Spinal Injury CLE Session I - Anatomy of the Spine
As the leading litigation publisher in the United States, we know that the most successful personal injury attorneys focus on learning the medicine as well as mastering litigation methods.
To support lawyers in improving their skills in handling a wide variety of spinal injury cases, Trial Guides created the most comprehensive and advanced educational series in the legal profession for spinal injury lawyers. This will help lawyers achieve better insurance company settlements, and trial verdicts for their spinal injury claims.
Trial Guides founder, Aaron DeShaw, who obtained a Doctorate of Chiropractic before his career as a trial lawyer, created this educational course for lawyers and paralegals. The course is aimed at lawyers, paralegals and legal staff without health care training, and covers spinal injury topics in basic to moderate complexity.
The spinal injury lawyer webinar series helps lawyers and legal staff better understand the types of injuries that can occur in many personal injury practice areas including; car accident, trucking accident, workers compensation, premises liability (including slip and fall), product liability / defective products, construction defect, medical malpractice or other type of trauma where clients suffer a spinal injuries.
In Spinal Injury Cases Session 1, Dr. DeShaw covers basic issues of anatomy including planes of motion, and basic anatomical terms including: proximal, distal, unilateral, bilateral, superior, inferior, axial, sagittal, transverse and more. Anatomy of the spine is covered in introductory to moderate levels of sophistication including topics such as:
The bones of the spinal column, in each area of the spine.
Cervical -7 (C1, C2, C3, C4, C5, C6, C7)
Thoracic – 12 (T1, T2, T3, T4, T5, T6, T7, T8, T9, T10, T11, T12)
Ribs (what are “True” and “False” ribs)
Lumbar – 5 (L1, L2, L3, L4, L5)
Sacrum – 5 fused segments (S1, S2, S3, S4, S5)
Bones of the Pelvis and Sacroiliac joints (Ilium, Ischium, Pubic, publis symphysis)
Coccyx – 5 fused segments
The anatomy of vertebra
Anatomy of the vertebra is discussed in depth, including unique things about each of the following types of spinal structures.
- Pelvis / Sacroiliac joints
Anatomy of the vertebra and vertebral joints of the spine including:
- Vertebral body
- Spinous process
- Transverse process
- Pars interarticularis
- Uncinate joints
- Facet joints
- Intervertebral discs
- Nucleus Pulposus
- Annulus Fibrosis
Cervical ligaments are discussed in depth, including why ligament sprains are different from muscle and tendon strain injuries. In particular, the course considers the potential impact of injuries to the Alar Ligament, Transverse Ligament and Capsules of the upper neck. DeShaw discusses how that can create significant neurological symptoms.
In the thorax, the anatomy of thoracic spine, ribs, costovertebral joints, and sternum is discussed.
Anatomy of the lumbosacral and pelvic ligaments is discussed and how lumbar and sacroiliac injuries can result in low back pain and radiating pain into the legs including sciatica.
The neurology of the spine is covered including overviews of the
Central nervous system including:
- The Brain (Cerebrum and Cerebellum)
- Brain Stem (including Cranial Nerves as well as what they do)
- Spinal Cord
- Conus Medularis
- Cauda Equina
Autonomic Nervous System (Sympathetic and Parasympathetic)
Peripheral spinal nerve injuries
- Peripheral Neurology of the Cervical Spine
- Peripheral Neurology of the Thoracic Spine
- Peripheral Neurology of the Lumbar Spine
- Stretch or compression injuries to the Brachial Plexus
- Multiple Crush Syndrome including Thoracic Outlet Syndrome
- End organ impact due to injury to the spinal cord, autonomic nervous system or the vagus nerve.
The live presentation of this course on spinal anatomy was heavily attended. Live participants rated this presentation at a 4.56 / 5.0. 100% of participants found this program to have significant current professional content to their practice. This program is available to lawyers on demand through the Trial Guides continuing education center.
