Academy of Chiropractic
Quickie Consult 1220
Clinical Information 268 CI
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
"Age Dating Herniated Discs"
Dr. Studin: So, what's going on with your patient? You just briefly gave me the scenario. Could you just repeat it please?
Guest: Right, yes. Doing with an acute time period on an MRI when fluid would show up. What I'm interested in knowing is there a time period in there in which the fluid, would go away in less than that acute time period of four to six weeks. So, if the person gets injured and let's say an MRI's done four weeks later and there's no fluid in there, then can you say okay there was no acute injury to this patient's disc or model one changes to the did the bone or is it possible that the fluid actually went away earlier since there was no MRI that was done sooner than that.
Dr. Studin: Alright, so you had originally told me also that you have an orthopedic surgeon who is semi-retired, and he takes all of these types of reports. He reports half-truths and he's basically saying anything more than four to six weeks in a case where there is no high signal, it's strained sprain and it should be resolved in that time frame. Correct?
Dr. Studin: Alright. Okay. So, there's a couple of issues. We need to know what half-truths he's telling. That's part of the equation. The other part of the equation. What about no high signal in the disc or the bone showing no fluid on the outside and no motive, one changes. And should it resolve in six weeks. And is there any literature to support acute scenarios in the absence of high signal? Did I get it all down?
Dr. Studin: Okay. So, number one, what half-truths is he telling?
Guest: Yeah, well, one of the things that he will talk about, it's when there's an injury to a patient that all these sprains, strains heal up in four to six weeks.
Dr. Studin: Okay. So that's not a half truth. That's his opinion. And he's entitled to his opinion.
Guest: I know, but he brings it off as if that's what the AMA got. That's what the AMA says. And that's what research says.
Dr. Studin: Well does he post the research?
Guest: No, he usually just talks to them about it.
Dr. Studin: He can't just talk about it then quote research. So, what has to happen, because there's a personal injury case is the lawyer must subpoena. Okay. Subpoena the research studies courting in that article. Okay. That's number one. Because you don't treat a patient based upon our research. We're a population-based study. It's not about a population and how I would respond to that and that's really what you bring the doctor. But how you respond to that is that I am sure that that there might be literature even though the literature citation was not provided, there might be literature suggests that some patients do respond and get better with it, there are some patients that that might get better or respond within four to six weeks. However, there are also other patients that don't respond and get better than four to six weeks. So when you take any literature study, which is based upon hopefully enough of a cohort cohort means the size of the study, um, that that looks at a population more than two or three or four patients, which is why it's important to look at the literature that he's quoting.
There are certain patients that don't, and this is predicated upon a clinical evaluation tied into a patient's symptoms and clinical findings. And in my patient, Mrs. Jones, she still exhibits a positive straight leg raise test, the positive for bear Patrick positive four of a five indicating that additional care is indicated. Now, does this doctor evaluate the patient or did he just give an opinion off records?
Guest: Off records
Dr. Studin: So this is a peer review and these, he's probably not even doing it. The carriers are doing it, he's just starting his name toward or there's a rubber stamping it and giving a money. So, this is how you respond to that. That's number one. Number two, the fact that there's no high signal in the desk or the bone, I would tend to agree that, that it's not a cute, especially if the MRI is taken, you know, four, six, eight weeks after the trauma. I would agree with that. But you're arguing the wrong thing. You should be using, you should be x-ray, digitizing, go to some veteran if you have the, if you have that device. Or the technology in the tool, x-ray digitize is the solution to all of these issues. And that is, I'm in agreement that it doesn't appear that this is acute. However, the trauma did hair ligaments and there's lacks of ligament, which is an advanced form of strain sprain, but it's connected. It's a connected tissue pathology and according to the AMA guides with lax of the, of ligament, um, there is a permanent Trauma rating and the patient will never get better according to the literature. And you could quote that literature article from the open rehabilitation journal, which says that the tissue never heals the same way. It's always a four-grade additional meaning collagen in the last one are replaced with just collagen. So that's important, which is why I would, if I was practicing, listen what I practice. I did a video fluoroscopy. It's funny, I found all the DVD. That's how all the technology, was in my basement in a box. I mean, I mean I must have had a thousand, you know, DVDs in there for patients. Um, but that shows ligament Heron. You don't need to do video fluoroscopy or, or digital motion x-ray anymore. You just x-ray, digitize your patients at the end stage and it shows you lacks of the ligament and then you have demonstrative. That's the key demonstrative. Can I show that something's there? Because right now all you're doing is you are arguing, I'm right and he's wrong. His literature is wrong and my opinion is right. Where's the proof?
