Lara Law Firm
Schedule Your Free Consultation
520.276.4727

August 2017 Archives

Alar Ligament - Craniocervical Junction

A PARTIAL REVIEW OF THE LITERATURE OF THE CRANIOCERVICAL JUNCTION

  1. The upper cervical ligaments are the most brittle ligaments in the human body, and were never meant to withstand the forces generated in a motor vehicle collision (MVC).
Saldinger P, Dvorak J, et al.  (1990) The Histology of the Alar and Transverse Ligaments.  Spine 15, 257-261
  • The authors noted that collagen structures fail at 6-8% of stretch beyond their resting length, and that elastin could tolerate elongation up to 200%, and then abruptly fail.
  • The elastin fibers were found to tolerate only 20% of the load that collagen could tolerate.
  • They noted that the elastic properties of ligaments decrease with age.
  • They reported that both the alar and transverse ligaments consisted almost entirely of collagen fibers, and they could only find a few isolated elastin fibers in the loose connective tissue that surrounded the transverse ligament. The transverse ligament transitioned into fibrocartilage on the ventral side (which contacts the dens), and the ligament thickened somewhat in the central area.
  • Since the contribution from the few elastic fibers to the mechanical behavior of both the transverse ligament and the alar ligaments is “neglibly small,” the authors stated that “a major elongation of the ligament is almost impossible.”  They went on to state, “the fact that the alar ligaments  consist mainly of collagen fibers supports the hypothesis that those ligaments could be irreversibly overstretched or even ruptured when the head is rotated and in addition flexed, a movement seldom induced physiologically.   However, in motorcar accidents, especially in unexpected rear-end collisions, the head, initially slightly rotated, will go into maximal rotation followed by a ‘whiplash’ movement caused by the impact.”

  1. The medical literature throughout the past three decades has been loaded with articles about the damage done to the alar ligaments as a result of MVC’s.
Dvorak J, Panjabi MM.  Functional Anatomy of the Alar Ligaments.  Spine 1987;12:183–9
  • Upper cervical spine ligament may remain undetected radiographically and may lead to clinical instability causing neurologic deterioration in as many as 33% of patients.
Dvorak J, Froehlich D, Penning L, et al. Functional Radiographic Diagnosis of the Cervical Spine: Flexion/Extension. Spine 1988;13:748–55.
  • The alar and transverse ligaments play key roles in stabilizing the upper cervical spine because of the absence of intervertebral discs and the presence of horizontally aligned facet at the atlantooccipital region.
Panjabi M, Dvorak, J, Crisco J, et al.  Flexion, Extension, and Lateral Bending of the Upper Cervical Spine in Response to Alar Ligament Transections.  Journal of Spinal Disorders (1991), Vol 4., No. 2, pp. 157-167
  • The alar ligaments limit lateral flexions ipsilaterally at C1-C2, and also limit flexion at C0-C1; increases in all of the above indicates alar ligament damage.
Radcliffe KE, Hussain BS, Moldavsky MS, Klocke MS, et al.  In Vitro Biomechanics of the Craniocervical Junction- A Sequential Sectioning of Its Stabilizing Structures.  Spine 15 (2015), pp. 1618-1628
  • The transverse and alar ligaments appear to be the main stabilizers of the craniocervical junction.
White AA, Panjabi MM. Clinical Biomechanics of the Spine, 2nd ed. (Philadelphia: Lippincott, 1990).
  • “Rupture of the alar and transverse ligaments often occurs without associated vertebral fracture and may result in upper cervical spine instability leading to neurologic injury or death.”
Maak, TG, Tominaga, Y, Panjabi, MM, and Ivancic, PC.  Alar, Transverse, and Apical Ligament Strain Due to Head-Turned Rear Impact.  Spine 2006 (Volume 31, Number 6), pp 632-638
  • Whiplash-Induced soft tissue injuries produce chronic head and neck pain and upper cervical spine instability.
Saternus K. Die Wirbelsaulenuntersuchung im Rahmen der Forensischen Obduktion. Beitr Gerichtl Med 1988;46:489–95. (No, I didn’t actually read this one.)
  • The author found that among 397 whiplash patients, 85.6% had upper cervical ligamentous lesions whereas only 14.4% had bone fractures.
Volle E, Montazem A. MRI Video Diagnosis and Surgical Therapy of Soft Tissue Trauma to the Craniocervical Junction. Ear Nose Throat Journal 2001;80:41-4,46-8
  • This MRI study of 95 whiplash patients demonstrated alar ligament lesions in nearly 75% of subjects.
Krakenes J, Kaale BR, Moen G, et al. MRI Assessment of the Alar Ligaments in the Late Stage of Whiplash Injury: A Study of Structural Abnormalities and Observer Agreement. Neuroradiology 2002;44:617–24
  • In a follow-up MRI study of between two and nine years, Krakenes et al documented persistent injury of the alar ligaments in 51% of whiplash patients. (Krakenes also published five other papers from the same study which documented the use of thin slice proton density MRI data sets for the diagnosis of injury to the tectorial membrane, the posterior atlanto-occipital membrane, the posterior atlanto-axial membrane, the transverse ligament, and the apical ligament.  More on this one later).
Adams, VI.  Neck Injuries:  III.  Ligamentous Injuries of the Craniocervical  Articulation  Without Occipito-Atlantal or Atlanto-Axial Facet Dislocation:  A Pathologic Study of 21 Traffic Fatalities.  J Forensic Sci 1993;38:1097-104
  • Post-mortem evaluation of 21 fatalities with atlanto-occipital dislocation revealed alar ligament injuries ranging from partial to complete rupture in 95% of the cases, elucidating the vital role of the alar ligaments in stabilizing the atlantooccipital region.

