Medical Flashcards
Five pillars of a case
1 policy limits
2 liability
3 property damage or scene photos with premis case
4 MRI results
5 prior medical history
Spinal anatomy
Bones in total
- 7 cervical
- 12 thoracic
- 5 lumbar
- 5 sacrum
- 5 coccyx
Tyes of abnormal discs
Bulge
Herniation (focal) focal means it takes up less than 25% of the space
Herniation with sequestration- floating around in spinal cavity
Extruded disk- blown out disc
Herniation (focal) focal means
it takes up less than 25% of the space
Herniation with sequestration
floating around in spinal cavity
Two parts of a disc
: annulus and nucleus
Extruded disk
blown out disc
3 structures in neck, 2 in back
Spinal cord, nerve root, Thecal sac (surrounds cord):
Doctors don’t do surgery for …
…for pain, alone
-Prevent a ticking time bomb
-They do surgery for Neuropathic and neurogenic issues: cord/ nerve
-Maybe for pain if it is chronic for more than a year alone
Nerves are ______, Spinal cord injuries cause __________
Nerves are sensory, spinal cord are motor function issues
So if shooting pain: Nerve impingement or touching
Nerve pain could be __________ (2 things)
- DISC HAS COME OUT & HITTIN THE NERVE
- CHEMICAL IRRITATION: RECENT TRAUMA TO THE AREA SO THERE’S A CHEMICAL REACTION HAPPENING DUE TO THE BODY SENDING PROTEINS TO THE AREA AS THE BODY’S WAY OF HEALING ITSELF.
WHY DO I BRING THAT UP??? . . . PLANT THE SEED DAY 1 . . . LIKELY TO
CERVICAL SPINE DERMATOMES
Stenosis
disc pushes on the nerve
A good word for us, game one
Spurling test
doc trying to create a stenotic issue, to determine, determine where pain radiates too
Hoffmans Sign test
for cervical herniated disc
Flicking middle finger, looking for an involuntary response in pointer finger
Myelopathy
Spinal cord compression
A nervous system disorder that can permanently affect the spinal cord. It causes a loss of sensation, loss of function, and pain or discomfort.
Lumbar radiculopathy
Sciatica AKA
inflammation of the nerve root in the lower back, pain and irritation in back and down the legs, involves sciatic nerve
Why have surgery for nerve pain
squeezing finger analogy, blood comes back into finger, but not if it is for a long time: like a garden hose, cut the supply for the nerve root off. A year or more, when we go into decompress it, wont be able to get the blood supply back
Lumbar pathology physical exam findings
positive straight leg raise test
Buzz words in MRI
Flattening
Hitting
Contacting
Abutting
Touching
Most surgeons don’t mess with …
the c2 c3 because too close to the brain stem
Edema
fluid, inflammation, Means a recent trauma or injury, especially if within the same month as accident
migrates
moving, maybe a sequestration
Neural foraminal stenosis
tells you which side the pain will go, nerves, radiologist is saying the canal is narrowed and is now pushing on the nerve.
A condition, narrowing in parts of spine cause compression of spinal nerves. most cases don’t cause symptoms, but can. Rest to surgery are the options
Mass effect
term used to describe the effect of a growing mass that results in secondary pathological effects by pushing on or displacing surrounding tissue. Mass effect can occur in any part of the body where a lesion grows and compresses adjacent structures, such as the brain, muscles, abdomen, or pelvis. Mass effect can cause symptoms such as pain, swelling, neurological deficits, or organ dysfunction.
brain: when something is pushing on something, brain is being squeezed bc blood fills up
2 types of views MRI
sagittal (side view) and axial view top view down
Degenerative changes
does not mean it is preexisting, just means changes in neck consistent with age
Osteophytes:
bone spurs
Spinal cord compression injuries
motor skills, balance, dropping stuff, bladder issues, finger gets stuck in a position, (hand stuck claw—cusp of paralysis)
MRI stage
Conservative Chiro and PT has provided either no relief or only temporary. It is time for surgical and pain mgmt.
