Spine. The following case studies relate to injuries to the Spine.

Transcription

1 Spine The following case studies relate to injuries to the Spine. More detailed information regarding the assessment of spinal injuries may be found at Chapter 4 of the MAA s Permanent Impairment Guidelines and Chapter 3.3 of the AMA4 Guidelines. The Motor Accidents Authority of NSW makes no warranties or representation about the accuracy or completeness of the information contained in these Case Studies. It should be noted that the information contained herein is not provided as a substitute for legal advice.

2 Spine Case Study # Brief Description Primary Body System Secondary Body System Spine1 Cervical and thoracic spine injuries Spine Upper Limb Spine2 Thoracic spine fracture Spine Spine3 Pelvic fracture methodology Spine Spine4 Pevis and sacrum fractures Spine Lower Limb Spine5 Cervical spine fracture Spine Spine6 Cervical, thoracic and lumbar spines Spine Spine7 Cervical multilevel structural compromise Spine Upper Limb Spine8 DRE categories Spine Skin Spine9 Thoracic spine fractures Spine Spine10 Thoracic fractures Spine Lower Limb Spine11 Compression Fracture L1 and L2 Spine Spine12 Pre-existing Spinal Surgery Spine Spine13 Multilevel Structural Compromise Spine Upper Limb Spine14 Whiplash Spine Spine15 Spinal Spacing Devices Spine Spine16 Pre-existing Lumbar Impairment Spine Upper Limb Spine17 Sciatica/Psoas muscle Spine Lower Limb Spine18 Pre-existing Spinal Fusion Spine

3 Injuries: Cervical spine soft tissue injury Thoracic spine fracture Right shoulder - AC joint Right knee soft tissue injury The claimant was the driver of a vehicle; another vehicle hit her on the passenger side of their car and she received impact damage to the left side of her body. The momentum from the impact caused her to strike the right-hand side of the car door sustaining injuries to the right-hand side of her body. Current Symptoms Cervical spine pain She describes a central, constant ache; this radiates to the right and left shoulder. She states that it is non-specific and will come on at any time but is particularly worse after she has been looking down for a period of time (e.g. working on a computer). Thoracic spine pain The claimant describes a constant, interscapular ache; it is interspersed with episodes of sharp pain which is localised. The constant ache will invariably radiate to the right shoulder. This back pain is increased by movement especially repetitive lifting, pushing, pulling or attempting to work above her head. The pain is also increased by sitting for 45 minutes. She has problems sleeping at night and needs to us a body pillow. Right shoulder pain The claimant describes an intermittent, sharp pain in the outer aspect of the right shoulder. This radiates to the upper outer arm and can also spread to the right wrist. She will often notice early morning numbness involving both hands (right greater than left) and this is often associated with reduced grip. Her right shoulder pain is aggravated by lifting, working with her arms out in front of her, pushing and pulling and any repetitive movement. Right knee pain She describes an intermittent ache within the joint; this is associated with a tight feeling and she states she invariably experiences a swelling which she notices is in the suprapatellar area. She denies locking or giving way. Clinical Examination On examination she was of average stature and overweight. She walked with a normal gait. She rose steadily using both hands to push herself off the chair. She dressed and undressed slowly but was able to stand independently on each leg without support. She had a normal posture; there was no evidence of pelvic tilt or limb shortening on measurement. Examination of the thoraco-lumbar spine did not reveal any skeletal deformity or abnormality. There was no scoliosis, lumbar tilt or rotational deformity. The kyphotic and lordotic curves were normal. She was specifically tender over the T7 vertebra but

4 this was not associated with any muscle spasm or guarding. I note X-rays performed of the thoracic spine describe a depression in the superior end plate of the mid-thoracic vertebral body which is taken to be T7 on the frontal view; so there is a loss of vertebral height of approximately 20%. No other focal vertebral body abnormality was detected. Examination of the cervical spine showed the neck to be short and thick; the attitude was neutral and normal. There was no evidence of torticollis. There was no specific tenderness over the spinous processes, interspinous ligaments or paraspinous muscles. The trapezii were normal; there was no evidence of muscle spasm and no region acting as a trigger area. Examination of the shoulders showed the bony and soft tissue contours to be equivalent. There was no evidence of rotator cuff or spinate muscle wasting. The AC joint was tender on the right side compared with the left; the SC joints were unremarkable. The following shoulder movements were obtained: Shoulder Measurements (goniometer verified): AMA 4 Figures 38, 41 & 44 (Pages 43, 44 & 45) Measurement RIGHT Measurement LEFT Flexion Extension Adduction Abduction Internal Rotation External Rotation The upper arms were symmetric in dimension and there was no evidence of loss of tone, wasting or tenderness about the triceps or biceps muscles. The grip of the hands was strong and equivalent; there was no evidence of small muscle wasting. Examination of the knees did not demonstrate any condylar or patellar expansion, synovial hypertrophy or effusion (negative swipe test). On repeated flexion extension of both knees there was evidence of some retropatellar crepitus involving the right knee (the Clarke s test was positive). Power throughout the range of movement was strong and equivalent; there were no bursii or cysts associated with the knee joint. There was no medial or lateral joint line tenderness, collateral ligament laxity, increased drawer movement or abnormal tibial rotatory movement. Impairment Evaluation The claimant s cervical spine has been assessed initially from Table 4.1 MAA Permanent Impairment Guidelines; and then from Table 73 of the Fourth Edition of the AMA Guides.