  1. Some of the best information about upper cervical ligament damage and the resulting subluxations is found in rheumatoid arthritis literature.
Weissman, BNW, et al.  Prognostic Features of Atlantoaxial Subluxation in Rheumatoid Arthritis Patients.  Radiology 144:  September 1982, pp. 745-751
  • While anterior atlanto-dental subluxation (aADI) is very well known as a manifestation of rheumatoid arthritis in the cervical spine, the researchers noted that lateral subluxation of C1 on C2 was documented concurrently in 20.6% of the study’s subjects. “Because this deformity further reduces the diameter of the spinal canal, it is more frequent in neurologically abnormal patients.”
Taniguchi, D, et al.  Evaluation of Lateral Instability of the Atlanto-Axial Joint in Rheumatoid Arthritis Using Dynamic Open-Mouth View Radiographs.  Clin Rheumatol (2008) 27:851-857
  • The authors studied a group of 30 patients with rheumatoid arthritis in comparison with a control group of 22 patients.
  • Standard flexion-extension stress radiographs and special anterior-posterior (AP) open mouth with maximum right and left lateral bending views were made.
  • The ADLS (lateral shift) in the rheumatoid arthritis group was significantly greater than that in the control group;
  • The authors believed the lateral shift was due to weakening of the alar ligaments and “loosening” of the lateral atlanto-axial joint (which would implicate the accessory ligaments).
  • “In the present study, we found dynamic lateral instability of the atlanto-axial joint in rheumatoid arthritis, and its frequency of occurrence was as high as that of anterior atlanto-axial subluxation (aAAS).”
Pisitkun P, et al.  Reappraisal of Cervical Spine Subluxation in Thai Patients with Rheumatoid Arthritis, Clin Rheumatol (2004) 23: 14-18
  • The overall prevalence of cervical spine subluxation was 68.7%, which could be characterized into anterior (26.9%), posterior (14.9%), lateral (17.2%), vertical (16.4%), and atlantoaxial and subaxial subluxation (28.4%).
  • Corticosteroid use was associated with cervical subluxation, regardless of dose and duration of treatment because the steroids lead to ligament laxity, osteoporosis, and decreasing muscle mass, which accelerated the subluxation.
The point is that it doesn’t really matter what causes the lateral instability at C1-C2- a disease process or an abrupt trauma- the outcome is the same and is manifested by lateral translation of C1 on C2 during side bending (lateral flexion).
  1. Anecdotal Case Studies of Alar Ligament Injury
Demetrious J.  Post-Traumatic Upper Cervical Subluxation Visualized By MRI:  A Case Report, Chiropractic & Osteopathy, December 19, 2007, 15:20
  • Smart chiropractor Dr. Demetrious spots abnormal C1-C2 lateral translation not spotted by the reading radiologist, corrects him on it, and proceeds to a good outcome with his patient, who lives happily ever after. Probably should be made into a made-for-TV movie.
Tasharski, CC, Heinze, WJ, and Pugh JLDynamic Atlanto-axial Aberration:  A Case Study and Cinefluorographic Approach to Diagnosis.  JMPT 1981; 4:65-8
  • Tasharski is a long-time DACBR at National University of Health Sciences (formerly National Chiropractic College) who uses videofluoroscopy to diagnose ligamentous damage in the cervical spine of a 35-year old male.
Derrick LJ, and Chesworth BM.  Post-Motor Vehicle Accident Alar Ligament Laxity, JOSPT, Vol. 16, No. 1, July, 1992
  • The authors are physical therapists who describe a case presentation in a patient whose radiological findings supported the clinical findings of right alar ligament laxity.
  • The radiological findings? APOM with lateral flexion, bilaterally.
It has been well established in the literature for several decades that there is no lateral flexion movement available at C1-C2 with side bending.Because the rheumatoid literature will allow 1-2 mm. of movement between C1-C2 with lateral flexion, we do not consider very mild lateral translation there to be of clinical significance.  Krakenes (2002) stated that he considered 1.7 mm of lateral translation at C1-C2 to be indicative of subluxation and poor prognosis.  And his statement was based on patients who only had images created in the neutral position, without the benefit of dynamic positioning.  So who’s right?  I’d say, when in doubt, always remember that radiographic findings of all types must be correlated to the patient’s clinical presentation; otherwise, they are of no relevance.
  1. Should MRI be the gold standard in the diagnosis of spinal ligament injuries? 
Stabler, A., Eck J., Penning R., Milz, SP, Bartl R., Resnick D, Reiser M.  Cervical Spine:  Postmortem Assessment of Accident Injuries- Comparison of Radiographic, MR Imaging, Anatomic, and Pathologic findings.  Radiology, 2001; 221 (2):340-6
  • 28 lesions were identified.
  • 3 lesions were fractures (11%) with two of them not visible with x-ray.
  • Only 11 (total!) of the 28 lesions were initially found with MRI.
  • The other 17 were found only after using specially prepared 3-micrometer slices of the spinal segments.
  • “Direct depiction of the ruptured apophyseal (facet) joint capsule was almost impossible.”- Donald Resnick, MD
  • Bottom line? The resolving power of X-ray and MRI is insufficient to visualize the full spectrum of trauma.
Long DM, et al.  Fusion for Occult Posttraumatic Cervical Facet InjuryNeurosurg Q, Vol. 16, No. 3, September 2006
  • 67 patients with intractable neck pain and headaches following MVC
  • All had failed at 2 months of physical therapy and exercise rehabilitation.
  • All patients had no positive diagnostic findings, including plain film, CT, and MRI.
  • Facet capsule damage was diagnosed with anesthetic blocks (sixteen patients had negative results and were eliminated from surgical options).
  • 44 patients opted for the offer of posterior surgical fusion (Brooks’ triple wire fusion) of the symptomatic levels, with good results, because the instability was corrected.
  • Parting shot from the authors? MRI could not identify the ligament lesions:  “Imaging studies currently available do not define these ligamentous injuries.”  This statement did not include the use of digital motion x-ray.