You have no tangible proof. So, the key is how do you make it, the demonstrative means show Intel. What can you show to prove? And it's not just about, impairment ratings when you digitize a patient and you also have the opportunity to do a full spine, x-ray digitization, not just, you know, cervical and lumbar, but now you say, here's the proof. This will be repeated. And, you know, re-evaluation is going to be done when the person has MMI. It's going to be repeated to see what the static position is of this patient. You follow?
Guest: Sure, yep.
Dr. Studin: Now you've got something demonstrably you're arguing, you know, you're playing their game and reacting to what they're saying versus changing the whole table and playing on your field.
Guest: Not most of this stuff that he does is, this is like courtrooms type stuff. Not so much arguing that your care's not necessary,
Dr. Studin: But here's the thing, every single personal injury case ends up here. Nothing's changed. And the carriers look at it. Are they going to pay you? The lawyers look at it. Are they going to work with you? This is your reputation. This is your livelihood. This is where it comes down to. You must respond to this. But the old, so the first three scenarios are two scenarios that give you a say, right and he's wrong. The last scenario I gave you is here's the visual tangible, the month demonstrative means I'm going to show you show and tell. Here's the demonstrative proof show Intel, here's the bones slipping back and forth. Here's the bones twisted sideways. Here it is.
Guest: We did that and we do that with these and you know what he does is like for instance in court and things, what do you, in this particular case, there was a previous fusion in the and the cervical spine that made the patient more prone to injury, well, I've got literature that shows that this doesn't make the patient any worse. And then you, it's just a battle of his literature, our literature.
Dr. Studin: No, you still don't get it. First, he's wrong. It does make it worse. That's decoratively.
Guest: No, no. When you have fusion...
Dr. Studin: Bobby still has to have normal movement. So, the bone above and the bones below are going to now move too much. So now what happens is you get the x-ray digitize it. Yeah, this is fuse. But this one should only move three and a half millimeters. The cervical spine that's moving six, it's normal AMA guides. Here it is three and a half. Now it's moving six. And the same thing. And now you take his argument off the table. How could you argue with the fact that the guy says three and a half minutes moving six and I have a research article which says 0.6 millimeters is the normal excursion. That's all it allows. And now you've got six millimeters. You can't argue with that. It all goes back to the same thing.
Guest: Hey, I understand all of that. I do all of this. I mean, no matter what you do, he's still going to argue.
Dr. Studin: It doesn’t matter what he says. Well, ends of the day. It's up to the lawyer. You have to educate the lawyer and it's up to the lawyer to shove it up his ass.
Guest: Yeah. And that's the hard part is getting the lawyers to be educated because they are difficult sometimes.
Dr. Studin: No, you're still not using all your resources. I'm your ultimate resource. You tell the lawyer, listen, one of my professors from medical school who also lectures to the insurance companies on this topic is a favor to me he'll happily get on the phone and explain how to argue this. He also, he also teaches trial lawyers associations. So if you want, I can arrange a 10 minute phone call, a conference call between the three of us and put you on the phone and it might be worth 10 minutes of your time. Because on this particular issue with lacks of the ligament, no herniated disc, the average settlement just before trial is 125,000. There are been, there was one that went up to $750,000, which was up in Denver, but the average think I said, well what about Arkansas? Not Arkansas. You're right. That's, that's what they said and all the other venues, you know, that it's not my state. It's not this, you don't understand the courts. And your answer is it worth a 10-minute conversation with this guy? I've already arranged it for you. I've already pulled the favor. It's on the table. You want to use it. It's not going to cost you anything, but I want you to understand because I'm fighting for my patients. Got it?
Guest: Yeah. Well I agree with you. It's just there's a lot of moving parts at this guy and so we've done a lot of this, but educating the attorney is part of it and I agree with you.
Dr. Studin: And that's why you also need to do a lawyer seminar because you put 30 in a room. You give me them for three hours, not just once, but a bunch of times. I beat it into their brain, so they get it. All of these little things matter. So, listen, and I get your frustration that this one lawyer doesn't get it. You know my favorite word is “next”. Just move on. There's a lot of attorneys and a lot of players. Okay?
Guest: Okay. Thank you.