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Spine-Related Musculoskeletal Conditions – Part 3 – Stenosis

In this series, we have been looking at spine-related musculoskeletal conditions that many dentists and surgeons suffer from.  In this post, we will be looking at spinal and foraminal stenosis.

Cervical Spinal Stenosis:

Definition: The narrowing of the spinal canal in the cervical vertebrae, often due to inflammation of the surrounding cartilage and tissue.

Overview: The spinal canal is formed by the hollow spaces in the middle of the vertebrae, which form a protective tunnel for the spinal cord to pass through the spinal column. Cervical spinal stenosis is a progressive and potentially dangerous condition that occurs when inflammation narrows the cervical spinal canal. The narrowing of this already tight space can result in direct pressure on the spinal cord, leading to a number of neurological complications.  Cervical spinal stenosis can be crippling if the spinal cord becomes damaged.

Symptoms: Symptoms usually develop gradually over time and can include numbness, weakness, tingling in neck, shoulders, arms, hands, or legs, as well as intermittent, sharp pain in the arms and legs, especially when bending forward.  Deterioration of fine motor skills and issues with gait and balance can also occur.  In more severe cases, bladder and bowel issues may develop.

Causes: Though in rare cases cervical spinal stenosis is a congenital condition, it often results from inflammation due to other spinal conditions, such as spinal osteoarthritis, degenerative disc disease, and disc bulging.

Diagnosis: A combination of X-ray, MRI, and computed tomography (CT) scans may be used to diagnose spinal stenosis.  Blood tests may be used to eliminate other diseases such as multiple sclerosis and vitamin B12 deficiency.

Treatment: Conservative, non-invasive treatments may include exercise, physical therapy, and activity modification.  Medications may include anti-inflammatory drugs, narcotic pain medication, muscle relaxers, and epidural steroid injections.  In more severe cases, several surgical options exist, dependent upon the particular characteristics of the patient’s condition:

  1. Anterior cervical discectomy/corpectomy with fusion (ADCF): The spine is accessed through the front of the patient’s neck, the disc is removed from between the two vertebrae, and the vertebrae are then fused together to stabilize the spine.
  2. Laminectomy: This is a “decompression” surgical procedure performed to relieve pressure on the spinal cord. In this surgery, the lamina (the rear portion of the vertebra covering the spinal canal) is removed from the affected vertebra to enlarge the spinal canal and decrease pressure on the spinal cord.
  3. Interspinous Process Spacers: In this procedure, small metal spacers are surgically placed between the vertebrae to restore the spacing typically created by a healthy disc. This procedure is typically reserved for individuals with foraminal stenosis, however, and has only had limited effectiveness with patients suffering from spinal stenosis.

Foraminal Stenosis

Definition: Compression of the nerve roots connected to the spinal cord, caused by the narrowing of the passageway through which the nerves exit the spinal column.

Overview: The nerve roots branching off the spinal cord to other parts of the body exit the spinal column through small openings on the sides of the vertebrae called a foramen. This space can become clogged or narrowed due to a number of spine-related conditions. The narrowing or partial obstruction of the foraminal canal caused by one of these conditions can put pressure on the nerve roots emerging from the spinal column, and may lead to an array of neurological symptoms that get progressively worse over time.

Symptoms: Tingling, numbness, or weakness in the feet or hands.  Local pain in the extremities.  “Pins and needles” or burning sensation. Intermittent neck or back pain.

Causes: Bulging or herniated discs may obstruct the foraminal canal, putting pressure on the nerve roots.  It can also be caused by spinal osteoarthritis, osteophytes, and spondylolisthesis.  Dentists are susceptible to foraminal stenosis, as they often hold their necks in extended positions.

Diagnosis: A CT scan and a Myelogram are used to diagnose foraminal stenosis. A Myelogram is an X-ray in which an opaque dye (which shows up on the X-ray) is injected into the sac around the nerve roots. The dye moves through the foramina, allowing the doctor to see the degree to which the foramen is narrowed or obstructed.

Treatments: Conservative treatments may include physical therapy, stretching and strength training, and oral pain-relieving medication. Corticosteroid injections are an option for more severe cases to reduce inflammation and pain.  In extreme cases, a surgical procedure known as a foraminotomy may be used to remove the bone spur or disc material that is putting pressure on the nerve root as it exits the spinal column through the foramen.