  1. Imaging of upper cervical ligaments-  Jostein Krakenes, MD
These articles describe the use of thin slice proton density MRI data sets in imaging the ligaments and membranes of the upper cervical spine.  Jostein Krakenes is a Danish radiologist who did a landmark study in 2001, out of which he generated a half dozen game changing papers about the upper cervical ligaments.Vetti N, Krakenes J, et al.  MRI of the Alar and Transverse Ligaments in Whiplash-Associated Disorders (WAD) Grades 1-2:  High-Signal Changes by Age, Gender, Event and Time Since Trauma.  Neuroradiology (2009) 51: 227-235
  • “High-signal changes of the alar and transverse ligaments are common in WAD 1-2 and are unlikely to represent age-dependent degeneration.”
Krakenes, et al.  MRI Assessment of the Alar Ligaments in the Late Stage of Whiplash Injury- A Study of Structural Abnormalities and Observer Agreement.  Neuroradiology (2002) 44:  617-624
  • “For detailed resolution of the alar ligaments good spatial resolution and optimized contrast are critical. A slice thickness of 2 mm gives excellent spatial resolution.  T2-weighted images gave inadequate discrimination between ligament, bone and soft tissue due to low signal-to-noise ratio.  T1-weighted images afforded poorer contrast resolution and thus less ability to differentiate small variations in signal.  We therefore found a proton-density weighted sequence the technique of choice for assessment of ligamentous abnormalities.”
Kaale RB, Krakenes J, et al.  Whiplash-Associated Disorders Impairment Rating:  Neck Disability Index Score According to Severity of MRI Findings of Ligaments and Membranes in the Upper Cervical SpineJournal of Neurotrauma, Vol. 22, No. 4, 2005, pp. 466-475
  • “In the WAD patients, MRI lesions to the alar ligaments showed the most consistent association to the reported pain and disability. Lesions to other structures often occurred in combination with lesions to the alar ligaments.  Lesions to the transverse ligament and to the posterior atlanto-occipital membrane also appeared to be related to the NDI score.”
Krakenes J and Kaale BR.  Magnetic Resonance Imaging Assessment of Craniovertebral Ligaments and Membranes After Whiplash Trauma.  Spine Vol. 31, No. 24, pp 2820-2826
  • “The number of high-grade changes in whiplash patients compared with noninjured individuals indicates that these lesions are indeed caused by a whiplash trauma...Our findings add support to the hypothesis that injured soft tissue structures in the upper cervical spine, particularly the alar ligaments, play an important role in the understanding of the chronic whiplash syndrome.”
Krakenes J, Kaale BR, et al.  MRI of the Tectorial and Posterior Atlanto-Occipital Membranes in the Late Stage of Whiplash Injury.  Neuroradiology (2003) 45:  585-591
  • “This study strongly indicates that whiplash trauma can damage the tectorial and posterior atlanto-occipital membranes; this can be shown on high resolution MRI.”
Kaale BR, Krakenes J. et al.  Head Position and Impact Direction in Whiplash Injuries:  Associations with MRI-Verified Lesions of Ligaments and Membranes in the Upper Cervical SpineJournal of Neurotrauma, Vol. 22, Number 11, 2005
  • “The difference in MRI-verified lesions between WAD patients and control persons, and in particular the association with head position and impact direction at time of accident, indicate that these lesions (to the alar, transverse, tectorial, and posterior atlanto-occipital membrane) are caused by the whiplash trauma.”

