Academy of Chiropractic Personal Injury & Primary Spine Care Program

Quickie Consult 1191
Narratives 95 N

From the Desk of Dr. Mark Studin
Academy of Chiropractic

Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time. -Mark Studin 2006

"Neurosurgeon wanted to have breakfast with me....What I did"

"Apportionment, Exacerbation & Aggravation Reporting"


Dr Studin: you've got very challenging case that we just discussed for five minutes. That's convoluted. That was in three accidents, first How old is the patient now? Female, male?

Guest Dr: male, early 40th.

Dr Studin: And the dates, the approximate dates of the three accidents are?

Guest Dr: by year? 2018 off the top of my head, I would say 2017 2016.

Dr Studin: the same lawyer?

Guest Dr: it's the same attorney now and all three accidents I'm not sure if it's relevant or not, but she's minding her own business, sitting at a red light. It gets creamed from behind.

Dr Studin: So there's no issue of causality. There's no issue on the who's a fault, so she's rear-ended while stopped with all three, give me the three basic issues that are on the table.

Guest Dr: So issue number one is that the attorney is requesting a report and they would like a report closing out the initial case or two while keeping the third one open. She's going for some type of surgical consult. She's probably seen 15 different physicians somewhat trying to bounce from a pain management person that'll help, or an orthopedic surgeon that can give her an answer or a neurosurgeon that can give her an answer.

Dr Studin: So you told me that the lawyer dropped on you about 300 pages of documentation and said, put it all together.

Guest Dr: that I'm aware of not including whatever is accrued in the last 6 months or eight months.

Dr Studin: a minimum of 300 pages. So as far as reporting goes, before we get to the apportionment issues, it would be my suggestion with something like that, because that is a boat load of work, in the report I would um put down the name of the doctor and the diagnosis and that's it. And, put on the heading of the report This report is limited only to your specific work on this patient because it's just too much. And then for the lawyer, I would charge a lawyer $200 a hour. And then you might want to hire dr Minoni, who writes the IME rebuttals. He does PI IME work of taking all of these documents and putting it together and if you charge $250 an hour, he would take like half of that. He would do all the work and then you were finding at the very end and this way you don't have to spend the 10 hours of sifting through this. He's very good at it of organizing this stuff. And you have someone with 30 years of experience to talk to, he'd be really helpful. Now with that being said, the next step is apportioning. So what you want to do is a portion the case.

Guest Dr: Yes, some parts of that or part clear. For example, she came in with certain radicular pains or whatever those resolved and they occurred again after the third accident, those resolved and things. the part that I'm unclear about how to a portion she qualifies for AOL MSI on three to four vertebral segments and her cervical spine. And frankly, I don't know which accident caused that.

Dr Studin: here's the issue. Obviously you take a piece of paper, you draw two vertical lines, you have three columns, you put symptoms, clinical findings and diagnostic tests in each column. And you'll see which ones match up and what's accident one, what's accident two and what's actually and three and you see which one carries through. So you want to know if there's an aggravation versus exacerbation. Now let me explain to you what the difference is because people often get that confused. exacerbation means there's more pain but no additional bodily injury, aggravation it means there's more pain and more bodily injury. For instance, if between accident one and two, for accident one there's a two millimeter herniation pain, six out of 10. Now accident two there is a two millimeter, the same size herniation, but the pain was had nine out of 10. That's an exacerbation. But if an accident 2 in the same region, the herniation went to six millimeters from two, regardless of what the pain is, that's now an aggravation cause there's no bodily injury. Now, the other thing you have to consider of an age dating you have to look from motive changes, the safest current inflammation. You have to look for bone spurs. You have to look to see if there's high signal in places there wasn't before Showing new nuclear proposes material going on the outside from the inside and then you can age, date, all of those things.

Guest Dr: How do I age date the plain film AOMSI findings?

Dr Studin: both spurs. So simple.

Guest Dr: so in this particular case, there's already spring throughout the cervical spine from day one.

Dr Studin: from day one? Well, there's the remodel, then you're going to get to a clinical decision, But if they were remodeled on day one and they have a ligament laxity or AOMSI on day one for the first accident in 2016 and it persists and it's the same amount of translation And then if it's remodeled, you might have osteous locking mechanisms in there preventing it from moving forward. But you're at an early forties should not be all that much.

Guest Dr: I think her neck wasn't amazing, the issue just with by the time I got ahold of her it was between it after accident two, Accidents three, so when I did the images for AMSI, that's where I was. But I think the original, if I recall correctly, I've talked in my head the original MRI findings there was already a spring. So we're talking about a condition.

Dr Studin: But when their motor changes, so she might've had preexisting issues, then the only thing you could go by your symptoms and clinical findings, that's a clinical decision. And a lot of cases you've got to bring it down to a clinical decision. And I know that's not the answer you're looking for, but it's the only answer, remember some lawyer, some docs go Well, where's the literature for that? Where does the research, when you were in a court of law, all the lawyer wants is your opinion, not the research, but you've apportions appropriately, you've diagnosed appropriately, you're able to determine if there's an exacerbation or an aggravation and you're clinically apportioning it based upon what the clinical findings are What's your signs and symptoms. So it seems to me like you've taken this very complicated case and you put it together. Now the patient's not an MMI because there might be, as you told me before, future surgery. So you don't know if they're permanent and stationary, if it's static, because there's still more care in the form of surgery. But you can tell them that you can MMI them for conservative care, that they're stationary and permanent, pending surgical intervention and what that will show. But right now this is as good as it's going to get forever and ever, can't do anymore.

Guest Dr: that's really useful. that answers all the questions. 

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