5 There was no evidence of muscle guarding present today. There was no evidence of muscle tenderness over the lower fibres of either trapezius which could have resulted in any neck restriction. There was minimal neck restriction observed at today s examination. There was no evidence of dysmetria noted. Imaging has not shown evidence of pre-existing disease. The claimant s thoracic spine was assessed as a fracture of T7 with less than 25% compression using Table 4.1 MAA Permanent Impairment Guidelines; and then from Table 74 of the Fourth Edition of the AMA Guides. The claimant s right shoulder was assessed using Figures 38, 41 and 44 of AMA4 Guidelines due to loss of range of motion. Examination of the right knee revealed some retropatellar crepitus. I refer to AMA Guides Edition Four, page 83, Table 62 and the sub-caption under this table which states In a patient with a history of direct trauma and complaint of patellofemoral pain and crepitation on physical examination but without joint space narrowing on X- ray, a 2% whole person impairment is given. In my opinion, the claimant s right knee qualifies for a 2% whole person impairment on the basis of this directive. Body Part or System AMA Guides/ MAA Guidelines References (chapter/ page/table) Chapter 3; Table 73 Chapter 3; 1. Cervico-thoracic spine 2. Thoraco-lumbar spine Table Right shoulder Chapter 3; Figures 38, 41 & Right knee Chapter 3; Table 41 & 62 Stabilised (YES/NO) * %WPI = percentage whole person impairment Current %WPI* %WPI* from pre-existing OR subsequent causes Yes Yes Yes Yes %WPI* due to motor accident Determination Regarding the Degree of Whole Person Impairment of the Injured Person as a Result of the Injuries Caused by the Motor Accident The total percentage whole person permanent impairment for assessed injuries caused by the motor accident is 12%.

6 This matter was subject to review by a Medical Review Panel. These are the Review Panel s findings. Claimant s Date of Birth: 7 October 1970 Date of Motor Accident: 28 July 2005 Injuries: Wedge fracture of the T12 vertebra (thoracic spine injury) Panel Findings The report of the X-Ray thoracic and lumbar spine on 9 November 2005 records a healing fracture of the superior end plate of the body of T12 which is virtually complete. There is a residual anterior wedged deformity of approximately 20% There is a mild Tii/12 kyphosis. The Review Panel inspected the plain x-rays of the thoracolumbar spine. Assessor A measured the heights of thoracolumbar vertical bodies (T10, T11, T12, L1) as being 25mm, 24mm, 23mm, 32mm respectively. The corresponding measurements obtained independently by Assessor B were 26.5mm, 24mm, 22mm and 28mm (the variations were within the margins of error of the measurement procedures, and variations in reference point). The radiological parameters clearly indicated significant compression of both T11 and T12 vertebral bodies. Panel Deliberations This is assessable in terms of the DRE criteria, p 106, AMAG4. The panel was in no doubt that the documentation provided clear evidence of a significant thoracic spine injury. There had been unequivocal documentation of a wedge fracture of the T12 vertebra, with associated pain. The panel concluded that examination of the latest films also provided clear evidence of a fracture of T11 (as well as T12) vertebra. The panel now notes that various radiological and clinical entries have raised the possibility that in addition to the T12 fracture there has been a T11 (and/or T10) fracture (vide supra re radiological report from Bankstown Hospital also Liverpool Hospital admission note and subsequent progress notes which refer to possible T11/T12 fractures). The presence of two vertebral body fractures is classified as multi-level structural compromise for purposes of DRE classification (see para 4.33, p28, MAA Permanent Impairment Guidelines). Accordingly, there is a DREIV designation for thoracic spine impairment, and this equates to 20% WPI (see p 106, AMAG4). Panel Decision The whole person permanent impairment of the injuries caused by the accident was calculated as follows:

7 Body Part or System AMA Guides/ MAA Guidelines References (chapter/ page/table) 1. Thoracic spine P106, AMAG4, para 4.33, MAA Guidelines Permanent (YES/NO) * %WPI = percentage whole person impairment Current %WPI* %WPI* from pre-existing OR subsequent causes Yes 20% 0% 20% %WPI* due to motor accident Determination Regarding the Degree of Whole Person Impairment of the Injured Person as a Result of the Injuries Caused by the Motor Accident The total percentage whole person permanent impairment for assessed injuries caused by the motor accident is 20%. Therefore the total whole person impairment is greater than 10%.

8 This matter was subject to review by a Medical Review Panel. These are the Review Panel s findings. Claimant s Date of Birth: 13 November 1973 Date of Motor Accident: 10 February 2006 Injuries: Pelvis and sacrum multiple fractures Lumbar spine soft tissue injury Clinical Findings The claimant s gait and lower limb functions were all normal. She was able to squat fully and in a normal fashion although with complaint of low back discomfort. Trendelenburg s tests were negative bilaterally. The slump test was positive with complaint of pulling discomfort in the left buttock. On inspection her hands were clean suggesting she had not been performing heavy tasks with the arms. Otherwise joints were held in normal position. There was no joint swelling, no muscle wasting and no changes of complex regional pain syndrome. There was no leg length discrepancy and no mal-alignment of the thoracolumbar spine. On palpation of the lumbar spine there was no allodynia or inflammation of the skin. There was no guarding over the lumbar spine. There was complaint of tenderness over the right and left sacroiliac joint but no true guarding. There was no coccygeal tenderness. There was no tenderness around the left hip joint. There was tenderness over the right anterior superior iliac crest but no guarding. There was no pain on springing the pelvis. Passive movements of the right hip joint were pain free. Passive movements of the left hip joint and external rotation were associated with complaint of pain. There was no hip joint instability. The straight leg raising test was negative bilaterally. Examination of power and reflexes was normal. Tone was normal in the lower limbs. The Babinski response was down going bilaterally. Sensation testing was normal. Range of motion in the lumbar spine was such that extension was two-thirds normal and left rotation two-thirds normal. Other movements were normal. Measurement of the leg lengths was equal. Measurement of the limb circumferences was equal. Range of motion in the hips was as follows: HIP Measurement RIGHT Measurement LEFT Flexion Extension Full Full