Spinal Injuries Cases Session 2 addresses many different types of injury to the spinal anatomy seen in different legal practice areas including the following;
- motor vehicle accidents,
- truck crash litigation,
- workers compensation claims,
- premises liability litigation,
- construction defect cases, and
- other cases where spinal injuries requiring medical care occur.
This webinar is meant to improve the knowledge of spinal injury attorneys and spinal cord injury lawyers in writing spinal injury demand letters to insurance companies, mediating spinal injury claims, and trying spinal injury cases in arbitration and jury trial.
Dr. DeShaw provides an important discussion about the differences between ligament sprain injuries in the spine versus muscular or tendon strain injuries in the spine. A key takeaway is that the legal profession seems very confused about these terms and their effects with even leading state and national trial lawyer associations such as AAJ providing articles and lectures on misnomers like “muscle sprain” cases. Since strain and sprain injuries are very common spinal injury cases, lawyers need to understand the difference, and it is properly differentiated in this presentation.
This leads to a discussion of spinal vertebra hypermobility and vertebra instability after trauma. Dr. DeShaw discusses the 3.5 mm measurement or greater than 11 degrees of angulation in lateral spinal flexion or extension radiographs and how medical literature supports surgery with that instability as well as an AMA permanent impairment rating of 25-28%.
Part of the lecture focuses on C1 vertebra instability due to injuries to the alar ligament, transverse ligament, and facet capsules at Occiput – C1 and C1-C2. DeShaw discusses how this creates permanent and often life changing consequences for people sustaining this type of injury.
Diagnostic and imaging methods for proving the injury are discussed.
An unprecedented discussion of vascular blood flow and vascular “irrigation” of the brain is discussed in this context due to vertebral artery compromise common to C1 vertebra instability and how this can result in symptoms including loss of consciousness and temporary blindness. Given the seriousness of the injury, this discussion is provided due to DeShaw’s experience with the insurance company’s defenses in these cases.
There is also a discussion about the danger of prolotherapy or stem cell therapies in the C1 area which is why even if the therapy did work, most doctors and patients are unwilling to undergo the risk of sticking a needle into an area deep in the spine directly next to the brain stem. The surgical fusion of this area is briefly discussed. This indepth discussion helps spinal injury lawyers understand this condition when it is presented by their clients.
The effect of fusion or stabilization surgery in the spine is discussed and the effect of spinal fusion on AMA permanent impairment ratings. Lumbar instability is also discussed and DeShaw differentiates congenital L5-S1 anterolisthesis from traumatic hypermobility or instability in other parts of the spine.
DeShaw discusses concerns about lawyers undervaluing a client’s injury classified by insurance companies as merely “soft tissue.” He starts a discussion in this session on “Hyperinnervation supersensitivity” after trauma to a ligament, muscle or tendon that results in scar tissue and then overproliferation of nerves into the area. He discusses how this makes people with injuries susceptible to chronic pain from these nerve fibers and how this overly sensitive area can be impacted by changes in barometric pressure that occurs with weather changes. Medical literature citations are used to support this along with recommendations on a mobile phone app that can track changes in pain. (This chronic spinal pain discussion continues in Spinal Injury Cases Session 3 where DeShaw covers new scientific literature on the structural and biochemical changes that occur within the intervertebral disc after injury.) DeShaw discusses the importance of chiropractic, physical therapy and massage therapy for scar tissue from trauma, which can decrease the likelihood or severity of chronic pain.
DeShaw also covered grades of sprain, grades of strain, as well as injury severity ranking systems such as Dr. Arthur Croft's Cervical Acceleration Deceleration (CAD) Classification System published in 1993, and the Quebec Task Force Whiplash Associated Disorders Grading System that misappropriated Croft’s work, published in 1995.
“Trigger Points” in muscles, tendons and ligaments is covered, as is the topic of referred pain, how it occurs, why it doesn’t follow peripheral nerve or dermatome patterns of pain, a brief mention of embryology of the nervous system, and how insurers and insurance doctors mischaracterize referred pain as psychogenic or malingering.
