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By Michael Z. Lighthouse
For special investigative personnel charged with educating claims employees, a lesson in back injuries is a good idea. Such injuries are commonly misunderstood, and many claims are immediately settled when even a casual mention is made of a back injury. “Oh oh,” says an inexperienced adjuster, “I better pay this one quick because the medical report says the claimant has a disk bulge! ”
Not so. There are many factors to consider before any assumptions are made. How old is the claimant? What type of loss occurred? What were the biomechanics of the accident? What diagnostic tests were performed? What are the claimant’s current and past occupations? And on and on.
First, a brief overview of the spine and some of its parts.
The spinal cord is a collection of nerves that connect the brain to all of the peripheral systems (arms, legs, heart, etc.) of the body.
The vertebrae (seven cervical, twelve thoracic and five lumbar plus four sacral, which are usually fused into one equals 24+) are the bony structures that surround the spinal cord. The function of the vertebrae is to protect the cord from trauma andto provide structure for the purpose of movement. Think about it this way: With no bones at all, we could not stand up straight;with a solid bone, we would have no ability to bend or flex. Having a series of little bones allows us both protection and flexion.
The disks are the soft cushions between each of the vertebrae. They serve as shock absorbers whenever the body moves. Each of the disks has a spongy center (nucleus) and a tougher outer ring (annulus) which contains pain fibers. The nucleus is filled with fluid and the movement of this fluid allows the vertebrae to rock back and forth between the disks allowing flexion and movement.
It is common knowledge that a person will be slightly shorter at the end of the day than at the beginning of the day. The reason for this phenomenon is simply this: while a person sleeps, the nucleus fills with fluid and presses against the annulus. So while you may be tallest in the morning, you’re also taut and less flexible. (And the reason that a true disk injury can more easily occur in the early morning hours.) During the day, fluid is pushed in and out of the nucleus, nourishing the disks as the individual moves around. As fluid is slowly lost, so are inches, and that’s why we are shorter at the end of the day. In the evening, the annulus is more flexible and injury becomes less likely.
The facet is a joint between the vertebrae. There is a small, smooth, flat surface on each side of each vertebrae that effaces the similar structure on the next vertebrae. The joining orjoint is the facet.
A foramen is an opening, in this case the opening between two vertebrae. This is where the nerves exit the spinal cord to connect with the rest of the body.
The ligaments “knit” the vertebrae together. They’re like fibrous bands, although unlike muscles, they do not expand and contract. They do, however, contain pain fibers.
Given all of the above, there are myriad injuries that can and do occur. Some are brought about by trauma, others simply by the process of aging. The trick is understanding the physiology involved and determining the most likely reason for the resultant injury.
Some common spine and disk problems include the following:
A disk tear is actually a torn annulus. It can occur more commonly in the morning when the annulus is taut from a sudden movement. Nearby ligaments may also stretch, irritating pain receptors and causing discomfort.
A bulging disk occurs when the inner, jellylike nucleus begins to bulge into the annulus, irritating the pain receptors in the annulus and causing pain. While such an injury can, in some cases, be from a single traumatic injury, it is far more commonly caused by repeated flexion in conjunction with a drying out process of the disk. Bulges are a natural result of simple aging and a large percentage of people have one or more disk bulges of varying degrees. Obviously, this occurs more often with advancing age; however, bulges may start the natural progression as early as childhood in some. Later, in the late 30s, 40s and beyond, bulges are far more naturally common.
A ruptured disk will ordinarily occur as the result of a sudden movement. This happens when a disk bulges and the nucleus moves closer to the outer edge of the annulus. If a sudden movement causes the annulus to rupture, the nucleus can squeeze out and irritate a nerve. The patient’s symptoms typically increase, usually involving an additional part of the body. For instance, if the nerve at T5/L1 is affected, the individual may show signs of sciatica because the affected nerve (the sciatic) exits at that point of the spinal column, traveling down over the buttocks all the way to the foot. A good medical nerve chart isan excellent addition to the desk reference material of anyone involved in the claims process. Why? Because sometimes the 22yearold typist charged with generating the bogus medical report from his/her overused word processor will combine the wrong setof symptoms with the wrong injury description.
It can also be helpful to understand the physiological process involved in a spine injury. A good example is the “stressfracture”perhaps one of the most misunderstood diagnoses there is. Claims personnel have been known, all too often, to concentrate on the second word (fracture) when they see this diagnosis and make a mad dash to up the reserve.
But stress fractures are almost always are the result of a slow process a “stress” process, just like the name suggests. While it is not theoretically impossible for such an injury to occur in, say, a store aisle slip and fall, it is highly unlikely (like 99 percent unlikely! )Generally, when a stress fracture does result from sudden trauma, the accident report will include a parachute jump, a fall from a second story building or something similar. Auto accidents, slip and falls or workers’ compensation (“I was lifting a 20 pound box of papers to the top of my desk and I suddenly felt this pain in my back… “) claims will almost never produce a stress fracture.
Spurs are another good example. A spur is a bone growth; and, no matter what is being claimed, a bone does not instantaneously grow during a split second accident. If the onset of symptoms is immediate and a spur is discovered, the spur was there long before the accident. And while such a finding may not negate any real injury, it can help put the injury in proper perspective.
While we’re at it here, let’s talk about pain: how and when it occurs. A “capper” who does not understand the physiology of pain will often make an error when training his staged accident “victims. “Part of the passengers’ script may call for them to sit at the side of the road, immediately after the accident, holding their necks.
It is extremely rare for a true soft tissue injury to cause instantaneous pain. Such an injury is the result of strain (pulling) or sprain (tearing) of the ligaments. When this happens, the body’s defense system will flood the injured area with fluid to cushion the injury and begin healing. The name for this process is swelling! When all of the extra fluid enters the afflicted area, the sudden added mass will put pressure on the nerves which will, in turn, send a message of pain to the brain. Thus, a true soft tissue injury (involving strain) will generally not produce any instant pain. Unless the gentlemen who exits the slightly damaged car has a protruding bone or visible blood, his immediate grabbing of the neck should be viewed as a red flag. The process of swelling takes far more than 30 seconds and pain just doesn’t appear that quickly.
These are just a few examples of why it is worth the time to understand how an injury occurs and what that injury might really be all about. The answer, obviously, lies in training.
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Michael Z. Lighthouse doesn’t exist. We confess, it’s a penname used, just this once, by a certain Alikim staff member who felt like spouting off on a favorite topic and ending her diatribe with yet another plea for training.
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