Should be scheduled for a consultation with a surgeon or pain mgmt. specialist within a week of the MRI
-don’t let time pass allows client to minimize injury
trigger point injections
oTrigger point injections- muscular, muscle spasms, typically for extremities
When use:
* Build quick value for elderly or unwilling to treat clients
* Lower policy limits (10K or less)
* Client needs to understand that this is strictly muscular and will not address neural compression component of spine injuries
PRP stem cell injections
(platelete rich plasma)
Similar to trigger point, won’t build much value to case
Can be very expensive even tho do not substantially drive up case value in adjusters eyes
Facet joints
are paired structures at the back of each vertebra (spinal column bones). The facet joints, like other joints in the body, form a working motion unit that allows movement between two vertebrae
Facet mediated pain
Result of damaged capsule in the facet joint
MRI will not sho the damaged torn capsule as it is too small
But MRI will show edema/fluid near the facet joint, indicative of recent trauma
So when adjuster says no bulge or herniation on the MRI. Tell them the are correct…because disk disruption has nothing to do with facet mediated pain symptomology – pain on extension and pain reduction on flexion which unloads the facet join
FACET INJECTIONS
- Trying to hit the generally area of the facet joint. Diagnostic and therapeutic at the same time. Trying to determine which joint hurts
o Pain relief tells physician located damaged area - Should result in 1-2 weeks of relief
- Client needs to understand this is likely only temporary
- This injection along with prior chiro pt treatment and MRI should result in tender of a 10K policy
MEDIAL BRANCH BLOCK (FACET)
- More focal than facet injection
- Focused n getting pain relief at the correct location of the affected nerve
- Provides day or two of relief
- Usually used to pinpoint the spot of the Rhizotomy or ablation
- Facet injection with medial branch block and reco for subseq radiofrequency ablation could/should result in tender of policies up to 30K
Rhizotomy/ radiofrequency ablation
AKA: neurotomy/ biacuplasty (adjusters wont call this a surgery)
Obliterates the nerve
3 ways
* Can be performed chemically, by heating the nerve or freezing the nerve
Only temporary as the nerve will likely regenerate and the procedure may need to be performed again
Procedure should be performed on policies 25k or greater and less than 100K
100K policy, only consider rhizotomy first if the client refused to do anything more invasive, but 25-50 could be good
Be mindful on 100k policies where this is reco along with a separate surgery
* Ask the client willing to have surgery then why would we do the Rhizotomy first?
2 types of Epidural Steroid Injections
2 types: interlaminar (cord compression) and transforminal (nerve compression)
Epidural steroid injections
Both lumbar and cervical levels
Diff than facet inj or MBBs bc addressing pain caused by disc disruption as opposed to facet joing pain, seerate part of the anatomy
May provide up to 6 mos relief
One ESI should result in tender of $10k policy, two ESIs possibly coupled with surg reco, should result in tender of policies up to 25-30K
2 ESIs along with a surgical reco and or RFA performed should result in $50k policy
Multiple ESIs along with RFA and surg reco may tender 100k, but again b mindful when client is willing to have the surgery
What about pain meds?
o Fine for doc to prescribe but builds little to no value in case
o Be weary of client whose primary concern is Rx pain meds and dismisses other treatment options
o Adjusters will try toallege pill seeking, secondary gain motivation. Even on cases with great PD and no priors, where client had surgery, but continuously fills pain med scripts
Doc is concerned with how much medication person is consuming
Don’t want to paint the wrong picture in the eyes of the carrier, should scale this pain meds use back
Don’t be afraid to discuss optics of this with clients
Disc decompression or laser/micro discectomy
SURGICAL OPTION
Minimally invasive
Can be stuck into disk and suction, so it brings back the bulge
Suction, laser, heat ablation, cut a piece off, leave the disc, but get the compression off root or cord
Lumbar or vervical
Minimal cost, but still a surgery
Case value range from 150K to 250k
Client needs to understand that following this procedure, they will need to likely lead to a very sedentary lifestyle (especially for lumbar) as the disc is still in a weakened state and could easily herniate again and or collapse, necessitating further. More invasive surgery
Might not be for them if very active
Laminectomy
SURGICAL OPTION
Typically along with micro discectomy
Removes bone from spine
Lumbar mainly, but can cervical
Remove a portion or all of the lamina bone to create space for the compressed cord o nerve to shift backwards to relieve pressure
More invasive than decompression or laser discectomy, but less invasive than full discectomy and fusion
Value of 150k-300k depending on how many levels
Can do this with a 100k policy
Client needs to be careful in the future to ensure that disc does not herniate wors/ again or collapse
Ask adjusters: does damage to the disc itself cause pain?
Yes is the answer, can cause localized pain at the disc. If he is saying the disc doesn’t touch the cord or only touches the sac
Adjusters will say there is degeneration all over the place. Yeah but there is an annular tear, so recent trauma, if it was old it would be calcified over the top of it
You wouldn’t see the tear if it was old
Anterior Cervical Discectomy and Fusion
ACDF
SURGICAL OPTION
Goes through the front of the neck move voice box out of way, remove the disc itself
Allograft is placed in between vertebrae, can come from the hip so two surgeries at once
Provides stability and eliminates pressure on cord caused by disc disruption
Goals is to get the two bones to become one big bone, eliminates 20% range of motion in neck…but if two done then eliminate 40% of range of motion
Who knows what will happen if we wait another 6 months
Seen up to four level fusions completed
1- level ACDF typical valued at 350K, 2 level 500K, 3 level 600K+++
If a surgeon is willing to do a 2 level on a 100k policy, get it done
* Ask them what they are going to want back on their bill
Bone allograft from ither cadaver or harvested from client’s hip will be utilized
Say to adjuster, if he says preexisting, degenerative: who is waiting around to do this, today is the day I am going to have this accident so I can have massive surgery so I can get 30K
No one is doing this if they don’t need it
In litigation, this is what is coming. I will be the one standing in front of the jury and asking this question: he is faking it? Who would sign up for this. This is being done bc needed
Spondylolisthesis
A spinal disorder in which one vertebra (spinal bone) slips onto the vertebra below it. This causes pain in lower back or legs.