Also covered in detail is the insurance company / insurance doctor myth that all people heal from all spinal injuries within 4- 6 weeks. DeShaw discusses Dr. Croft’s work from his Trial Guides video Mastering Motor Vehicle Cases and book Whiplash and Mild Traumatic Brain Injury Cases, demonstrating that there are no peer reviewed studies supporting the insurance company and IME doctor position that everyone heals within that time. DeShaw notes that conversely there are 90 or more peer reviewed medical and scientific journal articles supporting chronic pain after a traumatic spinal injury. Some of these studies are discussed, which scientifically validate chronic spinal pain after injury.
Nervous system injuries are discussed in much more depth than any legal work to date. DeShaw is a nationally known traumatic brain injury lawyer and combines his extensive experience in TBI litigation cases with his doctorate educational background in the nervous system to provide a unique and in depth discussion for lawyers on nervous system injuries that goes well beyond herniated disc pain cases. The discussion includes:
Central Nervous System Injuries
- Cervicomedullary Injuries
- Chiari (Type II) / Tonsilar Ectopia
- Brain Stem Injuries
- Cranial Nerve Injuries
- Spinal Cord Injury cases including complete spinal cord injury
- Autonomic Nervous System Injuries and their impact
Peripheral nerve injuries
- Damage to the intradiscal nerves and facet nerves
- Nerve root impingement resulting in radiating pain in the arms and legs
- Peripheral Nerve Injury in the Cervical Spine and the effect
- Peripheral Nerve Injury in the Thoracic Spine and the effect on end organs
- Peripheral Nerve Injury in the Lumbar Spine and the effect
- Multiple Crush Syndrome (including Thoracic Outlet Syndrome)
- Neurogenic vs.peripheral nerve injury in cases involving urinary Incontinence after trauma
Dr. DeShaw covers intervertebral disc injuries in depth, covering topics including: the structure of the annulus fibrosis, the nucleus pulposus material, disc bulges, disc herniations, disc protrusions, disc extrusion, and fragmented extrusion or disc sequestration.
Aaron DeShaw also covers the impact of the Intradiscal nerves on pain in disc injuries that are termed “internal disc derangement” rather than a disc bulge or disc herniation. (See Spinal Injury Cases Session III for a much more extensive discussion of Internal Disc Derangement and the imaging methods used to identify and classify IDD.) Spinal stenosis is also discussed briefly.
Spinal facet Injuries are discussed including how they occur, and the impact on spinal structures including the facet capsule, nerve innervation of the facet joint, facet cartilage and fracture of the spinal facets.
DeShaw discusses the concept of pleading and using pattern jury instructions on “prior infirm condition” and “aggravation” so that insurers and jurors know that the defendant is legally responsible for the full amount of damage caused by defendant’s conduct even in cases where the client had pre-existing osteoarthritis (often called “degenerative joint disease” or “degenerative disc disease.” Briefly mentioned is the concept of “Judo Law” in cases of prior infirm condition, as well as the benefit of such jury instructions in “minor impact” or what insurers call “MIST” (Minor Impact Soft Tissue) cases. DeShaw also discusses that medical literature supports a substantial increase in osteoarthritis in the spine after trauma.
Lastly in Spinal Injury Cases Session 2, DeShaw addresses a variety of spinal fractures including fractures of the vertebral body (often appearing as wedge fractures), fractures of the transverse process, fractures of the spinous process, fractures of the facet, and fractures of other specific structures of the spine. A traumatic C1 Jefferson fracture from one of DeShaw’s cases is used as a teaching example, showing 3D reconstruction of the CT scan taken in the hospital. Hangman fractures of the C2 vertebra are also discussed. Lastly, DeShaw discusses the significant spinal pain experienced with vertebral end plate fractures, how these are classified, and how these can be imaged better when other medical imaging such as x-ray, CT and MRI do not demonstrate positive findings.
Live attendees rated this program a 4.75/5.0. 100% of participants found this program to have significant current professional content to their practice.
Spinal Injury Cases Session 1 and 2 are presently available for on demand video streaming in the Trial Guides CLE Center.