Back Injuries

Lower and Upper Back Injuries

The following information provides an overview of common back injuries that typically are the subject of personal injury lawsuits and other litigation. Also included is information related to back and neck injuries related to the spinal cord that could lead to paresis or paralysis. Neck injuries are not covered entirely, but most of this information can be applied to the neck or cervical personal injuries.

Some of the possible witnesses that could be called in litigation involving a back injury are:

  • Neurologist
  • Family doctor
  • Psychiatrist
  • Nurse
  • Occupational expert
  • Economist
  • Witnesses before and after
  • Work or vocational counselor
  • Neurosurgeon

Overview


Back injuries are common in a variety of accidents. Back injuries that occur from lifting heavy objects comprise many accidents in industrial and manufacturing situations. Most injuries in car accidents to the spine and its related muscles also involve the neck; this is because the head’s weight is being thrust forward or backward at the top of the spinal column. Back injuries are very common in these accidents. As seatbelts have become commonplace, there also are injuries in car accidents to the lower back if there is excessive slack in the shoulder restraint. This allows the top of the torso to be thrust violently forward. This can lead to a type of ‘jackknife’ injury. Premises lawsuits involving slips and falls is another major source of back injury litigation.

National Health Survey statistics state that most back injuries related to the lumbar region. Therefore, we will focus in this section on the lower back region.

Types of Back Injuries


Common back injuries that make up most personal injury lawsuits include:

  • Vertebra fracture
  • Spinous process fracture
  • Transverse process fracture
  • Pedicle fracture
  • Articulating facets subluxation
  • Herniated or ruptured disc
  • A disc that bulges out from the spinal column
  • Strain or sprain
  • Torn tendons, ligaments or muscles
  • Stretched tendons, ligaments or muscles

Other Anatomical Facts Related to Back Injuries


  • The number of cervical vertebrae in the back is seven.
  • There are 12 dorsal or thoracic vertebrae.
  • The number of lumbar vertebrae is five.
  • The sacrum is a bone in a triangle shape that is connected and articulates with the 5th lumbar vertebra above but below the coccyx.
  • The 5th lumbar vertebra articulation and the sacrum generates an acute lumbosacral angle that makes disc space very likely to be injured in an accident.
  • The tailbone or coccyx has four rudimentary vertebrae that are located below the sacrum and are fused.
  • Generally, the vertebrae get larger from the top and going down.
  • The lumbar vertebrae are the tallest and widest vertebrae in the back.
  • The spinal cord stops at the second lumbar vertebra.
  • The nerves that come from below the L-2 are from the cauda equina or horsetail that is located below the end of your spinal cord.
  • The weight of the upper body is upheld and transmitted via the lumbosacral and sacroiliac joints.
  • Ligaments that are attached to the vertebrae assist to hold them in position. These are called the posterior longitudinal ligament, anterior longitudinal ligament, the ligamentum flavum, the interspinous ligament and the supraspinous ligament.
  • The prominences that feel bony along the back of your spine is actually the spinous process. This also is known as the posterior spinous process.
  • The wing-type bones of two that come out of both sides of the spinous process are called the transverse processes.
  • The anterior longitudinal ligament is attached to the anterior surface of the axis body and extends down to the sacrum. It is attached to the vertebral bodies.
  • The posterior longitudinal ligament is connected to the posterior surface of the axis. It extends down to the sacrum and attaches to the vertebral bodies.
  • The posterior longitudinal ligament is thin at the cervical and lumbar areas.
  • The posterior longitudinal ligament is not as strong as the anterior longitudinal ligament.
  • Spinal ligaments, which include the posterior and anterior longitudinal ligaments, have little elasticity.
  • If a spinal ligament is torn, they will heal but will have scar tissue that has very little elasticity.
  • If you rupture an intervertebral disc, you can expect there will be damage to your ligaments in the spine.
  • Of the intervertebral discs, the lumbosacral joint has the most strain. This s because this joint gets almost 10 times the weight for each square inch as the joint of the knee.
  • Most ruptured discs – at least 90% - happen between L5-S1 and L4-L5.
  • The intervertebral disc space that gets the maximum amount of trauma is the L5-S1 space. This is because it is between the fixed vertegrae that is below the sacrum and the vertebrae that are movable above the sacrum. It is the last disc in your moveable spine. So, it has a bigger and heavier load. The vertebral column weight that is supported does not exactly rest squarely on your first sacral vertebra. Instead, it is at an angle that delivers a shearing force. It tends to slide the 5th lumbar vertebra in a forward motion.
  • The laws of physics mean that a man that lifts a weight of 100 pounds with his extended arms before him will make a force of more than 1600 pounds on the lumbosacral disc.
  • The nerves in the lumbar area come from the spinal canal via the intervertebral foramen. These nerves are bigger at the end of the lumbar spine vertebra and sacrum.
  • The next biggest lumbar nerve root comes from the 4th and 5th lumbar vertebrae, and so forth.
  • The lumbar spine foramen decreases in size from the top of your lumbar spine down to the bottom. This is so the nerve opening or foramina that are between the 5th lumbar vertebra and the sacrum is the opening least in size. But it still can accommodate the biggest of your lumbar nerve roots.
  • There is a possibility of nerve root irritation due to impingement at the foramina that is located at the 5th lumbar vertebra and sacrum as the opening is not as big, and the nerve is bigger.
  • Between each vertebra is a disc that consists of cartilage that is called the nucleus pulposus.
  • Located around the nucleus pulposus and holding it in the space that is between the vertebral bodies is called the annulus fibrosis. This attaches to your vertebral bodies and helps to hold the vertebral bodies aligned and together. It also holds all of the cartilaginous disc material in the space between said bodies.
  • The disc’s purpose is to be a shock absorber or buffer between the many vertebral bodies and to provide more flexibility to the spine.
  • Approximately 1/3 of the length of the lumbar spine is comprised of discs.
  • A herniated disc is a common injury after a car accident. Some of the effects of this injury may include:
    • Narrowed intervertebral space
    • Disc material suffers a degenerative condition
    • Mobility and flexibility of the spinal column is lessened
    • The ability to take repeated shocks and intense regular activity is lessened
    • Normal alignment of the vertebrae is compromised
    • Articulating facets can undergo serious subluxation
    • If there is a herniation of the 5th lumbar disc, it may displace on the sacrum posteriorly
    • The annulus fibrosis and interspinous ligaments may become flabby and not able to counteract muscular force.
    • The sciatic nerve is the biggest one in the body.
    • The sciatic nerve gives sensation and movement to the lower body and extremities.
    • A lumbosacral joint injury can be expected to lead to serious pain along the sciatic nerve.
    • A minor trauma or small accident can cause a disc rupture.
    • If a disc is ruptured, it will not regrow. But the extent to which it sticks out and hits a nerve root causing neurological symptoms to vary widely. This explains why there are remission periods and exacerbation of symptoms sometimes.
    • The procedure to remove a ruptured disc means the disc material must be removed; this is called a discectomy. Also, the lamina may need to be removed to drop pressure on the nerve root; this is called a laminectomy. Sometimes spinal fusion is called for to eliminate pain and mobility that causes pain.
    • A procedure that is less invasive for a ruptured disc is called chemonucleolysis. This is where disc material is pulverized by the injection of a chemical.
    • A disc rupture can happen again because not all the disc material was taken out.
    • A ruptured disc at another level can happen after disc surgery and fusion; spine immobilization can put higher forces on the next joint. This can tend to rupture the disc at another area.‚Äč