9 Internal Rotation External Rotation Abduction Adduction The most recent x-rays of the pelvis and sacrum, dated 11 January 2007, were carefully reviewed. These x-rays showed that the fractures had united without displacement. Panel Decision The pelvic and sacral fractures are assessed with reference to section 3.4, page 131 AMA4 Guides The injuries to the lumbar spine is assessed with reference to the Diagnosis Based Estimate (DRE) method. The whole person permanent impairment of the injuries caused by the accident was calculated as follows: Pelvis and sacrum multiple fractures The multiple fractures have healed without displacement and without residual signs. The panel noted the asymmetric ranges of movement at the hips and concluded that this was not due to the pelvic fractures because of the nature of these fractures. Therefore, with reference to section 3.4, page 131 AMA4 Guides, the permanent impairment due to these injuries is 0% WPI. Lumbar spine soft tissue injury The lumbar spine injury (injury to the lumbosacral spine) is assessed with reference to the Diagnosis Related Estimate method. The claimant has asymmetric loss of range of motion (dysmetria) with reference to the lumbosacral spine, and therefore DRE Lumbosacral Category II (5% WPI) is the appropriate evaluation. There are no symptoms or signs, that are currently present, that justify assessment of DRE III in this spinal region. Body Part or System 1. Pelvis and sacrum multiple fractures 2. Lumbar spine soft tissue injury: DRE II AMA Guides/ MAA Guidelines References (chapter/ page/table) Chapter 3, section 3.4, page 131 (AMA4) Chapter 3, page 102 (AMA4) Stabilised (YES/NO) * %WPI = percentage whole person impairment Current %WPI* %WPI* from pre-existing OR subsequent causes Yes Yes %WPI* due to motor accident Determination Regarding the Degree of Whole Person Impairment of the Injured Person as a Result of the Injuries Caused by the Motor Accident

10 The total percentage whole person permanent impairment for assessed injuries caused by the motor accident is 5%. Therefore the total whole person impairment is not greater than 10%.

11 This matter was subject to review by a Medical Review Panel. These are the Review Panel s findings. Claimant s Date of Birth: 17 April 1946 Date of Motor Accident: 6 June 2006 Injuries: Clinical Findings

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13 Panel Deliberations

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17 Panel Decision

18 This matter was subject to review by a Medical Review Panel. These are the Review Panel s findings. Claimant s Date of Birth: 26 September 1999 Date of Motor Accident: 12 July 2003 Injuries: Cervical spine fracture of spine with displacement Panel Findings

19 Panel Decision

20 This matter was subject to review by a Medical Review Panel. These are the Review Panel s findings. Claimant s Date of Birth: 22 January 1961 Date of Motor Accident: 17 September 2002 Injuries: Cervical spine Thoracic spine Lumbar spine Clinical Findings Cervical spine - disc bulge and protrusion The panel was of the opinion that it would be appropriate to list this injury as Cervical spine soft tissue injury as there was no clear evidence to indicate that a disc bulge and protrusion resulted from the subject accident. The panel noted that the clinical findings reported by Assessor X, namely evidence of asymmetrical neck movement, fulfilled the criteria for Cervicothoracic DRE Category II with 5% whole person impairment. Thoracic spine - disc bulge and protrusion, loss of the anterior height of vertebrae, anterior wedging of T8 vertebral body The panel was of the opinion that it would be appropriate to list this injury as Thoracic Spine anterior wedge compression fracture as there was no clear evidence to indicate that a disc bulge and protrusion resulted from the subject accident. The panel noted that the clinical finding reported by Assessor X, namely evidence of guarding in the right para-thoracic muscles, fulfils the criteria for Thoracolumbar DRE Category II with 5% whole person impairment. The panel also noted that review of the x-rays of the thoracic spine dated 30 January 2004 and 23 June 2004 revealed evidence of a compression fracture of the T8 vertebra with less than 25% compression (according to the method advocated at Item 4.37 of the MAA Guidelines) which also fulfils the criteria for Thoracolumbar DRE Category II with 5% whole person impairment. Lumbar spine - disc bulge and protrusion, fractured vertebrae The panel was of the opinion that it would be appropriate to list this injury as Lumbar spine soft tissue injury as there was no clear evidence to indicate that a disc bulge and protrusion or a vertebral fracture resulted from the subject accident. The panel noted that the clinical findings reported by Assessor X, namely evidence of asymmetrical lower back movement and guarding in the right para-lumbar muscles fulfils the criteria for Lumbosacral DRE Category II.

21 The panel noted that Assessor X had found no objective evidence of radiculopathy in relation to the upper or lower extremities as defined in the MAA Guidelines (Item 4.28 page 27). Panel Decision The whole person permanent impairment of the injuries caused by the accident was calculated as follows: Body Part or System 1. Cervicothoracic spine 2. Thoracolumbar spine 3. Lumbosacral spine AMA Guides/ MAA Guidelines References (chapter/ page/table) AMA4: Para 3.3h, Page 104 MAA: Pages 21 to 29 AMA4: Para 3.3i, Page 106 MAA: Pages 21 to 29 AMA4: Para 3.3g, Page 102 MAA: Pages 21 to 29 Stabilised (YES/NO) Current %WPI* %WPI* from pre-existing OR subsequent causes %WPI* due to motor accident Yes 5% 0% 5% Yes * %WPI = percentage whole person impairment 5% 0% 5% Yes 5% 0% 5% Determination Regarding the Degree of Whole Person Impairment of the Injured Person as a Result of the Injuries Caused by the Motor Accident The total percentage whole person permanent impairment for assessed injuries caused by the motor accident is 15%. Therefore the total whole person impairment is greater than 10%.