Our next post in this series will discuss spondylolisthesis.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional.  If you are experiencing any of the symptoms described below and have yet to consult with a doctor, do not use this resource to self-diagnose.  Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

References:

1. Spine-health, https://www.spine-health.com/.
2. Mayo Clinic, http://www.mayoclinic.org/.
3. The Neurological Institute of New York,
http://columbianeurology.org/about-us/neurological-institute-new-york.
4. John Hopkins Medicine, http://www.hopkinsmedicine.org/.
5. WebMD, http://www.webmd.com/.

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Spine-Related Musculoskeletal Conditions – Part 2 – Spinal Osteoarthritis

In the first part of this series, we discussed the fact that dentists and surgeons often suffer from musculoskeletal conditions.  In the remaining posts in this series, we will be looking at particular musculoskeletal conditions, starting with spinal osteoarthritis.

Spinal Osteoarthritis

Definition: Spinal osteoarthritis is also known as degenerative joint disease. It is a breakdown of the cartilage in the facet joints, which link together the spine’s vertebrae.

Overview: At the top and bottom of each vertebra is a small pair of joints called facets. Facets connect the vertebrae in order to restrict movement in certain directions and to allow the spine to move as one fluid unit.  The surfaces of the facets, like any other joint in the human body, are covered by a lubricating cartilage which allows them to operate smoothly and with little friction.

When the cartilage protecting the facets degrades or wears down, the bony surfaces of the facets rub against each other.  This can cause inflammation, severe pain, and the formation of osteophytes (bone spurs) on or around the joint surfaces.  It may also cause numbness and/or weakness in the legs and arms as a result of contact between the vertebrae and the nerves leaving the spinal cord.

Symptoms: Neck pain and stiffness. Severe pain may radiate down into shoulders and up the neck.  Weakness, numbness, or tingling in the fingers, hands, and/or arms are also often present.  Usually back discomfort is relieved when a person is lying down.  Studies have also linked anxiety and depression to osteoarthritis.[1]

Causes: Spinal osteoarthritis frequently occurs in conjunction with degenerative disc disease.  As the discs between the vertebrae in the spinal column degrade and decrease in volume, the increased pressure and contact between the facet joints can cause an accelerated degradation of the joint cartilage.

Repetitive strain or stress on the spine, often due to poor posture, to is a common cause of spinal osteoarthritis.  People with jobs requiring repetitive movements and strained positions are considered to be at greater risk for conditions like spinal osteoarthritis; however, injury or trauma to a joint or a genetic defect involving cartilage are also causes.  Dentists are at a higher risk than many other professions to develop this condition due to the awkward, static postures they must maintain.

Diagnosis: X-rays may be used to identify loss of cartilage, bone spurs, and bone damage. Magnetic resonance imaging (MRI) may be used to analyze the intervertebral discs and the nerves exiting the spinal column.

Treatment: Conservative, non-invasive treatment plans may include some combination of heat/cold therapy, medication, physical therapy, strength training, and stretching. In more severe cases, a surgical treatment such as spinal fusion is utilized.

Our next post in this series will examine spinal stenosis, another common cause of neck and back pain.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional.  If you are experiencing any of the symptoms described below and have yet to consult with a doctor, do not use this resource to self-diagnose.  Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

[1] Sharma, A., et. al, Anxiety and depression in patients with osteoarthritis: impact and management challenges, Open Access Rheumatology: Research and Reviews 2016:8 (2016).

References:

1. Spine-health, https://www.spine-health.com/.
2. Mayo Clinic, http://www.mayoclinic.org/.
3. The Neurological Institute of New York,
http://columbianeurology.org/about-us/neurological-institute-new-york.
4. John Hopkins Medicine, http://www.hopkinsmedicine.org/.
5. WebMD, http://www.webmd.com/.

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Spine-Related Musculoskeletal Conditions – Part 1 – Spondylosis

Living with a spine-related condition can be scary and overwhelming. Unfortunately, the complex nature of the spine and the nervous system can often make the search for answers a frustrating and demoralizing endeavor.  In this series of posts we are going to talk about several spine-related musculoskeletal conditions, many of which are frequently diagnosed in dentists, surgeons, and other physicians.

If you are suffering from a spine-related condition, you have likely visited not only your primary care physician, but also a physical therapist, a chiropractor, a neurologist, an orthopedic surgeon, and/or a pain management doctor.  It’s common for those suffering from a musculoskeletal condition to hear several different terms to describe a set of symptoms, be given multiple explanations for what is causing their pain, and be given a variety of (often conflicting) treatment recommendations.