Herniated Disc


A common dispute in back injury litigation is whether the injury is soft tissue or muscular-ligamentous injury. It also can be disputed if the injury is from a disc herniation.

It is important that the jury understand the pros and cons of this type of issue. So they need to have a good grasp of the vertebral column anatomy. If the attorney clearly explains the number and location of the major vertebrae and the sacrum and coccyx, as well as how the spine is curved, the jury can understand how the spine is a load-bearing structure, and the risks of injury to materials that join each vertebra. This is especially true at the bottom of the column end, in the L5-S1 interface. The majority of serious injuries happen at this level or at L4-L5.

Vertebrae are stacked on each other with the nucleus pulposis between each structure. It acts essentially as a shock absorber. It is contained the space that is between the vertebrae and what is called the annulus fibrosis. The nucleus pulposis is often compared to the stuff that is inside a golf ball. It may be referred to as a type of gristle-type material. If it tears or ruptures, the disc material will herniate. Depending on the location of this tear, the disc could impinge upon key nerve roots that go through the foramen and descend to make nerves that supply your lower extremities. Pressure or impingement on the nerve roots can cause pain and lead to significant impairment. Impairment may be the pain, sensation loss or numbness. Other problems could be muscle atrophy, muscle spasm, loss of range of motion and tenderness in the joint.

Note that the annulus fibrosis can be damaged and bulge and this may occur without an actual tear or rupture. If a disc bulges, there can be similar symptoms and can be very disabling to the patient.

How to Diagnose a Herniated Disc


There are many symptoms of a herniated disc, but all systems are not usually presented. Some symptoms relate to a higher injury level, which is thoracic, and others are related to an injury in the lumbar area.

Common symptoms that can present are:

  • Muscle spasms
  • Flattening of the spinal curve
  • Tenderness of muscles near the spine
  • Numbness and/or loss of sensation
  • Cramps in muscles
  • Reflex loss
  • Atrophy of muscles
  • Intervertebral space narrows