22 This matter was subject to review by a Medical Review Panel. These are the Review Panel s findings. Claimant s Date of Birth: 20 March 1972 Date of Motor Accident: 8 February 2006 Injuries: Neck injury C5/6 Left scaphoid fracture Left clavicle fracture Panel Findings Neck

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25 This matter was subject to review by a Medical Review Panel. These are the Review Panel s findings. Claimant s Date of Birth: 2 April 1985 Date of Motor Accident: 28 December 2003 Injuries: Cervical spine Thoracic spine Lumbar spine Scarring Clinical Findings Cervical Spine: On inspection of the cervical spine, the posture, alignment and contour were normal. There was reported tenderness over the cervical spine centrally and paracentrally on the right and left side and over the shoulder ridges. There was no muscle spasm and no muscle guarding. There was no dysmetria with a symmetric range of neck movements forward flexion and extension, lateral bending to the right and left and rotation to the right and left. Upper Limbs: Examination of the upper limbs was unremarkable. The circumference of the upper arms was 28 cm (right = left) and forearms 23.4 cm (right = left). There were no neurological abnormalities detected in the upper limbs with normal power, tone and deep tendon reflexes. No sensory deficits were elicited. There was a symmetric range of movement of the shoulders. At the extreme ranges of movement of the right shoulder and also the left shoulder, there were reported pains in the neck. The impingement tests were negative and there was no crepitus found in the shoulder joints. On further enquiry at the clinical examination, she did not describe non-verifiable radicular symptomatology in the upper limbs. Back: On inspection of the back, the posture, alignment and contour were normal. There was reported tenderness over the lower lumbar spine but not over the thoracic spine. There was no muscle spasm and no muscle guarding in the thoracic or lumbar spine. There was no dysmetria in the thoracic or lumbar spine with two-thirds normal range of flexion and extension and symmetric lateral bending to the right and left and symmetric rotation. Lower Limbs: There were no neurological abnormalities detected in the lower limbs with normal power, tone and deep tendon reflexes. No sensory deficits were elicited. The circumference of the thighs was 47cm (right) and 46.5cm(left) and calves 34cm (right

26 = left). Straight leg raising was to 80 degrees on each of the right and left side with a negative stretch test. On further enquiry in relation to the nature of her symptomatology in the lower limbs, the symptomatology that she described, was not of a non-verifiable radicular nature. On formal examination of gait, she walked normally and on her heels, toes and heeltoe and made a normal squat. Scarring: On examination of the scarring, there was a well healed hypertrophic scar of 1.5 cm x 0.5 cm with some slight colour difference over the posterior aspect of the right shoulder. There was no adherence and no contour defect. There was a well healed scar of 2.5 cm x 2 mm over the patellar tendon of the right knee. There was no contour defect and no adherence. There was some punctate scarring over the right foot which was not easily distinguishable and she indicated that she was tanned following a holiday. Panel Decision Neck: The Panel confirmed that there was a history of injury and pain in the neck but no clinical differentiators such as muscle spasm, muscle guarding, non-uniform loss of spinal motion (dysmetria) and no non-verifiable radicular complaints (see paragraph 4.17, page 26, of the MAA Impairment Assessment Guidelines of 01 October 2007) and no clinical radiculopathy and concluded that there was a DRE Impairment Category Rating I of the Cervicothoracic Spine which translates to a 0% Whole Person Impairment under Table 73, page 110, of the AMA 4 Guides. Thoracic spine: The Panel considered the examination findings noted above and particularly it was noted that there was no reported symptomatology now in the thoracic spine, no clinical signs of injury such as muscle spasm, muscle guarding and dysmetria and determined that the thoracic spinal injury had resolved. Lumbar Spine: The Panel considered the examination findings noted above and determined that there was a history of injury, pain in the lumbar region but no significant clinical differentiators no muscle spasm, no muscle guarding, no dysmetria, and no nonverifiable radicular symptomatology and no clinical radiculopathy and determined that there was a DRE Impairment Category Rating I of the Lumbosacral Spine which translates to a 0% Whole Person Impairment under Table 72, page 110, of the AMA 4 Guides. Scarring Laceration right leg, laceration left leg, embedded glass right foot: The scars were considered to be well healed but it was noted that the Claimant was conscious of the scars, there was some minor colour contrast with the surrounding skin, and the scars were mildly hypertrophic. The anatomic location was visible with usual clothing and there was minor contour defect but no effect on any activities of daily living and no treatment or intermittent treatment required and no adherence and thus determined a 1% Whole Person Impairment for the scarring under the TEMSKI.