  1. Recently published literature:
Lindgren KA, Kettunen JA, Paatelma M, and Mikkonen, RHM.  Dynamic Kine Magnetic Resonance Imaging in Whiplash Patients and in Age- and Sex-matched Controls.  Pain Res Manage 2009;14(6):427-432
  • 25 whiplash trauma patients with longstanding pain, limb symptoms and loss of balance indicating a problem at the level of C0-C2, as well as matched healthy controls were imaged using dMRI.
  • Coronal T2, PD weighted, and FSE axial sequences were used.
  • A physiotherapist performed the bending and rotation of the upper cervical spine for the subjects to ensure that the movements were limited to the C0-C2 level.
  • The signal from the alar ligaments was abnormal in 92% of the patients and in 24% of the control subjects.
  • Abnormal movements at the level of C1-C2 were more common in whiplash patients than in controls (56% vs. 20%).
Smith FW and Dworkin JS (ed). The Craniocervical Syndrome and MRI, Chapter 2, by Franck JI and Perrin P. “The Cranial Cervical Syndrome Defined:  New Hope for Postwhiplash Migraine Headache Patients- Cervical Digital Motion X-Ray, FONAR Upright Weight-Bearing Multi-Position MRI and Minimally Invasive C1-C2 Transarticular Lag Screw Fixation Fusion.”  Basel, Karger, 2015, pp. 9-21
  • "The essential radiological feature of the CCS is lateral C1-C2 ligamentous instability. Easily detected utilizing DMX, all patients underwent this low-radiation, portable, 15 minute, video-fluoroscopic exam of cervical motion in all axes, including open-mouth, odontoid, coronal lateral flexion-extension views."
  • Postwhiplash headache of migraine intensity
  • Neck pain
  • Difficulty with concentration and focus
  • Diminished memory
  • Tinnitus
  • Ataxia
  • Nausea/vomiting
  • Autonomic disturbances
  • Paresthesia
  • Weakness
  • Chronic pain
Steilen D, Hauser R, et al.  Chronic Neck Pain:  Making the Connection Between Capsular Ligament Laxity and Cervical Instability.  The Open Orthopedics Journal, 2014, 8, 326-345The following chart is taken from the text of the article, and it describes how the cervicocranial syndrome has been present in the literature for decades, but under different, unrelated names, which have existed as separate entities- until now.  All of them feature subfailure of the upper cervical ligaments, and the different authors describe numerous similarities in symptoms.

