Age of Injury

DR. Kenneth C. Fortgang is board certified in Diagnostic Radiology by the American Board of Radiology. In 1979 he received his M.D. at the Medical College of Georgia in Augusta. He completed his internship and residency in Diagnostic Radiology at the University of Southern California Medical Center where he also became chief resident for the Department of Radiology. Dr. Fortgang has also
completed a fellowship in Vascular and Interventional Radiology with special interest in CT/US Body imaging with an emphasis on Musculoskeletal Imaging.

Dr. Kenneth C. Fortgang specializes in expert testimony including case reviews, film reading, conferences, depositions, and trial court witness work for insurance companies and attorneys. Dr. Fortgang at Premier Radiology Services has perfected the “age of Injury” report. An age of injury report consists of reviewing the MRI, CT, X-ray reports as well as the actual study images. He will then relate reported findings to a specific time frame and draw a conclusion whether the findings
described are related or unrelated with the injury. With over 25 years of experience in the Diagnostic Radiology field Dr. Fortgang is well trained to give an expert report on injury related matters. He currently practices as a partner in a group that covers a level 1 and a level 2 trauma center. He is skilled in recognizing acute injuries that may require rapid management and in separating those from more chronic conditions.

In his practice in the area of legal review work he has worked with some of the top ranked law firms in Florida. His testimony has never been challenged or disqualified.  His testimony and opinions meet the Daubert Criteria for Peer review and for Generally Accepted concepts. In forming his opinions he relies on his experience in the area of trauma radiology and review of literature which is published in widely read and accepted textbooks of radiology. These textbooks are readily available to the public and are in later editions, having withstood the test of time.  Below, we have put together a 10 question tutorial on the “Age of Injury Report” for a better understanding on how this can be useful for your needs. In addition we have included some information on how Dr. Fortgang arrives at a decision for an injury based on an MRI of Lumbar Spine:

AGE OF INJURY ANALYSIS

  1. What is an Age of Injury (AOI) Report?
    An age of injury report from a Radiologist will review the MRI report and the actual MRI images and relate reported findings to a specific time frame and draw a conclusion whether the findings described are related or unrelated with the injury.
  2. What kind of conclusions may a claims manager expect from an Age of Injury (AOI) report?
    The specially trained radiologist will give an opinion based on the findings of an MRI and knowledge of date of injury in one of three categories. 

    a) Not related to date of injury (DOI)
    b) Indeterminate
    c) Related to date of injury (DOI)

  3. What percentage will be in the indeterminate category?
    Initial experience is less than 10 percent.
  4. Can we provide additional help in the indeterminate category?
    Yes, we can further subdivide into: 

    a) Indeterminate, but probably unrelated to date of injury (DOI)
    b) Indeterminate, but probably related to date of injury (DOI)

    So that when completed less than 5 percent of our initial reports will be completely indeterminate.

  5. Can anything else be done in the indeterminate category?
    Yes, we can provide a sequential AOI report which will look at multiple studies over a post injury time frame. Frequently, claimants have one or more prior MRI studies before a DOI or have an undisclosed MRI immediately after a DOI. Many times follow-up MRI studies may be helpful. We will provide guidance on what we believe would be most helpful in determining a relationship of any particular finding with an injury.
  6. Will this be helpful?
    Definitely, we believe insurers want to pay justified claims without delay and to deny unjustified claims without delay. Our AOI report is prompt, reasonable and reliable, and reproducible.
  7. Is our method supported by scientific data?
    Yes, our radiologists are all well trained in radiology in general and AOI analysis, specifically. An MRI study is an objective piece of information that will be available unchanged forever. In broad terms, radiologists are familiar with the signs of acute injury and also the signs of chronic changes on imaging exams.  Among all radiologists, there will be only a small intraobserver and interobserver variability. Our radiologists are specifically trained so that we can reduce that small variability even further. 

    Please also refer to more detailed information which will be provided for specific body parts.

  8. What if we disagree with the finding from the primary reporting radiologist?
    We understand that while radiologists reading “compensation” MRI exams are in general professional, that at times minimal findings may be overstated. For example, a simple disc bulge may be formally reported by some radiologists as frank herniation. We will supply more formalized and widely acceptable terminology. We divide disc abnormalities into several categories including diffuse bulge, broad-based protrusion, focal protrusion, extrusion and
    sequestration. We believe the term ‘herniation’ is less scientific and should be avoided.
  9. Are we willing to become involved in legal proceedings?
    Yes, we have experience and success in that area. Our goal is to make sure justified claims are paid and unjustified claims are denied. To that end, we are prepared to fully, truthfully and confidently state our professional opinion, whether in an AOI report, formal or informal deposition, or in the courtroom.
  10. Will you work with IME physicians?
    Yes, we believe a comprehensive solution is best. We are a fee based organization and will work in all avenues to ensure appropriate claim management can occur.

AGING OF LUMBAR SPINE FINDINGS WITH MRI

Background
Stability is provided in the lumbar spine by paired facet joints and the discs.
Degenerative changes to the facet joints are similar to degenerative changes in
any other joint and occur in predictability patterns over extended time periods.

Normal Disc

The central fluid filled nucleus pulposus is surrounded by an intact anulus fibrosis.

The disc may extend 1-2 mm beyond the posterior margin of adjacent vertebral bodies.

The posterior disc margins are generally concave at L1 through L3, flat at L4, and convex at L5.
Degenerative Disc and Peri-discal Change

Osteophytes

Vertebral body marrow changes (Modic)

These are changes which are focal or diffuse bands parallel to endplates

Facet joints degenerative joint changes

Cartilage loss
Subchondral sclerosis
Cyst formation
Osteophytes
Ligamentum flavum buckling in the canal
Marrow change of pedicles

Spinous process changes (Baastrup disease)

Lumbar lordosis
Breakdown of interspinous ligament with or without bursar formation
Decreased space between adjacent spinous processes

Disc Changes of Degeneration

Diminished hydration, diminished proteoglycan, increased collagen, increased fibrosis is shown by MRI as horizontal intranuclear cleft with diminished signal on T2 and diminished disc height.

Anular tears are shown on MRI as focal increased T2 change associated with disc bulge and protrusion.

Nuclear “herniation” through an annular tear shows a focal disc contour abnormality.

Vacuum disc with nitrogen filled nuclear cleft is shown by MRI as signal void on
T1 and T2. This may actually fill with fluid and be shown as increased signal on T2.

Calcified disc may show by MRI increased signal on T1 early, but diminished T1 and T2 signal with increase in calcification.

Overview of Aging Techniques of Disc Abnormalities

A clearly normal disc has normal hydration of nuclear material with an intact annulus fibrosis and degenerative changes in the paradiscal region appropriate for the patient’s age.

Clearly chronic changes are those associated with a degenerative disc and joint changes described above.

Clearly acute disc abnormality is associated with normal age appropriate disc hydration, abnormal annular changes felt to be acute and focal disc protrusion, extrusion or sequestration.

Progression of Degenerative Change

Injury whether acute or microtrauma @ desiccation of the disc, disc space narrowing, vacuum disc, calcified disc @ degenerative changes.

The above example is the progression of findings after an injury that occurs. These findings occur over several years and certainly not weeks or months.

Summary
All radiologists have in their experience banks a broad view of what mild, moderate and severe degenerative changes look like on MRI and would have no problem relating that to whether these changes were age appropriate or advanced for age. In addition, comparing a disc fragment for degree of hydration with the native disc is rather straight forward.

With the above guidelines we can be rather accurate in assigning a reasonable time frame
for most MRI findings.

For more info on Age of Injury please contact us.