]

Quote from Alpha Angle

Curious what others do with Age of Injury requests for Workers Comp/Personal Injury cases.

My general practice has been that if it is clearly acute, I call it acute. If it is clearly chronic, I call it chronic. If it doesnt fit into one of those buckets, it is Age Indeterminate (majority of cases).

I have noticed an increase in referrers pushing for reads in a style that promotes their practice. For example, a chiropractor that does tons of personal injury work wants everything read as acute. An orthopod that does a lot of Independent Medical Examiner work wants everything read as chronic, unless its clearly acute.

My response was to tell my group I would not be reading any cases for these referrers in the future. I have no problem reading workers comp or personal injury cases, but I would not want to defend a position I didnt truly believe in in a deposition or court room. Others are clearly willing to play the game.

Do you tailor your reports in that manner? Do you try to read cases as acute or chronic based upon your best guess? Are you ok calling a lot of cases Age Indeterminate and moving on?

 
I would not change how I practice. Especially not for a chiro who is obviously being paid by trial lawyers. For spine imaging I don’t think it is inappropriate to say “there is no objective evidence of acute trauma and the findings should therefore be considered chronic”. That is the guidance from the lumbar disc nomenclature from 2014.

[gustavobarraza_207]

“””I don’t think it is inappropriate to say “there is no objective evidence of acute trauma and the findings should therefore be considered chronic”. “””
 
I am curious. Exactly what would be considered OBJECTIVE evidence of trauma? Other than an acute fracture?
Would a disc herniation or “bulge” definitely NOT be objective evidence of trauma? Under any circumstances?
That approach would not withstand cross examination by the plaintiff.
 
I have testified for both sides.  Always have said you cant date findings on a single MRI without old studies. If I am allowed to be asked whether given the clinical history the findings are likely related to trauma, I would say yes. Similarly if asked whether the findings could pre-date trauma, I would also say yes

[toumeray]

Priors can tell you definitively if something is chronic, but even if a finding is not present on prior, it is not clearly acute. Still age indeterminate often, even if new, cause it could be new but old or new yesterday. Most of the time it is present on priors so its chronic and that simple, but not always.

Fractures on radiographs can be difficult to age, as can small avulsion fragments. I always look for cortication, callus, resorption along fracture line etc and have been fooled when given history. We can think we know the age but often we dont, even when we are confident we can tell how old an injury is.

Obviously with soft tissue structures, discs, menisci, labrum, etc it is impossible to age on imaging alone, aside from knowing its chronic because of a prior. Hard to ever say acute unless you have a prior from the previous day which is rare. Muscle/tendon stuff can say chronic if theres no edema, but even there its tough to age between acute or subacute, even up to months later I have seen edema.

For legal purposes, our imaging aging is rarely accurate enough to benefit the court case. I try to impress upon that when asked

[alex.nieto_484]

“Discs, in the absence of significant imaging evidence of associated violent injury should be classified as degeneration rather than trauma.” 
 
To me that means if there is no bone marrow edema, soft tissue edema, ligamentous injury, it should be classified as degenerative. 
 
The authors specifically use the words significant in regards to imaging evidence and violent for trauma. There is obviously a lot of subjectivity that is involved and 2 reasonable radiologists can disagree but that is my take on it. That is only for spine imaging and disc herniation (which is most of the cases).

[gustavobarraza_207]

as I asked before, what would qualify as SIGNIFICANT imaging evidence of ASSOCIATED VIOLENT INJURY??!!
 
When is the last time you mentioned violent injury in your interpretation?
 
do you think its not possible to get a herniated disc, acutely, without a fracture, edema, ligament injury??!! I lost count of how many acute HNPs I have seen with relatively insignificant etiology, ie, picking up a box/suitcase, heavy golf swing, even bending over to pck up a napkin, etc, etc.
 
Also, do you think its not possible to get an acute hnp, superimposed on chronic deg changes??!! One could argue that significant DDD in the lower levels may predispose to higher level discs with lesser cause.
 
IMO, aging a herniated disc is almost NEVER a radiological issue, its a clinical issue.

[alex.nieto_484]

Quote from drgl

as I asked before, what would qualify as SIGNIFICANT imaging evidence of ASSOCIATED VIOLENT INJURY??!!

When is the last time you mentioned violent injury in your interpretation?

do you think its not possible to get a herniated disc, acutely, without a fracture, edema, ligament injury??!! I lost count of how many acute HNPs I have seen with relatively insignificant etiology, ie, picking up a box/suitcase, heavy golf swing, even bending over to pck up a napkin, etc, etc.

Also, do you think its not possible to get an acute hnp, superimposed on chronic deg changes??!! One could argue that significant DDD in the lower levels may predispose to higher level discs with lesser cause.

IMO, aging a herniated disc is almost NEVER a radiological issue, its a clinical issue.

 
Lay off the caps lock, you sound deranged. I am going by the recommendations of people smarter than me. If you decide to just say whatever you feel is right in your gut from anecdotal experience more power to you. I always try to use literature to back up my opinions when giving them in a legal context.

[gustavobarraza_207]

in response, you cherry picked from that source, leaving out the important first part.
 
The full quote is:
[b]Whether or not a less than violent injury has contributed to or been superimposed on a degenerative change is a clinical judgment that cannot be made based on images alone; therefore, from the standpoint of description of images, such discs, [/b]in the absence of significant imaging evidence of associated violent injury, should be classified as degeneration rather than trauma.
 
to my point, in the absence of prior images, it is not possible to definitively date the onset of a herniated disc from a single study, leaving it a clinical judgement…. not radiologic.

[alex.nieto_484]

Quote from drgl

in response, you cherry picked from that source, leaving out the important first part.

The full quote is:
[b]Whether or not a less than violent injury has contributed to or been superimposed on a degenerative change is a clinical judgment that cannot be made based on images alone; therefore, from the standpoint of description of images, such discs, [/b]in the absence of significant imaging evidence of associated violent injury, should be classified as degeneration rather than trauma.

to my point, in the absence of prior images, it is not possible to definitively date the onset of a herniated disc from a single study, leaving it a clinical judgement…. not radiologic.

 
somehow we can both look at the same quote and come to opposite conclusions. to me that quote tells us to classify it as degenerative. we aren’t making clinical correlation as radiologists. but from an imaging standpoint that quote tells us to call it degenerative.
 
glad you found the caps lock key.

[gustavobarraza_207]

You have not answered the question. Have you ever seen a new herniated disc result from “less than violent injury”?