Urgent medical attention is usually recommended by healthcare providers
Certain types can be dangerous or life threatening
TOTAL DISC REPLACEMENT/ disc arthroplasty
SURGICAL OPTION
Cut channels into bone and place implant into where the disc used to be
Sames as ACDF, but not fusion, so range of motion is not drastically reduced
Limited in number of levels, typically anything over two levels, would likely involve a fusion and TDR combination for stability
Similar values as fusions, but easier for client to consider in light of range of motion preservation
Implants are pricey so be cognizant of hard costs of procedure before performing multi level TDR procedure on a 100K policy
Anterior lumbar interbody fusion
ALIF
SURGICAL OPTION
o Much more invasive than the posterior procedure
o Required when re-alignment of the vertebrae is necessary prior to fusion
o Likely requires a vascular sugeon to assist due to movement of the vessels and organs
o Didn’t need to happen, adjuster: so it was two doctors that put their license on the line for this?
I will ask the jury the same question
o Value of 350-500k for one level, 500-750k for multiple levels
o Benefits of lumbar fusion is stability and less worry regarding the future for the client following successful procedure
What type of a lifestyle do you wantto lead? Wouldn’t you rather have the peace of mind of only one surg procedure instead of the risk of many later
At least a 250K policy for this unless doc is willing to take pennies on the dollar
Posterior lumbar Fusion (In Situ Fusion)
SURGICAL OPTION
o Fusion cage
o Cut through ligament
o Less invasive with ALIF
o Less costly than ALIF, no vascular surgeon to pay
o Fusion provides stability and peace of mind for client
o Value for 1 level 350-400, 2 level 500-600k
Kyphoplasty
SURGICAL OPTION
o Injecting cement into the vertibrae where a compression fracture is
o Time is of the essence
o Elderly clients:value added to case
o After four weeks likely wont be able to perform the procedure
o Bc the bonewill heal on its own but wont be good bc
o Two types: with an without balloon
o Drilling into bone, inject cement
o Don’t lose out on opp to add value
PAINT MGMT SPECIALIST vs. SURGEON, factors to weigh
1 coverage!!!!
2 client’s appetite for treatment (doc reco surg…are you willing to undergo it?)(if the doc recos surgery, are you willing to have it? That is going to be a huge factor how much we can recover)
3 priors (preexisting can make them more vulnerable to injury, so can help, can make case easier)
4 client’s ability to receive treatment
5 MRI findings
6 when you are not sure send to a surgeon that also does pain mgmt.
CLIENT MAKING SURGICAL DECISIONS
Factors to consider
1 coverage!!!
2 MRI findings in conjunction with symptoms reported
3 client’s lifestyle
4 client’s employment
5 client’s age (younger resistant to surgery) (older may not be willing to have surgery)
6 client my need to be reminded that they only get to do this once (cant settle case now and come back in five years to get more money)(hate to see you later on when this turns bad, we cant get you compensated for it) if a doc told you need surg, opposing attorney will argue why aren’t they following what the doc told them to do, if they did they wouldn’t have all this pain)
Accurint
A program that is used as investigative technology that can expedite the identification of people, their assets, addresses, relatives, and business associates. It provides instant access to comprehensive database of public records that would normally take days to collect. This program can be expensive.
Anteriolisthesis
a type of spondylolisthesis, which occurs when one of the spine’s vertebrae slips out of position. Anterolisthesis refers to anterior (forward) slippage of the vertebra. However, when a vertebra slips backward (posterior), doctors call the condition retrolisthesis
Bodily Injury
BI
Bodily injury liability coverage helps pay for another person’s expenses if you injure them in a car accident. This type of coverage typically helps cover someone else’s medical bills.
3rd party that deals with Medicare liens
Centers for Medicare & Medicaid Services
CMS
Civil Remedy Notice
CRN
Used by parties that are beginning the process of filing suit against an insurer, when a party feels they have been damaged by specific acts of the insurer. Can be done on a BI claim.
BI Tender
When the insurance carrier pays the full policy limits for Bodily Injury.