Radiology for Motor Vehicle Injuries

X-Rays after a Car Accident

The chiropractic profession has advanced degrees available for anyone who wants to specialize.  We have neurologists, radiologists, pediatricians, internists, sports injury-ists- you name it, we have it.  All of these degrees require 300 hours of class time and passing grades on tests, with a final comprehensive test with which the degree is conferred.  My experience with those who have the advanced degrees is that they are cut above those who don’t have the degrees.  The diplomate degrees are earned by those who are true knowledge seekers who are in sharp contrast to the DC’s who feel that the state board’s 12 hour requirement for continuing education is a real burden that they would like to avoid.  To each his own, I say, because when I got out of school, I was one of the latter, as I had no time or inclination to go to more school.  But as time goes on, we all change, and five years ago, when I got my digital motion x-ray machine, I soon realized how woefully inadequate my training in personal injury was to that point.  I was being asked questions I couldn’t answer, and that stimulated me to start attending seminars taught by guys like Malik Slosberg, Larry Nordhoff, and Art Croft, all of whom are masters of the medical literature, which made me start to read the literature, and expand my education.  The outcome of all that has been the organizing of all the accumulated information into a continuing education seminar of my own, which is constantly changing as I read new stuff.  But that’s not really the point of this article.The real point of this article is that I just attended a great seminar this weekend, the fourth in the series put on by Dr. Gallagher’s American Academy of Motor Vehicle Injuries, one that taught me some new things, but also made me wish that everyone I know had been there.  It was entitled “Radiology for Motor Vehicle Collisions,” taught by medical radiologists from Elite Rad, a Florida based group of radiologists who really get personal injury.  They are headed up by Sean Mahan, MD, who along with Jay Cavanagh, MD, and Avery Knapp, MD, presented the seminar.   The seminar was sponsored by SimonMed, with whom I have had a confusing relationship over the past five years.  I haven’t found them to be particularly cooperative when it comes to doing custom MRI’s, nor have I found their neuroradiologists to be particularly competent when it comes to reading for ligament damage in the upper cervical spine.   And this has been a real problem for me, as one of the major obstacles I have had since I got into digital motion radiology has been the need for medical validation of my findings.  I’m not a board certified radiologist, though I have found my niche and have become reasonably well educated and conversant in the literature regarding motion x-ray, but in the minds of attorneys and the lay public who make up juries, any ol’ medical radiologist is better than me, even when they have absolutely no training in human biomechanics and x-rays that won’t sit still.   I was aware that for some time now SimonMed has been attempting to position themselves as the “go to” diagnostic facility for personal injury in our area, and admittedly was skeptical of their ability to do so, but I really didn’t understand what they were doing.Now I get it.  Elite Rad (www.eliterad.com) is a business separate from SimonMed, based in Florida, which has contracted with SimonMed to do diagnostic readings for personal injury cases.  All of the radiologists have been trained by Dr. Mahan, so they all read the same way, or they get yelled at.  They convinced me this weekend that they understand alar/accessory ligament tears, transverse ligament tears, anterolisthesis/retrolisthesis, and  interspinous ligament tears, and will write reports which will tell the truth and attest to the true state of our patients’ injuries.  Let’s face it:  not all radiologists are created equal.  If you put thirty radiologists at random in a room, I guarantee you that there are one or two who are head and shoulders above the crowd.  The radiologists at Elite Rad specialize in reading musculoskeletal studies, and when you do that all day long, every day, you get darn good at it.  One of the advantages SimonMed has had all along is that they are the only diagnostic facility locally which is willing to work on an attorney’s lien in a personal injury case, so when you refer to SimonMed, you specify that you want an Elite Rad radiologist to read the study.  In our age of the internet and teleradiology, it really doesn’t matter where geographically the radiologist is when the study is read.So this is what you do.  Get the latest prescription form for diagnostic studies from your SimonMed representative.  If you are ordering the MRI because I just did a digital motion x-ray on your patient and recommended that you follow up with the MRI, indicate on the form that you want the alar ligament protocol followed.  Write a short letter indicating the medical necessity for the study, and also include pertinent history information which will help guide the radiologists as to where to look.  When you fill it out, indicate on the form that the patient is a personal injury patient, and request that one of the Elite Rad radiologists read the study.  The Elite Rad radiologists are:Sean Mahan, MD; Avery Knapp, MD; Jay Kavanagh, MD; Andrew Akerman, MD; Jonathon Eugenio, MD; Robert Hardage, MD; and Valerie Eckard, MD.Drs. Knapp and Kavanagh are also licensed in Arizona, which is a medicolegal plus, and in addition to reading all standard plain films and MRI’s,  I gathered that they are reading the newest, most specialized studies, including MRI-DTI and MRI-SWI, both of which have applications for our concussed patients.If you have ordered an MRI from a different MRI facility, and gotten an inadequate report, Elite Rad will also over-read and give you a second opinion.   Elite Rad is willing to stand behind their work, and will make themselves available for depositions, arbitrations, and court hearings, whether by video testimony or in-person testimony.  Attorneys should contact Elite Rad Radiology Services  (5840 Red Bug Lake Road, Suite 185, Winter Springs, FL  32708; 1-407-699-1100) for details.

