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The Spine at Trial: Practical Medicolegal Concepts about the Spine
CHAPTER 1: What Holds Up Your Body?
Adult Anatomy and Biomechanics of the Spine
The Spine or Vertebral Column
The Vertebrae
The Vertebral Bodies
Arches
Pedicles
Facets
Laminae
The Spinous Process
The Transverse Process
The Cervical Spine (The Neck)
The Thoracic Vertebrae
The Lumbar Vertebrae
The Sacrum
The Coccyx
Discs, Ligaments, and Muscles
The Intervertebral Discs
Ligaments
Muscles
The Spinal Canal
The Spinal Cord and Nerves
The Lateral Foramina
The Blood Supply of the Brain and Spinal Cord: The Pipelines of the Neck
Circulation to the Brain
Circulation to the Spinal Cord
Some Biomechanics Concepts: How the Spine Moves and Tolerates the Load
The Three-Joint Complex
Biomechanics of the Cervical Spine
Biomechanics of the Thoracic Spine
Biomechanics of the Lumbar Spine
Spinal Stability
The Three-Column Principle
Checklist for Evaluating Instabilityin Every Region of the Spine
Surgical Procedures and Instability
Differences in Surgical Procedures between the Cervical Spine and Lumbar Spine
CHAPTER 2: The Baby's Spine Develops, Grows, and Ages
Developmental Anatomy
Underlying Principles and Vocabulary
Week-by-Week Development
Testing and Treating the Unborn Baby
Concepts about Teratology
Development of the Skeletal System
Ossification Centers
A Typical Vertebral Ossification
Developmental Anatomy
Typical Cases
Children in Car Wrecks
CHAPTER 3: The Aftermath of the Tornado
Healing and Repair of Injuries
The Dynamic of Wounding
Tissue: The Specialized Cells
The Process of Healing and Repair
Coagulation
Inflammation
SWELLING (EDEMA) _ PAIN _ HEAT _ REDNESS
Granulation
Scar Formation
General Modifying Factors in Wound Healing
Healing of Specific Tissues
Fasciae
Ligaments
Tendons
Muscles
Cartilage (Joints, Discs)
INTERVERTEBRAL DISC
Bones
Brain,
Spinal Cord, and Nerves
The Wonder of Healing
CHAPTER 4: The Bionic Eye
What Lawyers Should Know about Imaging Procedures and Neuromuscular
Tests
The X-Ray (Roentgen Rays)
Cervical Spine X-Ray Views
CERVICAL LATERAL (CROSS-TABLE LATERAL) RADIOGRAPHS _
CERVICAL ANTEROPOSTERIOR (AP) X-RAY PROJECTIONS _
CERVICAL OPEN-MOUTH X-RAY VIEWS _ CERVICAL OBLIQUE X-RAY
VIEWS
Thoracic Spine X-Rays
Lumbar Spine X-Rays
LUMBAR AP OR PA X-RAY VIEWS _ LUMBAR LATERAL VIEWS _
LUMBAR OBLIQUE VIEWS
Bone Scans, Radionuclide Imaging, or Nuclear Diagnostic Testing
Myelograms
Discograms
Computerized Axial Tomography (CT) Scans
Common MRI Concepts
Electrical Neuromuscular Tests
Nerve Conduction Velocity Studies
Electromyograms
Somato Sensory Evoked Potentials (SSEP)
Conclusion
CHAPTER 5 The Twisted and Broken Spine
Fracture and Dislocation of the Vertebral Column
Spinal Injuries to Unborn Babies
Neck Injuries in Children
Occipito-Atlantal (Occiput-Atlas [C1]) Injuries
Medical Information
Legal Application
Atlas Injuries (Jefferson Fractures: When the Atlas Is Crushed)
Medical Information
Legal Application
Atlanto-axial Injuries (Injuries at the Top of the Spine)
Medical Information
Legal Application
Odontoid Fractures: The Broken Tooth of the Spine
Medical Information
Legal Application
Injuries of the Axis (C2): The Hangman's Fracture