Dentists and physicians in certain surgical specialties are particularly susceptible to spine-related musculoskeletal conditions, which are among the top reasons insureds file disability claims.  The forward-flexed, static posture that dentists and surgeons must maintain to perform procedures can lead to the overuse and repetitive strain of the neck and back, and contribute to the development of a litany of musculoskeletal conditions.  One study showed that 62% of the general population present musculoskeletal work-related pain, and this increased to 93% when the sample population was made up entirely of dentists.[1]  Unfortunately, although one often thinks of spinal and back injuries occurring later in life after years of strain, chronic musculoskeletal pain is experienced by many dentists by their third year of dental school.[2]

We’ve created this series of blog posts as a resource to help clear up some of the confusion surrounding the common terms used to refer to spine-related musculoskeletal conditions.  For each term we’ll provide a definition, overview, list of common symptoms, causes, methods of diagnosis, and common treatments. In this post, we’re going to briefly look at spondylosis, and then in later posts we will take a more in depth look at some other spine-related conditions.

Spondylosis

Definition: This is an umbrella term used to broadly describe degeneration in the spine.  Some doctors may use it interchangeably with spinal osteoarthritis.  Spondylosis is a descriptive term rather than a clinical diagnosis – it is used to describe anyone suffering from both pain and spinal degeneration.  If your doctor uses this term to describe your condition, you may want to your physician for a more specific diagnosis.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional.  If you are experiencing any of the symptoms described above and have yet to consult with a doctor, do not use this resource to self-diagnose.  Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

[1] Dias, Ana Giselle Aguiar, et. al, Prevalence of repetitive strain injuries/work related musculoskeletal disorders in different specialties of dentists, RGO, Rev. Gauch. Odontol. Vol. 62 no. 2, Campinas Apr./June 2014,  http://dx.doi.org/10.1590/1981-8637201400020000042714  (citing Regis Filho GI, Michels G, Sell I. Lesões por esforços repetitivos/distúrbios osteomusculares relacionados ao trabalho em cirurgiões-dentistas. Rev Bras Epidemiol. 2006;9(3):346-59, http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1415-790X2006000300009&lng=en).

[2] Kristina Lynch, My back is hurting my practice, Part I, AGD Impact, Feb. 2006.

References:

1. Spine-health, https://www.spine-health.com/.
2. Mayo Clinic, http://www.mayoclinic.org/.
3. The Neurological Institute of New York,
http://columbianeurology.org/about-us/neurological-institute-new-york.
4. John Hopkins Medicine, http://www.hopkinsmedicine.org/.
5. WebMD, http://www.webmd.com/.

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Berkshire Criticized by Maryland Insurance Commissioner for “Artful Neglect”

Disability insurers have a duty to fully investigate claims for benefits, as the insurance companies are well aware.  Unfortunately, some claims departments may focus their efforts on looking like they are investigating and considering information rather than actually doing so.

Berkshire, a disability insurance company that sells own-occupation policies to dentists and doctors, has garnered criticism from at least one state’s insurance commissioner for this very practice.

In Berkshire Life Insurance Company v. Maryland Insurance Administration, 142 Md. App. 628, 791 A.2d 942 (App. 2002), Berkshire attempted to claim that its insured was only partially disabled, and therefore it was only obligated to pay a fraction of the total benefits that were payable under the policy.  In finding that Berkshire’s conduct was “arbitrary and capricious” in violation of Maryland’s insurance statutes and ordering it to pay restitution to the policyholder, the Maryland Insurance Commissioner also found:

Overall, Berkshire’s actions here represent what may be termed as “artful neglect.”  Berkshire gives the appearance of investigating a claim in order to render a good faith claims determination.  As part of this appearance, Berkshire timely requests financial information from its insured and then timely requests more information from its insured.  In direct contrast to this “appearance,” however, Berkshire does not analyze the information at all, much less use an analysis in a cogent and rational way to support a proper claims determination.

In a more recent Arizona case, Nunley v. Berkshire Life Insurance Company of America, 2009 WL 529901 (D. Ariz. 2009), Berkshire tried to have the United States District Court rule that it could not be subject to punitive damages in a case involving a disabled dentist’s total disability claim.  The Court, however, denied Berkshire’s motion, finding that Berkshire might have to pay punitive damages because it did not investigate the dentist’s claim adequately or in a timely fashion.

This “artful neglect” is unlawful, and may subject a disability insurance carrier to bad faith liability.  A disability insurance claimant who thinks her insurer is not adequately investigating the claim should contact an attorney to help protect her rights.

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Northwestern Mutual Offers Insight Into How Disability Insurers Interpret and Apply “Own Occupation Coverage”

Northwestern Mutual Life Insurance—a major provider of disability income insurance for physicians and dentists—has just launched a new website, the “Disability Income Insurance Knowledge Center,” which it claims will help policyholders understand the terms of their “own occupation” disability insurance coverage.