Pre-Existing Degenerative Conditions

Pre-Existing Degenerative Conditions

We all know that it’s difficult to find a human being over the age of 40 who is in your office complaining of neck pain, who, when an x-ray is taken, won’t be found with some degree of degenerative change.   If they are unlucky enough to be injured in an auto collision, and the x-rays are taken as a result of that, then the insurance company which accepts responsibility for the injuries will more than likely try to blame all of the symptoms on the “pre-existing condition.”  Let’s face it:  when it comes right down to it, auto insurance companies don’t want to pay for anything.  A perfect world for them would be one in which they collect monthly premium payments from all of their insured, and no one is involved in any auto collisions, so there are no claims, so they can take that money and invest it and make more money, and keep their shareholders (not their policy holders!) and senior executives happy with dividend payments and lucrative golden umbrellas.  But because some people are rude enough to drive their cars into other people’s cars, claims are made, and their perfect world is shattered, and that’s why we doctors have to fight so hard to get paid for the good work we do.  It shouldn’t be that way.The bottom line is that pre-existing degenerative change in our car crash patient’s spines should not be a factor which weakens the case, but should in fact strengthen the case.  Attached to this letter is a short article written by attorney Matt Powell of Tampa, Florida, entitled, “Pre-Existing Claims and Why They Increase the Value of an Injury Claim,” which appeared in the January 2010 issue of the American Journal of Clinical Chiropractic, which is a publication of the Chiropractic Biophysics technique organization.  In the article, he describes why he thinks pre-existing degeneration is a good thing for his case, and how he uses it in trial.   Now, I am acquainted with Matt Powell via my association with the digital motion x-ray people, and I know that he is an attorney who has taken it upon himself to learn about  and become conversant about the pathology of damaged ligaments and the diagnostic imaging protocols necessary in order to document their presence objectively.  Do yourself a favor and go to his website (www.mattlaw.com)  and take a look at all the professionally produced video material he makes available to anyone who wants to use it- free of charge- and begin to use it yourself.Too often, I have been in conversations with attorneys who bring up things like the pre-existing degenerative changes- because it has been a point of contention with the defense- and have already taken the “glass half-empty” route, and are ready to surrender and accept a crappy settlement.   But knowledge is power.  You can turn this situation into a “glass half-full” scenario really easily, if you just take the time to educate yourself about the facts concerning pre-existing degenerative conditions and accident injuries.I always tell people that the literature is loaded with medical articles which establish the fact- THE FACT- that those who enter into a motor vehicle collision with pre-existing pathology will be injured more seriously than those who are disease-free.  By pre-existing pathology, I mean to include the following conditions:
  1. Degenerative joint changes;
  2. Disc bulges/herniations;
  3. Genetic conditions (Klippel-Feil syndrome, congenital fusions);
  4. Nutritional disorders (anemia, stomach stapling);
  5. Endocrine conditions (diabetes, hypothyroidism);
  6. Spondylolisthesis, DJD, stenosis (both neural and central canal), scoliosis, kyphosis;
  7. Myofascial disorders;
  8. Previous spinal surgery.
Doctors, just take a little time with each of these and think them through, and you will see the rationale behind the inclusion of each of these.  But the most obvious one we have to deal with is number 6.  Consider the following literature references as ammunition for supporting your claim that your patient with the arthritic neck really got the short end of the stick when they got rear-ended.Mackay, M.  Biomechanics and the Regulation of Vehicle Crash Performance.  AAAM, 1989:323-36.  Accident Research Unit, University of Birmingham, UK.   “AAAM” is the acronym for Association for the Advancement of Automotive Medicine (www.aaam.org or www.carcrash.org), which is one of several organizations which have been set up, and are funded by, of all people, the insurance industry.  So it’s not like they don’t know that information like this exists (and in this case, since 1989), which is contradictory to what they claim to be true when they go to court.To quote Dr. Mackay, “Corridors for acceptable combinations of forces which the neck, perhaps more than any other body region, exhibits age and disease effects which must profoundly influence the nature and level of tolerable applied force.  The loss of elasticity of ligamentous structures and reduced disc spaces of themselves must alter greatly the mechanical response of the spine to certain loads and motions, which will result in great variation in tolerance to injury.  Clinically documented cases are reported of serious neck injuries occurring under extremely low severity conditions usually where some prior medical condition was present.”  To put that into English, he means that pre-existing degeneration greatly reduces the toleration of force, and makes it much easier to be injured in a car crash.Pike JA.  