Medical Information
Legal Application
OTHER WAYS TO SUFFER HANGMAN'S FRACTURE
Injuries of the Neck below C2
Medical Information
Legal Application
LATE INSTABILITY
Conclusion on Injuries of the Neck Below C2
Thoracolumbar Trauma in Children
Clinical Presentation
COMPRESSION FRACTURE _ SEAT-BELT INJURY _ FRACTURESAND
DISLOCATIONS _ BURST FRACTURES
Thoracic Fractures in Adults
Thoracolumbar Junction
Fracture of the Lumbar Spine
Injuries to the Spinal Cord
Medical Information
Legal Application
CHAPTER 6 The Wrecked Back
Soft-Tissue Injuries of the Neck and Lower Back
Soft-Tissue Injuries of the Neck
Neck Pain
Headache
Dizziness
Temporomandibular Joint Disorders Following Whiplash
Dysphagia and Dysphonia after Whiplash
Imaging Procedures in Soft-Tissue Injuries of the Neck
HYPEREXTENSION INJURIES IN WHIPLASH _ HYPERFLEXION
INJURIES
Low Back Pain Following Whiplash
Injury of Degenerated Discs
The Future of the Patient Who Suffers Whiplash Injury
Soft-Tissue Injuries in the Lumbosacral Spine
Backache
Facets
Leg Pain
Additional Diagnostic Procedures
Compensation Neurosis
In Soft-Tissue Neck Injuries
EMOTIONAL SUFFERING CAN ALSO INCREASE PAIN PERCEPTION
In Soft-Tissue Lumbar Spine Injuries
CHAPTER 7 Jelly Doughnuts of the Spine
What Lawyers Should Know about Discs
General Concepts
Commonly Asked Questions
What Is This "Diffuse Bulging"That Radiologists Describe?
What Else Do We Need to Know about Disc Deterioration?
What Happens to Facet Joints in Disc Degeneration?
Is This Back Then Stable?
What Happens to the Disc When It Loses Water?
Do Discs Degenerate to the Same Extent, at the Same Rate?
How Does This Affect Back Movement?
Is Natural Degeneration Painful?
How Many Lawyers Limit Their Clients to Those Who Are Eighteen Years Old
with Normal Discs?
If One Herniated Disc Indicates a Bad Trauma, Do Three or Four Discs Favor a
Worse One?
So What Does it Matter If a Disc Herniates?
Do the Discs Keep Changing over the Years?
How Does Herniation Affect an Already Degenerated Disc?
Do Discs Degenerate in a Particular Direction? Does Direction Affect Symptoms?
What Is Displacement?
How Much Do We Need to Know about Involved Muscles?
What Is the Difference between Displacement and Location?
How Should We Respond If Symptoms Are Not Consistentwith the Radiology
Reports?
What Should the Physical Exam Involve? What Should We Look For?
Does Mobility Reflect the Symptoms?
Does the Size of the Spinal Canal Play a Role in Symptom Development?
What Does Soft Disc Herniation Mean?
Degenerated Herniated Cervical Discs
General Concepts
Symptoms Specific to the Level
C2-C3 = C3 NERVE RADICULOPATHY _ C3-C4 = C4 NERVE
RADICULOPATHY _ C4-C5 = C5 NERVE RADICULOPATHY _ C5-C6 = C6
NERVE RADICULOPATHY _ C6-C7 = C7 NERVE RADICULOPATHY _ C7T1 = C8 NERVE RADICULOPATHY
Controversies Concerning Sleep and Cervical Herniations
Diagnosing Degenerated Herniated Cervical Discs
THE PATIENT'S HISTORY _ THE PATIENT'S PHYSICAL EXAMINATION
Recommended Tests and Diagnostic Procedures
ABOUT CT SCAN _ ABOUT DISCOGRAPHY _ ABOUT COMBINED
MYELOGRAPHY/CT SCAN _ ABOUT MRI
Treatment of Degenerated Herniated Cervical Discs
MEDICAL TREATMENT _ SURGICAL TREATMENT _ WHEN IS THE
POSTERIOR APPROACH USED?