“Own occupation” policies are often marketed by disability insurers as allowing physicians and dentists to receive their full disability insurance benefit, while at the same time working in another occupation, as long as they can no longer practice medicine or dentistry. Some insurance policies further specify that the insured’s specialty will be considered his “occupation” for purposes of “own occupation” coverage. Under these policies, as they are frequently marketed, an insured could receive his full benefit, even if he is still working as a physician or dentist, as long as he is disabled from his former specialty.

As an example, a neurosurgeon who develops a hand tremor may still be a capable doctor, but he can no longer perform surgery. Since he can no longer perform the principal medical duty of neurosurgery (i.e., surgery), it would be logical to conclude that he would be disabled from his occupation as a neurosurgeon. However, Northwestern’s new website has an interactive “Fact or Fiction” quiz in which it offers its interpretation as to how these “own occupation” provisions should be interpreted. Northwestern’s conclusions are gross oversimplifications that fail to consider the nuances of a disability claim, and ignore differences in policy language and the manner in which the policies have been interpreted under Arizona law. These oversimplifications appear designed to dissuade individuals with legitimate disability claims from pursuing their remedies. Nevertheless, they offer a glimpse into how disability insurers often view an insured’s occupational duties. Some samples from the “quiz” include the following statements:

Statement: If I could not perform my principal medical duty, the one that’s my “bread and butter,” I’d be considered totally disabled under an “own occ” policy.

Northwestern Mutual: FICTION. “To be totally disabled under traditional ‘own occ’ disability income insurance definitions, you would have to be unable to do ALL of your principal duties.

Depending on the terms of his “own occupation” policy, an Arizona physician or dentist may be totally disabled if he cannot perform any substantial part of his ordinary duties in his usual and customary manner. In one major case, an invasive cardiologist was no longer able to perform invasive procedures—a substantial part of her original duties—but continued work in non-invasive cardiology and geriatrics. The jury found her totally disabled under her “own occupation” policy and held that her insurer had denied her disability insurance claim in bad faith. It then awarded her $84.5 million.

This statement also reflects an important issue in interpreting these policies – while countless words and phrases are defined, the phrase “principal duties” is generally not defined. Taking advantage of this fact, insurers often attempt to transmute incidental duties, such as staff oversight or pre- and post-operative patient consultation, into principal duties, without any justification for doing so. If insurers were permitted to do this, as Northwestern suggests, it would render “own occupation” coverage illusory since, absent a catastrophic injury, the insurer would always be able to find that the insured could perform some duty of his prior occupation. Fortunately, Arizona courts do not permit insurers to classify all duties as “principal duties.” As one Arizona court noted “[f]ew specialty occupations could survive such piecemeal scrutiny. If separated into an hour-by-hour analysis, only asking the question whether these tasks are also performed in a more general setting, specialists who choose to continue to work in a more general practice after becoming disabled from their specialty could never qualify for total disability benefits, although the policy specifically allows for this.” Continue reading Northwestern Mutual Offers Insight Into How Disability Insurers Interpret and Apply “Own Occupation Coverage”

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California Insurance Commissioner Petitioned to “Kick [UnumProvident] the Hell Out” of California

Disability insurer UnumProvident was recently fined $15 million and ordered to reopen 115,000 claims in a multi-state regulatory settlement, and the California Department of Insurance separately fined Unum $8 million and ordered the insurance company to reopen an additional 26,000 claims.  The fines against UnumProvident were the largest in insurance regulatory history.  Now one of the San Francisco attorneys who assisted in the three-year investigation of Unum, Ray Bourhis, has petitioned California Insurance Commissioner John Garamendi to “make good on his promise to kick the Company the hell out of the largest insurance market in the world.  And that’s what I’m calling on Garamendi to do.  Period.”

Bourhis tells the Insurance Journal:

John Garamendi was right last October when he called UnumProvident an “outlaw company.”  That’s exactly what they are.  And Garamendi should make good on his promise to kick them out of California if they continue breaking the law.

The investigation of Unum concluded that the disability insurance company was engaged in widespread violations of state insurance regulations and bad faith claim denials and terminations. According to Bourhis, “The truth is that no matter how much you fine them, it still pays for them to do this. . . The company is making the disabled destitute, policyholders whose claims it was ordered to reopen, wait — often for years — for their reevaluations.  This is despite the fact that the law requires claims to be handled ‘promptly, fairly and expeditiously.”

A complete copy of Mr. Bourhis’s letter to California Insurance Commissioner Garamendi is available here.

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