One of the most troublesome injuries to evaluate is injury to the back. The back can be injured in a number of ways including trauma, overuse, cumulative wear and tear, disease processes, and deterioration due to age. The underlying cause of back pain can be difficult and expensive to diagnose. People with back pain tend not to seek medical care until the pain is debilitating or interferes with everyday life activities. Therefore, it is difficult to ascertain the extent of aggravation to a preexisting condition since it may have not been diagnosed.
For all these reasons, the liability adjuster faces significant challenges in confirming that the accident either caused or aggravated a back condition and the extent of the condition that was caused by the accident. Since the diagnosis of back pain is often subjective, it is difficult to evaluate its impact on the injured party.
Because of the subjective nature of back pain, injured parties may exaggerate the extent of the pain or loss of use. In some cases, the exaggeration may be fraudulent. On the other hand, back pain is one of the most common complaints of legitimately injured individuals. Since the back is exceptionally flexible and responsible for managing the majority of the body's weight, back injuries can lead to significant disability. It has been estimated that as much as 50–70 percent of the US population may have some form of back pain, making it an invasive condition throughout the population.1
The back is constructed of vertebrae through which the spinal cord extends. The vertebrae are identified as follows: starting at the neck are 7 cervical vertebrae (C-level), followed by 12 dorsal or thoracic vertebrae (T-level), then 5 lumbar vertebrae at the small of the back (L-level), then 5 fused vertebrae forming the sacrum (S-level), and finally, the coccyx at the extreme lower end, which is made up of 4 fused vertebrae. The spinal cord extends through the central canal from the brain through the cervical, thoracic, and first or second lumbar vertebrae, where it extends out as nerve roots. Through the length of the column, nerves extend through the structure to service the muscles of the body.
Intervertebral discs are positioned between the vertebrae and consist of a nucleus pulposus, which is surrounded by the annulus fibrosis, which holds it in place. The intervertebral discs cushion the vertebrae when the spine is flexed or bent.
The intervertebral discs can be ruptured, causing their gelatinous material to bulge through the annulus fibrosis and put pressure on the spinal column itself. This phenomenon is called a bulging or ruptured disc and can result in excruciating pain, numbness, even loss of use of a limb such as in the case of paralysis—paraplegia or quadriplegia.
Diagnosis of the cause of back pain begins with a physical examination to evaluate range of motion, reflexes, nerves, sensation, and muscle strength. Physical examination alone can be very accurate in determining the existence and location of the back injury. The majority of people suffering back pain will heal within 30 days of the injury. Therefore, imaging technology is not often prescribed immediately. However, imaging technology is frequently used prior to surgical intervention or if other red flags emerge.
X-rays are not considered significantly helpful in diagnosing back injuries unless a fracture is suspected. Consisting of bone material, vertebrae can be fractured by traumatic injuries.2
Myelograms are a type of X-ray used with a radio-opaque dye injected directly into the spinal column. Any blockage due to a herniation will be revealed by the dye. Because of potential severe side effects, myelograms are seldom prescribed except in severe situations.
Magnetic resonance imaging (MRI) is used when diagnosis has been difficult, the pain has continued for a period of time, or there is fear of infection. MRIs utilize magnets to form a picture of the body. MRIs are not foolproof. Approximately 40 percent of MRIs performed on people without back pain have been positive for a bulging disc, and MRIs fail to diagnosis about 20 percent of ruptured discs that are found during surgery.
With chronic pain or a question as to whether the pain is due to muscle or nerve root injury, a physician may utilize an electromyogram (EMG), which involves placement of small needles into muscle to determine the electrical impulses.
The tendency today is toward conservative treatment without surgery. The vertebrae are flexible and can very often return to their pre-trauma state with rest. Lingering sensations of pain can be alleviated with the use of steroid shots directly into the spinal canal to calm the nerves of the spinal cord. Fractures can heal with limitation of motion and use of braces. However, surgery is sometimes the only solution for the relief of pain or return of motion. There are significant side effects to surgery as with any operative procedure, and most physicians suggest it as a last resort.
Because of the questionable and subjective nature of back injuries, it is important for the claims professional to carefully investigate the injury and the accident. The investigation should include details about the occurrence, such as:
Complete facts about the accident occurrence, the direction and type of trauma that occurred, the manner of occurrence
Discussion with witnesses to corroborate the claimant's statements and allegations about how the accident and subsequent back injury occurred
Complete medical information is extremely important and should include:
The type of work and activities engaged in by the claimant
A complete description of symptoms and when they began
Previous medical history
History, diagnosis, and prognosis as given to the treating physician, any record of hospitalization both prior to the injury and post-accident as well
The reputation and competency of the treating physician
A comparison of prescribed treatment to medical guidelines
Extent of disability due to the injury including loss of wage-earning capacity
The claims professional will also want to determine historical information about the claimant, such as:
Family stressors—marriages, divorces, job stability, dependency of parents and children
If the treatment extends beyond what is expected, then surveillance or neighborhood activity checks may be required to confirm that the claimant continues to be disabled as a result of the subject accident and not for some other reason.
By conducting a thorough investigation, the claims professional will have the information necessary to appropriately evaluate the impact of the back injury that resulted from the accident as objectively as possible.
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