CAD
computer aided dispatch
CME
Compulsory Medical Exam
Done during the litigation process and is when the defendant hires an ortho, neuro, or another doctor to examine the plaintiff to determine if there was really an injury & it is permanent. Also helps rule out if the injury was caused by the accident or was an existing injury.
CDR
crash data retrieval
Used to image the data stored in the EDR, i.e., downloading data. Data remains in the module and the CDR tool will image the data without changing the data stored within the EDR.
-Does the analysis on the EDR
Declaration Page
Dec Page
On an insurance policy, it is a summary of essential policy information
Dermatome Chart
Dermatome maps depict the sensory distribution of each dermatome across the body. Clinicians can assess cutaneous sensation with a dermatome map as a way to localise lesions within central nervous tissue, injury to specific spinal nerves, and to determine the extent of the injury.
EDR
Event Data Recorder
A device installed in motor vehicles to record technical vehicle and occupant information for a brief period (usually in seconds), before, during, & after a crash.
-The “black box” unit in the car.
-Is what is analyzed when the CDR does the analysis.
Herniation
Rupture or protrude through an abnormal body opening
Impingement
Rubbing or pressure on tendon nerve etc.
IME
Independent Medical Examination
Done during pre-litigation and it is when the client’s insurance company requires a [chiropractic?] exam & gives an opinion for if the client needs more treatment or if the treatment that has been done was necessary.
ISO
Insurance Services Office, Inc.
Company that collects statistical data, provides rating information, develops standard policy forms, and files information with state regulators on behalf of insurance companies.
-Anytime an insurance company receives a claim for an individual, they will report it to this program. It helps them determine coverage for when the client applies for insurance.
Letter of Protection
LOP
Letter sent by personal injury lawyer to client’s medical provider that guarantees them payment for medical services.
Letter of Representation
LOR: Letter that the personal injury lawyer sends to all insurances involved in the case. It outlines that all correspondence for the client should be done through the injury lawyer for the remainder of the case.
Liens
A charge on real or personal property for the satisfaction of some debt or duty.
Medical Payments Coverage
MedPay
Part to an auto insurance policy; may help you pay you or your passengers’ medical expenses if you’re injured in a car accident, regardless of who caused the accident
PRR
public records request
This request is usually sent to the police stations, investigating agency, or governmental agency to receive public records on the individuals involved in the case.
Retrolisthesis
one of two types of spondylolisthesis: this one is a joint dysfunction that occurs when a single vertebra in the back slips backward along or underneath a disc. Retrolisthesis is the opposite of Anteriolisthesis, which occurs when a vertebra slips forward.
Subrogation
Subro
Allows a third-party company (health insurance, PIP insurance) to get reimbursed for payments made to the doctors that treated our client.
-Payments on behalf of the client once case is settled.
Tender
insurance co pays full policy limits
Thecal Sac
The thecal sac or dural sac is the membranous sheath (theca) or tube of dura mater that surrounds the spinal cord and the cauda equina. The thecal sac contains the cerebrospinal fluid which provides nutrients and buoyancy to the spinal cord.
Underinsured Motorist Coverage
UIM
Applies when the driver who caused the accident has liability insurance, but the limits aren’t high enough to cover the damages. In this case, the other’s driver’s insurance would pay first, and your UIM coverage would make up the difference in costs, up to the client’s limits.
Uninsured Motorist Coverage
UM
Helps compensate the insured or another protected person (as a passenger) for damages caused by another motorist without insurance.
Uninsured Motorist Subrogation
UM Subro
Allows car insurance company to get reimbursed for payments that were made with the UM coverage once the case is settled.
radiculopathy
pinched nerve
gadolinium
Gadolinium is a rare-earth metal that enhances the quality of MRI images by acting as a contrast agent
Diffuse degenerative disc desiccation
a condition where the discs between your vertebrae lose their fluid and become dehydrated. This can cause stiffness, weakness, and pinched nerves in your back.
anterior
near the front
posterior
near the back
paracentral
lying near the center or central part
myelomalacia
a pathological term referring to the softening of the spinal cord. Possible causes of myelomalacia include cervical myelopathy, hemorrhagic infarction, or acute injury, such as that caused by intervertebral disc extrusion. Myelomalacia. MRI image shows spinal bleeding
Syringomyelia
SYRINX
develops when cerebrospinal fluid, which usually flows around the outside of your brain and spinal cord, collects inside your spinal cord and forms a fluid-filled cyst (syrinx)
focal disc protrusion
It describes a condition where damage to the disc causes it to protrude/bulge outwards or herniate, coming into contact with nearby spinal nerves as they exit the spinal canal, causing pain and discomfort
Lumbarized
Lumbarization: when top of the sacrum (S1) can be separated from the sacrum and the lumbar spine appears to have 6 vertebrae, not 5
paraspinal
The muscles surrounding and attaching to the spine
