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INFORMATION
FOR ATTORNEYS > MORE
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Diagnostic Procedures
Which
test and why
All physicians will agree that a patient's
diagnosis is derived primarily from the
initial consultation and examination.
However, with the increased documentation
requirements by third party payors the
medical-legal arena has changed. Objective
evidence of injury has taken the place
of the "expert physician opinion"
which is based solely on the subjective
findings of conventional orthopedic, neurologic,
physical and chiropractic examinations.
Many new procedures are available for
the objective documentation of soft tissue
injuries.
The attorney needs to keep abreast of
these hi-tech procedures to assure that
the health care team managing their client's
care is also considering the documentation
requirements of the case. The soft tissue
health care team which is usually composed
of neurologist, orthopedist, chiropractor,
physiatrist, psychologist, radiologist
and general medical specialist should
work in concert to assure that all necessary
diagnostic and documentation requirements
are satisfied.
The following are some of the tests which
can benefit the patient's care as well
as document the extent of injury:
Magnetic Resonance
Imaging (MRI)
MRI scanning has earned it's place
in the soft tissue injury arena because
of it's sensitivity in identifying early
degenerative changes which can occur
in the disc post-traumatically. It's
applications go far beyond just locating
areas of disc disease and most attorneys
appreciate this increased sensitivity.
Like CT scanning it has the benefit
of identifying fractures and disc herniations
but an increased benefit is it's fine
density resolution of the neural elements
which are often damaged in trauma cases.
Video-Fluoroscopy (VF)
Also known as fluorovideo Motion Analysis
(FMA), Dynamic Motion X-ray (DMX) and Cineradiography, it has
the ability of recording spinal motion x-rays on video tape.
This is useful in evaluating kinetic
and kinematic abnormalities. It is extremely
sensitive for the evaluation of ligamentous
integrity. This test is most appropriate
for patients who have sustained acceleration/deceleration
trauma when there is the liklihood that
the anterior and posterior supportive
structures of the spain have been put
under excessive stresses. It is the
single most valuable test in identifying
abnormalities of joint coupling which
is the underlying cause of spine pain
from biomechanical origin. Recorded
on video it is a powerful forensic tool
for demonstrating to a lay person the
results of trauma.
3-D Computed
Axial Tomography
3-D CT scanning and reformatting capabilities
have given the radiologist greater ability
to evaluate structures which were previously
inaccessible. With this procedure the
radiologist can visualize the spine
and soft tissues from nearly any angle
and plane. This can be particularly
helpful in diagnosing stenotic foraminal
conditions secondary to bony or soft
tissue involvement.
Electromyography
(EMG)/Nerve Conduction Velocity (NCV)
EMG and NCV examinations are the examination
of choice for people who have motor
or sensory problems involving the spine
and extremities. It has the capability
to differentiate between nerve, muscle
and motor neuron junction diseases.
For radiculopathies myelopathies and
plexopathies involving the motor system
it is particularly sensitive. The one
short comming is the inability to document
sensory complaints which occcur proximal
to the plexus. Therefore, the majority
of patients who have pure sensory complaints
arising from the spinal cord or spinal
nerve root may go undetected. To fully
assess both motor and sensory pathways
EMG, NCV and SSEP should be performed.
Bi-Directional
Doppler, Photo and Pneumo Plethysmography
Doppler and plethysmographic equipment
is used to assess blood flow, direction
and velocity. Vascular studies such
as doppler and plethysmography further
define the patient’s compliaints
of pain. Often times a patient involved
in a trauma may develop extremity complaints
of a vascular origin. Conditions such
as Thoracic Outlet Syndrome (TOS) can
occur as a result of cervical muscle
spasm or adhesions and are best diagnosed
by plethsmographic examinations. Reflex
Sympathetic Dystrophy also has vascular
components which may be secondary to
trauma and identified using photo-plethysmograhic
equipment. Patient complaints of headaches
must be differentiated from dangerous
vascular disease and therefore cerebrovascular
screening exams can assist in the diagnosis
of post traumatic headache by eliminating
carotid atery disease.
Somatosensory
Evoked Potentials (SEP)
SEP's are one of the most exciting
electroneurodiagnostic procedures to
hit the medical and personal injury
arenas. It has the unique ability to
measure sensory abnormalities which
conventional electromyography (EMG)
and nerve conduction velocity (NCV)
can not usually detect. When used properly
the SEP can localize and quantitate
the degree of sensory impairment and
assist the doctor prognosticate outcome.
Current Potential
Threshold (CPT)
CPT testing, like the SEP's, have the
ability to document involvement of the
sensory nervous system. When used in
conjunction with SEP's a assessment
as to which nerve sub-populations are
involved can be determined.
Electronic
Infra-red Thermography
Thermography has the unique ability
of measuring the physiologic status
of both the musculoskeletal and neurological
systems. When interpreted by a board
certified thermographer the test can
greatly assist the doctor and attorney
by graphically demonstrating the abnormalities
present. Juries are particularly impressed
by the color representation of soft
tissue damage.
Topographic
Brain Mapping
Brain mapping offers exciting possibilities
in the documentation of head trauma
cases. It represents a computer enhancement
of raw electroencephalographic (EEG)
data. It is displayed topographically
with colors representing different frequencies
and amplitudes of spontaneous brain
electrical discharge. Just out of the
research institutions, it promises to
offer tremendous insight into a variety
of neurologic related conditions.
Isokinetic
Muscle Testing
Isokinetic muscle testing equipment
has the ability of quantifying muscle
strength deficits which are produced
with extended exertion. Most quality
equipment will produce torque curves
which can enhance evaluation and fatigue
assessment. Cybex in particular has
established normative data which make
objective impressions to be generated
from the raw data.
X-Ray Digitization
The computerized digitization of plain
film and fluoroscopic images allows
for greater sensitivity in the interpretation
of radiographic studies. The computers
have the capacity to draw lines of mensuration
much more accurately than a technician
or even a physician. The computer can
instantaneously locate areas of altered
biomechanical stress or structural abnormality.
Areas of trauma and vulnerability to
trauma are identified and quantitatively
presented. Conditions such as canal
stenosis, spondylolisthesis, instability,
laxity, altered weight bearing, kyphotic
subluxation can easily be identified
and graphically presented.
Electronic
Digital Inclinometry
Range of motion studies of the spine
require the use of an inclinometer to
differentiate localized spinal movements
from accessory spinal movements. The
old method of using a goniometer could
not eliminate movement from adjacent
parts of the spine and therefore were
often times found to be inaccurate.
The American Medical Association’s
"Guide to the Evaluation of Permanent
Impairment" require the use of
an inclinometer in its assessment of
impairment using the range of motion
model. With this in mind it is prudent
to utilize electronic digital inclinometer
to asure accuracy and reproducibility
of the range of motion examination
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