The Spine at Trial.

The Spine at Trial

Jose Kuri Ed Stapleton Frank Costilla Hettie Rollins Odabashian American Bar Association www.abanet.org/abapubs/home.html 488 pp., $165

Attorneys who handle cases involving injuries to the spine need a solid reference book on spinal anatomy, injuries, and treatment. The Spine at Trial would make a good addition to their library. However, although the book gives a strong overview of anatomy and other background information, its discussion of specific causes and treatment of spinal injuries is far from complete.

The authors of this text do an admirable job of covering a variety of concepts pertaining to the spine and spinal medicine. There is a brief and straightforward discussion of spinal anatomy--one that conveys basic concepts of biomechanics and function while familiarizing the reader with commonly used terminology. I particularly like the sections on spinal fractures, imaging, and disk degeneration. The chapter on impairment evaluations is a valuable introductory guide for lawyers who need to know about this aspect of rating permanent injury.

However, from my perspective as a trauma epidemiologist (with a background in both medicine and chiropractic) who frequently testifies in spine injury cases, the book does not entirely live up to its title. Its concepts would not be particularly helpful to a lawyer presenting a case at trial or dealing with the defense's improper, unscientific approaches to spine injury.

For example, the section on medical imaging, while giving a nice overview of the subject, does not discuss how attorneys can effectively use such imaging in a trial setting. It would have been helpful for the authors to discuss how defendants use medical imaging to refute claims of injury--in particular, to support their faulty premise that preexisting degenerative changes suggest that symptoms also preceded a trauma.

The authors address crash-related trauma in two sections: one on children in car accidents and another on whiplash injuries. Neither is comprehensive or even particularly current. The authors use the 1960s-era model of "hyperextension" to explain the mechanism of neck injury in rear-impact collisions; this model has been invalidated by more recent research that demonstrates that injury can occur with little or no head extension, much less hyperextension beyond the normal range of motion of the neck. They badly need to revise this section.

The book also needs much more discussion regarding the latest (and typically orthopedic) methods of surgically correcting spinal injury and deformity--including spinal fusion using implanted devices such as titanium and bone cages. The authors do not mention minimally invasive surgical procedures such as intradiscal electrothermal treatment and nucleoplasty, two techniques that are commonly used in ambulatory surgeries.

Spinal-injection techniques for diagnosis and treatment have improved tremendously over the past 10 years, yet there is virtually no mention of these procedures, which can be valuable in pinpointing painful pathology. Every lawyer who deals with spinal injury should know how common and useful provocative discography has become as a means of detecting disk injury, and as such, this technique deserves much more discussion in this book.

Finally, it is difficult to imagine how a book about medicolegal issues and the spine could not include a single mention of chiropractic care. There are approximately 50,000 chiropractors in the United States, and they provide a significant proportion of spinal-injury treatment.

I do recommend this text for its solid coverage of spinal anatomy and a few other topics, but it should not be the only reference in a trial lawyer's library on medicolegal issues involving the spine. The Spine at Trial is an ambitious undertaking. This broad subject requires many different perspectives, and these authors are to be congratulated for getting a good start on the subject.

Michael D. Freeman is a clinical assistant professor in the Department of Public Health and Preventive Medicine at Oregon Health and Science University School of Medicine in Portland.