27 The following injuries were found to be resolved and give rise to no assessable impairment: Thoracic spine. The whole person permanent impairment of the injuries caused by the accident was calculated as follows: Body Part or System AMA Guides/ MAA Guidelines References (chapter/ page/table) 1. Cervical spine Chapter 4 MAA Guidelines 1/10/07, Chapter 3.3 AMA 4 Stabilised (YES/NO) Current %WPI* %WPI* from pre-existing OR subsequent causes %WPI* due to motor accident Yes 0% Nil 0% 2. Lumbar spine Chapter 4 MAA Yes Guidelines 0% Nil 0% 1/9/05, Chapter 3.3 AMA 4 3. Scarring TEMSKI Yes 1% Nil 1% * %WPI = percentage whole person impairment Determination Regarding the Degree of Whole Person Impairment of the Injured Person as a Result of the Injuries Caused by the Motor Accident The total percentage whole person permanent impairment for assessed injuries caused by the motor accident is 1%. Therefore the total whole person impairment is not greater than 10%.

28 This matter was subject to review by a Medical Review Panel. These are the Review Panel s findings. Claimant s Date of Birth: 6 October 1988 Date of Motor Accident: 15 November 2004 Injuries: Thoracic spine fractures T11 and T12 Clinical Findings The claimant s plain lumbosacral spine x-ray dated was made available and distributed to each of the panel members. This was only a lateral film. After considerable discussion it was agreed amongst the panel members that the clear cut superior and inferior borders of T11 and T12 and the depressed superior margins of these two vertebrae were consistent with compression fractures and were not consistent with the irregular superior and inferior vertebral body margins and the wedge shape of the vertebral body of lateral view characteristic of Scheuermann s Disease. The panel also considered that the below listed measurements also confirmed compression fractures of T11 and T12 vertebrae:- Vertebra Posterior Height Central Height Anterior Height T11 33cm* 23cm 24cm T12 33cm 25cm 25cm L1 35cm 31cm 33cm *The panel was able to confirm this height by the use of very bright illumination of this area and appeared to be consistent with extrapolation of the more clearly visible parts of superior and posterior border lines. Panel Decision On the basis of the above assessment of the forwarded lateral lumbar spinal x-ray film dated it was the panel s opinion that the claimant had sustained compression fractures of T11 and T12 in the motor accident on the previous day The panel concluded that in the presence of two thoracic vertebral body compression fractures that the claimant was to be assessed as suffering multilevel structural compromise (MAA Impairment Assessment Guidelines, 1 st October, 2007, Item 4.33, Page 28) and that this attracts a thoracolumbar DRE Category IV classification (MAA Impairment Assessment Guidelines, 1 st October, 2007, Item 4.40, Page 28) as there was no evidence of radiculopathy. In accordance with AMA 4, Table 74, Page 3/111, Section 3.3i, Page 3/106 the claimant is assessed as having a permanent 20% whole person impairment.

29 The whole person permanent impairment of the injuries caused by the accident was calculated as follows: Body Part or System 1. Thoracolumbar spine fractures T11 and T12 AMA Guides/ MAA Guidelines References (chapter/ page/table) MAA Impairment Assessment Guidelines, 1 st October, 2007, Items 4.33 and 4.40, Page 28, AMA 4, Table 74, Page 3/111, Section 3.3i, Page 3/106 Stabilised (YES/NO) * %WPI = percentage whole person impairment Current %WPI* %WPI* from pre-existing OR subsequent causes Yes 20% 0% 20% %WPI* due to motor accident Determination Regarding the Degree of Whole Person Impairment of the Injured Person as a Result of the Injuries Caused by the Motor Accident The total percentage whole person permanent impairment for assessed injuries caused by the motor accident is 20%. Therefore the total whole person impairment is greater than 10%.

30 This matter was subject to review by a Medical Review Panel. These are the Review Panel s findings. Claimant s Date of Birth: 11 May 1987 Date of Motor Accident: 13 May 2005 Injuries: Left knee chondromalacia patella Back compression fractures of 5 th, 6 th and 7 th thoracic vertebrae Panel Decision Left Knee The panel noted retro-patella pain and crepitus of the left knee. The panel concluded that the correct assessment for the left knee was 2% whole person impairment from the footnote of Table 62 of the 4 th Edition of the AMA Guides. Thoracic spine The panel noted the chest x-ray report dated 13 May 2005, which stated there is a suggestion of a significant acute compression fracture of the body T7 with loss of height anteriorly in the order of 25 to 30%. There is also the suggestion of bioconvexity and slight anterior depression of the bodies of T5 and T6. The panel had reviewed the subject chest x-ray individually and agreed that there was a 25% compression fracture of the body of a mid thoracic vertebra (presumably T7). The anterior height of the vertebral body was 18mm compared with 24 mm for the vertebrae below. Due to the poor clarity of the x-rays it was not possible to accurately measure the vertebrae above. The panel noted that it was difficult to accurately assess the level of the fracture due to poor clarity of the x-ray view. The panel noted that there was some minor irregularity of the two vertebral bodies above the compression fracture but was not able to confirm fractures at these levels. The panel could see no evidence of significant Scheuermann s disease in the thoracic spine. The panel noted the CT scan of the thoracic spine report dated 19 May The report states there have been compression fractures of the anterior superior end plates of T5, T6 and T7. The most marked compression is in T6. The panel was unable to review the CT scan as it has apparently been lost. The panel noted though that the report supported compression fractures of the mid thoracic spine. The panel could see no reason to dispute the findings of the specialist radiologist. The panel reviewed the thoracic spine x-ray dated 11 October 2006 and agreed that there was a compression fracture in the mid thoracic spine (presumably T7) of 25%. Again it was difficult to confidently ascertain the exact level of the fracture due to the clarity of the x-rays. The panel was not able to confirm fractures to any other thoracic vertebrae even though some irregularity was noted to the vertebral body directly