Neck Injury:  The Use of X-Rays, CT’s, and MRI’s to Study Crash-Related Injury Mechanisms.  SAE, R-628, 2002, page 140.  SAE is the acronym for Society of Automotive Engineers, and is also funded by the insurance industry.  In the section entitled, “Injuries Subsequent to Pre-Existing Conditions,”  Dr. Pike notes that “an individual with pre-existing pathology involving the cervical spine is at greater risk for sustaining injury to the neck in a motor vehicle crash.  Any condition resulting in compromise of the structural integrity of the spine, such as osteoporosis or arthritis, increases the risk of trauma to the bone and soft tissue structures of the neck.  Furthermore, congenital or chronic narrowing of the spinal canal (spinal stenosis) as seen in cervical spondylosis, predisposes the person to associated spinal cord injury in the event of a neck injury.”  I don’t think this statement requires any translation into English.  It’s pretty clear.Dang AB, et al.  Biomechanics of the Anterior Longitudinal Ligament During 8g Whiplash Simulation Following Single- and Contiguous Two-Level Fusion:  A Finite Element Study.  Spine, 2008;33(6):607-11.  Using cadaver spines, the authors simulated the whiplash event with a considerable 8g force (but this is not unreasonable, because remember, Dr. Croft’s live person whiplash simulations regularly measured between 9-12 g’s generated by crashes under 10 mph) and measured the forces which had to be absorbed by the anterior longitudinal ligament at the spinal levels adjacent to the fusion, both above and below.  For a single level fusion, the load was increased 15.5%, and for a two-level fusion, the load was increased by 40.8%.  It has been a long established principle of spinal biomechanics that when a segment is fixated, the levels above and below the fixation will be forced to take over whatever motion has been lost, and will therefore be subjected to more wear and tear in the future.  This study establishes that fact in the case of spinal fusion, whether the fusion is congenital or acquired.   Once again, the potential for harm increases for the pathologically challenged automobile driver!Tominaga, Y., Ndu, AB, Coe MP, Valenson, AJ, Ivancic, PC, Shigeki, I., and Panjabi, MM.  Neck Ligament Strength is Decreased Following Whiplash Trauma.  BMC Musculoskeletal Disorders 2006;7:103.  In this study, the authors used cadaver cervical spines which had been subjected to whiplash, and compared their ligaments’ elastic properties to healthy uninjured ligaments.  All of the whiplash-exposed ligaments were found to be significantly weaker than their healthy counterparts, and unable to stabilize properly their respective joints.  The ligaments included in the study were the anterior  longitudinal ligament, the posterior longitudinal ligament, the facet capsular ligaments, the interspinous and supraspinous ligaments, the middle third of the disc, and the ligamentum flavum.Another long held principle concerning ligament injury is that injured ligaments don’t heal, at least not in the generally accepted meaning of the word “heal.”  Healing comes from the word “health,” and the use of the term implies that an injured tissue can put itself back together to the point at which it is as good as new, or that it can improve to the point that it is just as it was before the injury occurred.  When ligaments are injured, it is done by stretching them past their resting length.  At 3-4% of their resting length, they are permanently injured, and at 8% of their resting length, the collagen fibers are disrupted and broken.  A stretched out ligament is never able to regain its original length, and is increasingly vulnerable to future insult.  That’s why we know as clinicians that our patients who are involved in a second car crash will most likely be injured worse than they were the first time.Counselor Powell makes this point about what the law says:“If the patient’s injury (from the new car crash) resulted from an aggravation of an existing injury or disease (such as degenerative changes), the jury should attempt to determine what portion of the patient’s condition was caused by the car crash. If the jury cannot determine what new damages were caused by the crash, then the jury is told to award damages for the entire condition.”But it looks to me like someone should find out, and if it’s the same, or similar, then all of those arthritic car crash victims should get a new lease on legal life, because when it comes to pre-existing degeneration, the glass is not half-empty, nor is it half-full-  it’s full.  It will all be decided in the legal arena, and it will all come down to the litigation skills of the attorney.  Knowledge is power.  You cannot defend what you don’t understand.  All it takes is to get educated.And doctors, remember, that if you don’t document the presence of degenerative problems in your case notes, then all of the above discussion is for naught.  You must correlate real life facts to the case.  For example, endocrine conditions such as diabetes mellitus may cause peripheral nerves to be more prone to injury and slower healing.  Just because the patient is diabetic does not mean that they have impaired healing.  Many diabetics are under control with diet and medication and have normal healing responses.  But if you feel that a condition has complicated the case, make a big deal of it in your notes.  It’s a common sense issue.

