Disc Herniation TRAUMATIC, Disc Bulge DEGENERATIVE

Disc Herniation TRAUMATIC, Disc Bulge DEGENERATIVE

There continues to be significant debate in the medical-legal arena in relating imaging findings to CAUSALITY. When there is a traumatic event and clinical findings indicate the need for MRI, correlating those objective findings to the event is what causality is all about. A paper by Fardon and Milette (2001) sought to unify the naming (nomenclature) of disc pathology. They went to great lengths to include every possible type of disc appearance and what they looked like on MRI. The problem is that radiologists are only concerned with how things “look,” also called morphology. The academic side of radiology has names for every possible configuration of disc pathology, but in the medical-legal world, we are concerned with only ONE thing… If there is disc pathology present, is it related to the traumatic event or was it pre-existing? That is it… the problem is that many in the medical-legal community continue to try and find answers about how the disc pathology “looks” (morphology) instead of how it was “caused” (etiology). Think of it this way; morphology is the noun and etiology is the verb. You can spend an eternity reading radiology research, but it is only focused on morphology. That is why there is so much debate. We are trying to turn a noun, morphology, into a verb, etiology, and it is causing confusion.

When we get down to the foundation of identifying and documenting causality related to the intervertebral disc, there is a special set of circumstances that needs to be identified and learned; how the intervertebral disc “responds” to biomechanical forces. What that means is what marker is associated with a single burst of energy through the disc such as in a car accident or fall, and what marker is present when the disc is subjected to forces a little at a time over a long period, as in a degenerative disc? The marker we are looking for is a tear in the annulus fibrosis. This can be identified either by seeing the tear on MRI or discogram or by how the disc behaves in the presence of a tear. Any type of tear can change the shape of the disc. If we look at etiology, there are two main causation categories of annular tearing, traumatic and degenerative. When we look at morphology, there are many.

The two types of etiological tears in the annulus fibrosis are radial and circumferential. Radial tears are produced by a burst of energy through the disc causing a tear through the many layers or bands of the annulus fibrosis. These result in a DISC HERNIATION. A circumferential tear occurs when the disc is exposed to sustained forces and there is a separation of the layers of the annulus fibrosis. This causes a DISC BULGE. This is a key factor in the association of clinical relevance to determining causality. In a study by Fazzalari and Manthey (1997) an investigation into the nature of annular tearing is done. The authors state, “No correlation was found between radiating tears and other types of anulus disease, such as rim lesions or concentric tears, indicating that these three types of anulus tears are independent pathological processes.” (Vernon-Roberts, Fazzalari, & Manthey, 1997, p. 2643). The concept that a radial tear resulting in disc herniation is not related to degenerative changes was substantiated by the authors stating, “Importantly, the proposition that concentric tears enlarge and coalesce to form radiating tears was not substantiated by our results” (Vernon-Roberts, Fazzalari, & Manthey, 1997, p. 2643). When correlating causality to bodily injury, clinicians that understand how the disc responds to traumatic forces are the key to proper triage and care of the injured.

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References:

Fardon, D. F., & Milette, P. C. (2001). Nomenclature and classification of lumbar disc pathology. Spine, 26(5), E93-E113.

Vernon-Roberts, B., Fazzalari, N. L., & Manthey, B. A. (1997). Pathogenesis of tears of the anulus investigated by multiple-level transaxial analysis of the T12-L1 disc. Spine, 22(22), 2641-2646.