31 above the fractured level. There was no evidence of significant Scheuermann s disease in the x-rays. The panel considered that on the evidence reviewed that the thoracic spine injury was either DRE III or DRE IV. The compression fracture of 25% at T7 (as a structural inclusion) would give an assessment of DRE III (15% WPI). The panel believed though that the CT report and the subsequent medical report were sufficient to support the probability of compression fractures at 3 levels. In this instance the MAS Permanent Impairment Guidelines (1 October 2007) state in clause 4.33 Multilevel structural compromise is to be interpreted as fractures of more than one vertebra. The panel concluded that the correct assessment of the thoracic spine was DRE IV from Table 74 of the 4 th Edition of the AMA Guides (20% WPI). The panel concluded that the combined permanent impairment assessment of all injuries from the subject motor accident was 22%. The whole person permanent impairment of the injuries caused by the accident was calculated as follows: Body Part or System AMA Guides/ MAA Guidelines References (chapter/ page/table) 1. Thoracic spine Chapter 3, Table 74 (AMA Guides) and clause 4.33 (MAA Guides) 2. Left knee Chapter 3, Footnote Table 62 Stabilised (YES/NO) * %WPI = percentage whole person impairment Current %WPI* %WPI* from pre-existing OR subsequent causes %WPI* due to motor accident Yes Yes Determination Regarding the Degree of Whole Person Impairment of the Injured Person as a Result of the Injuries Caused by the Motor Accident The total percentage whole person permanent impairment for assessed injuries caused by the motor accident is 22%. Therefore the total whole person impairment is greater than 10%.

32 Injuries: Compression fractures L1 and L2 At time of the accident the male claimant was in his mid thirties and had no history of problems of his lumbar spine. He was travelling on his motor bike and was hit from behind by another vehicle. The claimant recalls being thrown in the air and landing on the ground. The claimant stated he temporarily lost consciousness. He complained that he experienced low back pain. Pain persisted and a few days after the accident he saw his GP who arranged X-rays of the lumbar region. He was initially advised that there was no fracture. The claimant had continuing pain in the lumbar region for which he took regular strong pain relief. The claimant then underwent a CT scan of the lumbar spine in which revealed compression fractures of L1 and L2. Clinical Examination The assessor confirmed that the CT scan of the lumbar spine dated November 2007 showed an old healing wedge compression fracture of the L1 and L2 vertebral body without complication. A CT scan of the lumbar spine taken in June 2008 also confirmed the compression fractures at L1 and L2. There were no plain films available for review. The measurements of the vertebral bodies, measured on the CT scan dated June 2008 were as follows:- Vertebra Anterior Posterior Border- Height Saggital view T12 8mm 8mm L1 6mm 8mm L2 7mm 8mm L3 8mm 8mm This results in a compression fracture of 25% at L1 and 13% at L2 (rounding). Impairment Evaluation The assessor determined that the Lumbar spine - compression fractures of L1 and L2 was caused by the MVA of August He also noted that the compression fractures of L1 and L2 had stabilised. The fractures had united and there had been no change in the claimant s clinical condition in the past 3 months. The assessor determined that the claimant had sustained a multilevel structural compromise due to the compression fractures at L1 and L2. The assessor assessed the claimant as being in a lumbosacral category 4 in the diagnosis related estimate category (DRE) (reference Table 4.1, Chapter 4, page 22 in the Permanent Impairment Guidelines 1/10/2007).

33 A DRE Lumbosacral Category 4 results in a 20% WPI (reference Chapter 3, page 102 in AMA4). If the claimant had only suffered one compression fracture of 25% to the L1 vertebrae then he would have been placed in lumbosacral category 3 in the DRE category for which a descriptor is vertebral body compression fracture 25 50% (reference Table 4.1, Chapter 4 page 22 in the Permanent Impairment Guidelines 1/10/2007). A DRE Lumbosacral Category 3 results in a 10% WPI (reference Chapter 3, page 102 in AMA4).

34 This matter was subject to a review by a Medical Review Panel. These are the Review Panel s findings. Injuries: Neck severe strain Lower Back severe strain Right Wrist severe strain The claimant was involved in a MVA when the motor vehicle he was driving was struck from behind by another car and was written off as a result. The claimant was taken by ambulance to Hospital where he was kept under observation for a week. X- Rays were carried out and concern was expressed about possible spinal damage. Clinical Findings: On re-examination the claimant was observed to move somewhat awkwardly when sitting and when getting up from a sitting position but to be able to walk without difficulty. On formal examination of his active ranges of lumbar spinal motion all of these ranges were noted to be quite markedly restricted and it was particularly noted that trunk tilting and trunk rotation to the left was significantly more restricted than the right. Straight leg raising was restricted by pain in his back when prone to 35 in the right lower limb and 30 in the left lower limb. Whilst confirming the claimant s history and current symptoms he was noted to have very much freer ranges of neck motion in all directions than when subsequently formally examined at which time on repeated assessment he had very variable degrees of restrictions to all of these ranges of active motion. Panel Deliberations Neck Severe Strain After examining the claimant s range of movements and examining the medical evidence the Panel agreed that the claimant had a DRE Cervicothoracic Impairment Category 1 with a permanent 0% whole person impairment. Right Wrist Severe Strain The Panel considered that there was no abnormal physical findings on examination of his right wrist as his uninjured left wrist had identical ranges of motion. He was therefore assessed as having a permanent 0% whole person impairment with respect to the injury to the right wrist. Lower Back Severe Strain The Panel determined that as the claimant identified pain and numbness in his left leg associated with his back pain and that there was no contemporaneous evidence of a discrete injury to his left leg that the listed injury to the left leg required to be assessed in conjunction with his back injury. At the re-examination of the claimant there was evidence of asymmetrical restriction to the ranges of motion in his lumbar spine, somewhat variable restriction to the range of the straight leg raising in both his

