Ordering radiographs with the law in mind
CMAJ 1997;157:1352
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In the article "Variation in emergency department use of cervical spine radiography for alert, stable trauma patients" (CMAJ 1997;156[11]:1537-44 [abstract / résumé]), Dr. Ian Stiell and associates indicate that cervical spine radiography could be used more efficiently and cost-effectively if there were clinical guidelines governing its use. Even though I agree with these authors, I order this type of imaging for asymptomatic patients who have been in motor vehicle accidents, particularly rear-end collisions that may have caused cervical hyperextension. The explanation that "I didn't think, on clinical grounds, that such an imaging study was warranted" holds little sway in Canada's courtrooms.
If there is loss of cervical lordosis because of muscle spasm after a motor vehicle accident, the speed with which the first radiographs were obtained becomes a factor in determining what health problems eventually develop and the size of insurance settlements. A person who has survived such an accident may have loss of cervical lordosis immediately, but it may be 2 or 3 days before symptoms appear. The radiographs obtained initially will serve as a baseline for subsequent radiographic findings.
Because of my court experiences, I send patients to the radiology department as soon as I have seen them, even if the casualty officer feels that imaging is unnecessary. I know that in the long term I am the one who will be questioned extensively about muscle spasm, onset of symptoms and radiologic evidence of muscle spasm. I also order lumbar spine films because lap-belt injuries may cause lumbar muscle spasm. This means that evidence will be available should the problem reach the courtroom. The existence of radiographs often makes it unnecessary to go to court because, despite the possibility of pre-existing conditions such as osteoarthritis, the insurance adjusters and lawyers will decide that a claim is legitimate and settle it. In the long run these radiographs probably save money, even if they do not necessarily help me in deciding how to handle these soft-tissue injuries.
Legal questions sometimes dictate whether radiographs should be ordered. Twenty-five years of experience have led me to request such images as soon as possible after an accident because I might need them 3 or 4 years later in court.
Raymond Shandera, MD
Bay Roberts, Nfld.
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