“IT WAS ALREADY THERE” IS NOT A COMPLETE MEDICAL ANALYSIS
A cervical MRI shows multilevel degenerative disc disease. A lumbar MRI reports facet arthropathy. The patient had back pain several years before the collision. Osteoarthritis appears in the past medical history.
Those facts are relevant, and in some cases they may substantially weaken an allegation that a later event created an entirely new condition. But the presence of pre-existing pathology does not, by itself, answer the medical causation question.
The clinically appropriate inquiry is often more precise:
What was the patient’s baseline before the event?
Was the pre-existing condition symptomatic or silent?
Did the event produce a new injury, aggravate an existing condition, accelerate symptoms, alter function, or merely coincide with a continuation of the same clinical problem?
Those are different medical propositions, and the record should be analyzed accordingly.
DEGENERATIVE IMAGING FINDINGS ARE COMMON
One reason this issue is so frequently misunderstood is that degenerative findings become increasingly common with age and can be present in people who have no pain.
A widely cited systematic review by Brinjikji and colleagues examined imaging findings in asymptomatic individuals and found that multiple degenerative spine features were common and increased with age. The authors emphasized that many imaging-based degenerative features are likely part of normal aging and must be interpreted in the context of the patient’s clinical condition.
A later meta-analysis by the same research group also found that several degenerative MRI findings were more prevalent in symptomatic adults than in asymptomatic controls.
These two observations are not contradictory. They illustrate why neither side should oversimplify imaging.
Degeneration can be clinically relevant, but its presence on an MRI does not automatically tell us whether it caused the patient’s symptoms before an accident, whether it became symptomatic afterward, or whether trauma produced an additional lesion.
THE MOST IMPORTANT MEDICAL RECORD MAY PREDATE THE ACCIDENT
When aggravation is disputed, baseline evidence becomes indispensable.
Prior primary-care notes, orthopedic records, pain-management visits, physical-therapy records, pharmacy history, imaging, work restrictions, prior claims, and surgical recommendations can be more important than the first post-accident MRI.
The physician reviewer should reconstruct the pre-event clinical state.
Was the patient receiving injections?
Using opioids or muscle relaxants?
Missing work?
Reporting radiculopathy?
Considering surgery?
Was the patient essentially asymptomatic and fully functional despite radiographic degeneration?
Was there intermittent pain once or twice a year, or continuous pain requiring active treatment?
A chart entry that says “history of back pain” cannot be treated as equivalent to a documented chronic disabling syndrome.
COMPARE BASELINE WITH THE POST-EVENT TRAJECTORY
After defining baseline, the next task is comparison.
Did symptom intensity materially increase?
Did the anatomical distribution change?
Did new radicular symptoms appear?
Did the patient begin treatment that had not previously been required?
Did functional status deteriorate?
Did the frequency of care change from occasional conservative treatment to repeated specialty visits, injections, or surgery?
Were there new objective findings?
A before-and-after analysis can strengthen either side of a case.
A patient with rare mild lumbar discomfort who worked without restrictions for years and then develops persistent radicular symptoms after a documented traumatic event presents a different medical question from a patient who was already receiving repeated injections and had surgery scheduled before the accident.
The word “pre-existing” applies to both, but the medical implications are radically different.
AN MRI DOES NOT DATE EVERY ABNORMALITY
Post-event imaging is often treated as though it contains a timestamp for pathology.
Usually it does not.
Some findings may clearly appear acute; others may be chronic; still others may be indeterminate without comparison studies.
When prior imaging exists, direct comparison can be extremely valuable. When it does not, the physician must avoid pretending that morphology alone can always establish when an abnormality developed.
The radiologist’s descriptors – chronic, acute, subacute, degenerative, traumatic, edema, fracture, annular fissure, extrusion, stenosis – should be read carefully, but even radiologic language must be correlated clinically.
The absence of a prior MRI does not prove that every post-event abnormality is new.
Conversely, evidence of degeneration does not prove that trauma caused no clinically meaningful change.
AGGRAVATION REQUIRES MORE THAN TEMPORAL ASSOCIATION
A symptom worsening after an accident may support causation, but sequence alone is insufficient.
A physician should consider the mechanism, temporal relationship, anatomical correlation, objective findings, prior history, subsequent course, treatment response, and reasonable competing explanations.
An intervening injury, progressive degenerative disease, infection, systemic illness, medication change, or unrelated activity may alter the analysis.
The medical reviewer should also distinguish between a new structural injury and an exacerbation of symptoms associated with a pre-existing structure.
That distinction may be clinically and legally important.
Counsel should not assume that the medical vocabulary used in a treating note necessarily maps perfectly onto the legal terminology used in a particular jurisdiction.
PRE-EXISTING DISEASE CAN STRENGTHEN THE DEFENSE – WHEN THE RECORD SUPPORTS IT
A balanced review must identify unfavorable evidence.
If records immediately before the event document severe symptoms in the same location, repeated treatment, substantial functional impairment, and an already-planned intervention, and the post-event course is essentially unchanged, attributing the entire later condition to the new event may be medically difficult.
Likewise, inconsistent histories matter.
If a patient repeatedly denies prior symptoms after an accident despite extensive documented treatment before it, that discrepancy may affect the reliability of the history and therefore the strength of any causation opinion that depends upon it.
A useful physician reviewer should identify such problems before opposing counsel does.
QUESTIONS COUNSEL SHOULD HAVE ANSWERED
When a pre-existing condition becomes central to a case, counsel should be able to answer:
- What condition existed before the event?
- Was it symptomatic, asymptomatic, or intermittent?
- What was the patient’s functional baseline?
- What changed after the event?
- Is the claimed change anatomically and mechanistically plausible?
- Are there objective findings supporting a new injury or a changed clinical state?
- Are there alternative explanations?
- Is the treatment trajectory genuinely different?
- What does prior imaging show, if available?
Those questions turn “degeneration” from a litigation label into a medical analysis.
THE LEGALMDS PERSPECTIVE
The strongest medical review does not hide a prior condition.
It defines it.
Sometimes the records support a new traumatic injury superimposed on chronic disease.
Sometimes they support aggravation of an existing symptomatic condition.
Sometimes they show a temporary flare.
Sometimes they show no meaningful change attributable to the event.
LegalMDs can help counsel reconstruct the pre-event baseline, compare imaging and treatment trajectories, identify medical inconsistencies, evaluate alternative explanations, and frame the questions that treating or retained physicians should address.
That analysis can be valuable to plaintiff, defense, malpractice, workers’ compensation, disability, and other counsel because it identifies the actual medical issue before litigation shorthand takes over.
The decisive question is often not “Was something already wrong?”
It is “What, if anything, medically changed because of this event?”
REFERENCES
- Brinjikji W, Luetmer PH, Comstock B, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR Am J Neuroradiol. 2015;36(4):811-816.
- Brinjikji W, Diehn FE, Jarvik JG, et al. MRI Findings of Disc Degeneration Are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol. 2015;36(12):2394-2399.
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