35 lower limbs, absence of his left ankle jerk, muscle wasting in both his left thigh and left calf and sensory alteration in a distribution in the left lower limb which was predominantly in the distribution of L5 and S1 dermatome. On the basis of these findings it was the Panel s determination that the claimant had a DRE Lumbosacral impairment category III (due to radiculopathy) with a permanent 10% whole person impairment. WPI related to previous injury (10% - 5% = 5%) The Panel also determined that the observed lower lumbar midline surgical scar confirmed the history of previously having undergone discectomy but without any evidence of subsequent radiculopathy and, as such, the claimant had a pre-existing DRE Lumbosacral Impairment Category II with a permanent 5% whole person impairment. Subtracting the level of pre-existing whole person impairment from his current level of permanent impairment the Panel determined the claimant to have an overall permanent 5% whole person impairment for lumbosacral impairment caused by the MVA. Panel Decision The degree of permanent impairment of the injured person as a result of the injury to the neck severe strain, lower back severe strain to incorporate left leg severe strain, right wrist severe strain, caused by the accident, is not greater than 10%.

36 This matter was subject to a review by a Medical Review Panel. These are the Review Panel s findings. Injuries: Neck injury C5/6 Sternum fracture Ribs fracture Left Scaphoid fracture Left Clavicle and collar bone dislocation History The claimant was involved in a MVA on his way home from work when he had a head-on collision with another vehicle which had lost control. He was told that he had a fractured sternum and a fractured scaphoid in his wrist. He had problems with his left clavicular joint and also his neck. He required physiotherapy for the injury to his neck and needed a C5/6 fusion in August He had left arm numbness which continued following the fusion. He had previously undergone a C5/C6 disc replacement back in 2002 but claims he had no numbness following that surgery until after the MVA. Clinical Findings With reference to the neck injury the Panel noted that the claimant had a C5/C6 disc replacement in 2002 and recovered well. As a result of the subject MVA he had an anterior cervical fusion at the same level in August The Panel concluded that the original Assessor was correct in assessing the claimant s pre-existing impairment related to the neck injury at 25% WPI. The Panel however disagreed with the findings that the claimant s current injuries were classified as DRE IV. They noted that the original Assessor found neurological abnormalities in the claimant s left upper extremity at the time of examination which included sensory loss in an appropriate spinal nerve root distribution and asymmetry of reflexes. The Panel determined that these findings are consistent with radiculopathy as defined in clause 4.28, page 27 MAA Guidelines. Furthermore the Panel noted that clause 4.40 of the Guidelines state that multilevel structural compromise with radiculopathy is classed as DRE V which is equivalent to 35% WPI. Therefore the Panel determined that the WPI related to the neck injury sustained in the subject MVA was 35% minus 25% for pre-existing injury which equals 10% WPI. Panel Decision The Whole Person Impairment of the injuries caused by the accident was calculated as follows: Neck Injury C5/6: For the reasons outlined above, 35% - 25% = 10%

37 Sternum and Ribs Fracture: These injuries had completely resolved and gave rise to no assessable WPI. Left Scaphoid Fracture: The Panel accepted the original Assessor s assessment of 1% WPI related to this injury, based on a reduced range of movement. Left Clavicle Fracture: The Panel accepted the original Assessor s assessment of 0% WPI related to this injury. The Panel determined the WPI for assessed injuries caused by the subject MVA was 11%.

38 Injury: Whiplash In 2003, the claimant was a 39 year old passenger of a vehicle that was stationary at traffic lights and who sustained a whiplash injury when his vehicle was struck from behind. The claimant initially consulted his GP and was later seen by a specialist who recommended conservative treatment by way of physiotherapy and hydrotherapy whilst undertaking exercises at home. This continued for a little less than one year and he now only continues to take medication. Clinical Examination The claimant s range of movements were limited by voluntary muscle control but the painful tender muscles in the upper right shoulder girdle, in the Assessor s opinion, were significant and were considered as evidence of muscle guarding. Range of motion measurements were recorded as follows: Cervical Spine Flexion 30 Extension 0 Lateral Flexion 5 Rotation Rt 30 Rotation Lt 30 Examination of the thoracic spine revealed no tenderness. There was symmetrical range of movement in the thoracic spine with the thoracic movements being approximately half normal range but without muscle guarding or spasm. This is consistent with degenerative change. The movements are all symmetrical. The chest expansion is reduced but symmetrical and there was very minimal thoracic spinal extension on full inspiration, being consistent with the absence of muscle guarding or spasm noted clinically. The claimant presented with x-ray appearances which were consistent with a constitutional and degenerative condition and which do not carry features which would normally be present in traumatic fractures of the vertebral bodies. Diagnosis and Causation The Assessor determined that the claimant sustained a soft tissue injury to the cervical spine (with aggravation of previously asymptomatic degenerative change) and a soft tissue injury to the thoracic spine (with aggravation of a previously symptomatic degenerative/developmental condition) due to the subject motor vehicle accident.

39 Impairment Evaluation The Assessor found at the cervical spine there was no asymmetric loss of range of motion, but muscle guarding was deemed to be present, particularly on the lateral aspect of the neck and upper right shoulder girdle. There were no neurological changes in the upper extremities and therefore no evidence of radiculopathy. The claimant was assessed according to Tables 70 and 73, pages 108 and 110 in the AMA 4 Guides, as DRE Cervico thoracic Category ll. This equates to 5% PI. At the thoracic spine there was no asymmetric loss of range of motion and no muscle guarding or spasm detectable on examination. The claimant did not describe radicular symptoms in the trunk or lower extremities. There was no evidence of nerve root damage, therefore no detectable radiculopathy. The claimant was assessed according to Tables 70 and 74, pages 108 and 111 in the AMA 4 Guides, as DRE Thoraco-lumbar Category l. This equates to 0% PI. The total permanent impairment was 5%.