Legal Application
Herniated Thoracic Discs
General Concepts
Diagnosing Herniated Thoracic Discs
THE PATIENT'S HISTORY _ THE PATIENT'S PHYSICAL EXAMINATION
_ RECOMMENDED TESTS OR DIAGNOSTIC PROCEDURES
Treatment of Herniated Thoracic Discs
MEDICAL TREATMENT _ SURGICAL TREATMENT
Herniated Lumbar Discs
General Concepts
ANTERIOR HERNIATION OF LUMBAR DISCS _ MIDLINE HERNIATION
OF LUMBAR DISCS _ POSTERIOR HERNIATION OF LUMBAR DISCS _
L3-L4 = L4 NERVE RADICULOPATHY _ L4-L5 = L5 NERVE
RADICULOPATHY _ L5-S1 = S1 NERVE RADICULOPATHY
Diagnosing Herniated Lumbar Discs
THE PATIENT'S HISTORY _ THE PATIENT'S PHYSICAL EXAMINATION
_ SYMPTOMS _ DIAGNOSTIC TESTS AND PROCEDURES
Treatment of Herniated Lumbar Discs
MEDICAL TREATMENT _ SURGICAL TREATMENT
The Operative Report
Deposition-Basic Concepts
Prognosis in Patients with Herniated Discs
CHAPTER 8 Spondylolysis and Spondylolisthesis
An Easy Way to Understand These Conditions
Spondylolysis
Description
Causes
Symptoms
Diagnosis
Treatment
Spondylolisthesis
Description
Causes
ISTHMIC SPONDYLOLISTHESIS _ TRAUMATIC SPONDYLOLISTHESIS _
POSTSURGICAL SPONDYLOLISTHESIS _ CONGENITAL
SPONDYLOLISTHESIS _ DEGENERATIVE SPONDYLOLISTHESIS _
PATHOLOGICAL PONDYLOLISTHESIS Symptoms
Diagnosis
Treatment
CHAPTER 9 Understanding Impairment Evaluations
AMA Guides to the Evaluation of Permanent Impairment, 4th Edition Made
Easier to Use
Familiarity with the Guides
Overall View of Assessment
Medical Impairment Evaluation
Nature of the Injury
Range of Motion
Range of Motion for the Cervical Spine
Range of Motion for the Thoracic Spine
Range of Motion for the Lumbosacral Spine
Nerve Damage
Nerves of the Upper Extremity
Nerves of the Lower Extremity
Multiple Regions' Injuries of the Spine
Causalgia and Reflex Sympathetic Dystrophy
Injury Evaluation Examples
Evaluation of a Cervical Spine Injury
Evaluation of a Thoracic Spine Injury
Evaluation of a Lumbar Spine Injury
CHAPTER 10 The Frightening Greek and Latin Words of Medicine
Terminology
Definitions as Used in This Book
LIST OF FIGURES
1-1 Anatomical Positions and Terms
1-2 The Vertebral Column
1-3 Padlock Analogy for a Vertebra
1-4 Analogy of a Vertebra to a Man with Clasped Hands
1-5 Pedicle Screw Procedure
1-6 Spinal Nerves in a Vertebra Cross Section
1-7 Nerves
1-8 The Atlas and the Axis
1-9 The Cervical Spine
1-10 Front Views of the Cervical Spine Showing the Unicate Process
1-11 Luschka Joint Comparison
1-12 Lumbar Vertebrae
1-13 MRIs of the Lumbar or Lumbosacral Spine
1-14 The Sacrum and the Coccyx
1-15 Cheeseburger Analogy for the Vertebral Bodies
1-16 Cervical, Thoracic, and Lumbar Ligaments
1-17 Spinal Cord and Nerves
1-18 Spinal Cord Cross Section
1-19 The Lateral Foramina
1-20 Blood Vessels
1-21 Tricycle Analogy of the Three Joint Complex
1-22 The Spine as a Three Column Structure
2-1 Spina Bifida with Myelomeningocele
2-2 Encephalocele
2-3 Hydrocephalus
2-4 Spermatogenesis and Zygote
2-5 Fallopian Tubes, Ovaries, Uterus, and Vagina
2-6 Fertilization
2-7 The Fertilized Ovum
2-8 Syncytiotrophoblast
2-9 Endoderm, Mesoderm, and Ectoderm
2-10 The Placenta
2-11 The Ectoderm Forming the Spinal Cord and the Nerve Sructure
2-12 Ossification Centers
2-13 Three Spinal Curvatures
4-1 AP X-Rays of Vertebrae