Back Injury Tests


  • X-rays: One of the limitations of X-rays is it will not show a herniated disc; there are no boney structures involved. But an X-ray can help to document the disc space narrowing where the injury is. Also, a muscle spasm is caused by an injury to your spine may be shown on an X-ray by showing the loss of regular spinal curvature. The loss of curve could involve the spine being straightened.
  • Myelogram: This is a surgery where a needle is placed into your spinal canal. A radiopaque dye is then injected into the space around the spinal cord. The medium is allowed to go up and down your spinal canal by tilting you on the table. A myelogram is not often used for diagnosis; it is a preliminary procedure to show your injury level before having surgery for a disc problem. A myelogram is very accurate in diagnosing the herniation of a disc. It outlines the spinal canal, so the X-ray will show intrusion into this narrow space by a bulging or herniated disc.
  • Tomography: This is a type of X-ray where the X-ray beam focuses on a certain depth of the body and section it to any desired level. It basically slices the body visually into planes or anatomic levels. It also for a sharper image. This technique is largely being supplanted by CAT scans.
  • CAT scan: The CAT scan will combine the memory and calculating ability of a computer with the tomography technique described above. It allows you to cross-section your body at any level to view it. As with an X-ray, the procedure will rely a great deal on body tissue density. It is more sensitive to tiny differences in density than a standard X-ray. This procedure is mostly used with the lumbar spine, and not the cervical spine.
  • MRI: This used to be called a nuclear magnetic resonance test. This procedure creates high detail images via computer measurements that are gotten through the examination. Calculations are determined by placing you inside a magnetic field and using radiofrequency waves to make an image. This is one of the newest medical imaging tools in use that has supplemented both the myelogram and CAT scan. It is more accurate in the cervical back area than in the lumbar area.
  • Thermography: This is a new procedure that uses thermal imaging to visually measure surface temperatures of the body. It is useful in that as we are able to visualize temperature patterns on the body, the doctor can determine pain patterns. This can assist in obtaining a full and proper diagnosis. A thermogram uses temperature symmetry. Lack of temperature symmetry means there is an abnormal thermogram.

Neurologic Deficits


It is key in any back injury lawsuit to determine if there is a neurologic deficit. It is possible that the spinal cord or nerves that come from the spinal canal could have suffered damage. A routine back examination should include a neurological examination, no matter if the exam is performed by a neurologist, neurosurgeon, orthopedic surgeon or a regular doctor. The doctor should look for loss of reflex or another sign of pain that can be felt through a stretching exercise that shows nerve roots in the spinal column are involved. In chronic injuries, muscle atrophy can happen and may be due to a neurologic deficit. But in this case, the dispute legally will be whether the atrophy is due to disease or was due to the accident that caused a disturbance in the nerve endings that serve the lower extremities.

If a neurologic deficit can be documented, it clearly implies a more serve injury than where there is none present. Nerve conduction velocity tests and electromyography are ways to detect and test for neurologic problems.

Objective Vs. Subjective or Signs Vs. Symptoms


The purpose of a physician’s examination in a back injury lawsuit is to determine if there is a differentiation between the findings of the doctor that are subjective rather than objective. An objective finding means the doctor can document the condition visually or by performing palpations. A subjective finding is just what the patient says about his condition. An objective finding means there is a sign, and a subjective finding is a symptom.  

Objective findings, or signs, could be muscle spasms, rigidity, tenderness, swelling, atrophy, poor range of motion, loss of muscle tone or neurological problems.

Subjective findings or symptoms are usually reports of pain and discomfort.

An experienced physician should be capable of finding false pain complaints related to examinations, which can be straight leg raising tests or a pinprick test.

Sprains and Strains


These are two different types of injuries.

A strain is usually thought of as a stretching related injury to a ligament or muscle. Objective findings include muscle spasms, tenderness and limited range of motion.

A sprain is noted to be a wrenching or twisting of a joint that could feature ligament tears or rupture. It is often considered a serious injury that requires more treatment time.

How to Treat a Back Injury Conservatively


Soft tissue injuries in the back can be treated in the following ways:

  • Immobilization for a short period of time, followed by steady increase inactivity.
  • Muscle relaxants
  • Anti-inflammatory drugs
  • Various forms of physical therapy, such as heat, massage, and ultrasound
  • Traction
  • Back exercises
  • Brace or back corset

How to Grade for Intervertebral Disc Injury


The system outlined below is recognized in the medical and insurance professions for use in grading injuries to the intervertebral discs:

  • Grade I Disc: Normal
  • Grade II Disc: Bulging of the annulus fibrosis
  • Grad III Disc: Protrusion
  • Grade IV Disc: Extrusion
  • Grade V Disc: Sequestration

Disability Ratings


The Guides to the Evaluation of Permanent Impairment provided by the AMA offers guidelines for determining the percentage of disability in an extremity and in the entire body. But these are usually based upon a limited range of motion. The doctor should not just arbitrarily follow the guidelines. It should be taken into consideration the other symptoms and signs that include subjective symptoms to determine the effect of the injury on the person.

A fracture to the head of the lower arm radius could produce a smaller percentage of impairment that causes a 5% loss of arm flexion. But associated with that loss of motion could be an injury to your ulnar nerve that runs over the proximal part of the radius. This can cause numbness and tingle in your little finger and ring finder. Also, say the injured party is a surgeon and he needs dexterity in his hands to do his job. What could be just a 5% disability to the arm in one case could be a 25% disability in some cases. The same logic will apply to a back injury. What could be a minor impairment to an attorney could be a major disability and impairment to a crane operator. 


If you have been diagnosed with a back injury as a result of the wrongdoing of another, please contact Personal Injury Attorney Bart Herron at Herron Law at 503-699-6496  - 24/7 - today to set up a Free Consultation or fill out  FREE CASE EVALUATION  form or TEXT NOW to 503-367-0829 


 

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