40 This matter was subject to a review by a Medical Review Panel. These are the Review Panel s findings. This case study provides a practical example of how a Review Panel dealt with the assessment of spinal spacing devices, and specifically whether this equated to spinal stabilisation and therefore multilevel structural compromise. Injury: Lumbar Spine A 36 year old man was driving a truck that hit a bump in the road that threw him up, and as he came down the truck hit another bump and he forcibly made contact with the seat as the vehicle came up to meet him. A CT scan revealed a large central and right sided disc protrusion at L5/S1 and a mild bulge at L4/5 level. He eventually had surgery, which led to resolution of the right leg pain. However, back pain continued, radiating to the left buttock and left testicle and down the left leg. The MAS Assessment At the assessment, the claimant reported his current symptoms were constant pain radiating from the low back to the left buttock, thigh, calf and foot. He reported weakness in the left leg with occasions when the leg gave way. He still had some hesitancy initiating urination. He occasionally used a walking stick. Examination revealed some loss of lumbar extension (arching the back backwards), no evidence of spasm, normal power but some sensory impairment in the left lower leg and foot, no muscle wasting and absent left ankle jerk. Nerve tension tests were normal. The Medical Assessor determined the L5/S1 disc prolapse with radiculopathy was caused by the motor accident. The Medical Assessor noted the claimant underwent decompression of the L5/S1 disc as well as some surgery at the L4/5 with posterior stabilisation at L4/5/S1, but not an interbody fusion. The Medical Assessor determined DRE IV in accordance with clause and Table 4.1, noting surgery at two levels with radiculopathy. The total assessed WPI was therefore 20%. The Review Panel The Panel considered all the available evidence and decided that further information was necessary to clarify the nature of the posterior stabilisation device used in the operation and how it impacted upon the anatomy of the spine. They requested the operation report for the spinal surgery, the associated nurse s operating report containing the details specifically identifying the product used as the stabilisation device (including the sticky labels attached to the notes as product identification data), and all available imaging studies of the lumbar spine.

41 The information requested was received and the Panel reconvened. The Panel noted the spacing devices used between L4/5 and L5/S1 were called X- Stop. The Panel s research on this device shows that it is a distraction device which allows limited extension but allows normal flexion and has no significant effect on rotation or lateral motion of the spine. The literature reviewed supported the common thinking of the Panel that this does not constitute a spinal fusion. The product advisory information regarding X-Stop indicates that it is not considered as a spinal fusion device. The Panel noted the injury to the lumbar spine was associated with asymmetry of reflexes and reproducible sensory loss anatomically localised to an appropriate spinal nerve root. As there were two signs of radiculopathy, the Panel concluded radiculopathy was present, in accordance with clause 4.28 of the MAA Guidelines (p.27). The Panel assessed the injury to the lumbar spine impairment at DRE Lumbosacral Category III, Radiculopathy (Table 72, page 3/110 and page 3/102 of the AMA 4 Guides). This equates to 10% WPI.

42 This matter was subject to a review by a Medical Review Panel. These are the Review Panel s findings. Injuries: Lumbar spine aggravation of pre-existing condition Cervical spine soft tissue injury Left shoulder rotator cuff strain Panel Deliberations

43 Panel Decision

44 This matter was subject to a review by a Medical Review Panel. These are the Review Panel s findings. Injuries: Back musculoligamentous damage Neck musculoligamentous damage Right hip fracture, incorporating right leg fracture Right knee musculoligamentous damage Right psoas muscle tear to muscle and resultant atrophy Sciatic nerve right sided sciatic neurapraxia Clinical Findings The claimant had continuing complaints of pain which was constant and affected the right lateral thigh and posterior right calf; and was present intermittently in the right shin and he had a bruising type pain in the right gluteal muscles. He also noticed intermittent pain in the medial left thigh like a prick of needles going in but he said that he had never mentioned this before so he was informed that it could not be assessed. He said when walking, the ball of his right foot felt like he was walking on a rock or a bunched up sock in his shoe and interfered with walking. He had partial numbness around the scar in the proximal lateral thigh and irritation across the front of the right ankle. He has difficulty lifting his right leg to go up steps and he tends to trip over his toes and he has to lift his right leg with his hands in and out of the car. He can t run without hanging onto something because of thigh weakness. He can t lie on his right side because of discomfort. He can no longer ride distances on his motorbike and can t polish and do mechanical work on his motorbike. He was taking Nurofen Plus and Panadeine Forte. Examination His height was 175 cms and weight 99.2 kilos. Cervical spine: no guarding or spasm and no tenderness. The grip was strong in both hands and neurology of the upper limbs was normal. Flexion 40 Extension 40 Rotation to the right 60 Rotation to the left 60 Lateral bending to the right 35 Lateral bending to the left 35 Lumbar spine: lordosis was preserved and there was no muscle guarding or spasm. There was no tenderness. He stood erect with normal alignment of the lower extremities. Reflexes, power and sensation in the lower limbs were normal. Straight leg raising whilst supine was 90 on the left and 45 on the right with complaint of right hip pain whilst sitting straight leg raising was 90 bilaterally with negative flip test. It was concluded that limitation of straight leg raising whilst supine was caused