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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