4-2 Cervical X-Rays, Lateral, and Oblique Views 1
4-3 Bone Scans
4-4 Myelograms
4-5 Cisterna Magna Puncture
4-6 Injecting Dye for a Discogram
4-7 Axial View of a Lumbar CT Scan after a Discogram
4-8 CT Scans
4-9 Various MRIs of the Cervical Spine
4-10 Various MRIs of the Thoracic Spine
5-1 Jefferson Fracture of the Atlas
5-2 Posterior Arch Fractures of the Atlas
5-3 Fractures of the Anterior and the Posterior Arches of the Atlas
5-4 Fractures of the Odontoid Process of the Axis
5-5 How to Show How the Odontoid Process and the Atlas Relate
5-6 How to Show How the Relationship of the Odontoid Process to the Atlas, the
Transverse Ligament, and the Spinal Cord
5-7 How the Distance between the Atlas and the Odontoid Process is Measured
5-8 Hangman's Fracture
5-9 CT Scans
5-10 X-Rays taken after Spinal Instrumentation Surgery
5-11 A Burst Compression Fracture
5-12 Burst Compression Fracture
5-13 The Four Types of Partial, Incomplete Spinal Cord Injuries
6-1 Hemorrhage in Soft Tissue
6-2 Prevertebral Space
6-3 How Angular Displacement of the Cervical Spine Is Measured
7-1 Bulging Discs
7-2 Models of Osteophytes
7-3 Films of Osteophytes
7-4 Cervical Spine Osteophytes
7-5 Disc Hydration
7-6 Discogram of Contained Disc
7-7 Degenerated Disc Disease, Anterior Herniation and Lumbar Spondylosis
7-8 Herniated Discs
7-9 Neurological Examination
7-10 Herniated Lumbar Discs
7-11 Lumbar Spine Examination
7-12 Las?gue's Sign
8-1 Spinal Segments Showing a Spondylolytic Line of Fracture or Dissolution
8-2 Isthmic Spondylolisthesis
8-3 The Four Grades of Displacement in Isthmic Spondylolisthesis
8-4 Degenerative Spondyloisthesis
9-1 Cutaneous Innervation of Upper Extremity and Related Peripheral Nerves and
Roots
9-2 Sensory Nerves of the Lower Extremity and Their Roots of Origin
9-3 Motor Innervation of the Lower Extremity
LIST OF TABLES
2-1 Major Structures Derived from Primary Germ Layers
2-2 Development of the Embryo
2-3 Development of the Fetus
2-4 Progression of Growth and Development of the Vertebral Column after Birth
4-1 Echo Times and Repetition in Different Imaging Techniques
6-1 Researchers' Data Concerning Factors Contributing to Recovery from Whiplash
Injury
9-1 Station and Gait Impairment Criteria
9-2 Relationship of the Impairment of Upper Extremity to Impairment of the Whole
Person
9-3 Knee Impairments
9-4 Impairment Estimates for Amputations
9-5 Impairment Estimates for Certain Lower Extremity Impairments
9-6 Combined Values Chart
9-7 Lower Limb Impairment from Gait Derangement
9-8 Whole-Person Impairment Percents Due to Specific Spine Disorders
9-9 Impairment from Limb Length Discrepancy
9-10 The Pelvis
9-11 Hip Motion Impairments
9-12 Classification for Determining Impairment of the Upper Extremity Due to Loss of
Power and Motor Deficits Resulting from Peripheral Nerve Disorders Based on
Individual Muscle Rating
9-13 Maximum Upper Extremity Impairment Due to Unilateral Sensory or Motor
Deficits of Individual Spinal Nerves or to Combined Deficits
9-14 Maximum Upper Extremity Impairments Due to Unilateral Sensory or Motor
Deficits or Combined Deficits of the Major Peripheral Nerves
9-15 Impairments from Nerve Deficits
9-16 Classification for Upper Extremity Impairment Due to Pain or Sensory Deficit