Craniocervical Syndrome and MRI

Craniocervical Syndrome

I have a friend who practices on the south side of Tucson who does a lot of personal injury work and takes his own x-rays at this office.  He regularly sends them out to a DACBR for a reading.  My friend has had me do about ten DMX studies on his patients over the years, and on probably eight or nine of those studies, I have identified laterolisthesis of C1 on C2, which is indicative of alar and accessory ligament damage.  The DACBR he has been using for his films has told him on a number of occasions that lateral overhang of C1 on C2 with lateral flexion (side bending) is a normal finding.  If you have ever seen one of my alar-accessory ligament damage addendums, or if you have been to my seminar and seen my presentation on alar and accessory ligament damage, you know that I present compelling evidence from the literature which supports why I say what I do about these ligaments- that lateral overhang of C1 on C2 is definitely abnormal.In fact, it’s not just my friend’s DACBR, it’s just about every radiologist, neurologist, and neurosurgeon I have had the occasion to speak with about this lateral instability at C1-C2, who considers it not worth mentioning.  In fact, a couple of years ago, I took Arthur Croft’s series of four seminars in Newport Beach, CA, and when it came time to address alar ligament damage, he stated that he thought that some doctors (which I guess would include me) are just too hypersensitive about alar ligament damage.  He said that he thought that cervical DMX studies were overused and over-read.   I hadn’t been doing DMX studies for very long, and the main reason I went to his seminars was because he was The Man when it comes to whiplash, and I don’t think many people challenge Art Croft when it comes to the whole field of inquiry.   Because I was still just learning, I didn’t say anything.But I have learned a whole lot about the field of motion x-ray since then, and the fact of the matter is that he is wrong when it comes to the importance of alar and accessory ligament damage when it comes to car crash cases.  Besides the fact that the literature is loaded with articles attesting to the problems associated with alar ligament damage, a new book just became available within the past month which makes the strongest statements I have ever seen about the nature of the alar ligament lesions, and also addresses solutions for the problem.The book is entitled, The Craniocervical Syndrome and MRI, and is edited by Francis W. Smith, PhD, and Jay S. Dworkin, MD.  Of particular interest to me is the second chapter because it was authored by Joel Franck, MD, the prominent Panama City, FL, neurosurgeon, who has come up with a minimally invasive (for surgery), novel way to repair the damage to the C1-C2 level.  The chapter is entitled, “The Cranial Cervical Syndrome Defined:  New Hope for Postwhiplash Migraine Headache Patients- Cervical Digital Motion X-Ray, FONAR Upright Weight-Bearing Multi-Position MRI and Minimally Invasive C1-C2 Transarticular Lag Screw Fixation Fusion.”High points from the chapter:
  1. It is a retrospective study of 39 patients who sustained cervical whiplash injuries, and manifested the essential symptom of “postwhiplash migraine headaches” in association with neck pain.  Most of the patients also exhibited other, seemingly unrelated symptoms including difficulty with concentrating and focusing, diminished memory, visual disturbances, tinnitus, ataxia, nausea and vomiting, autonomic disturbances, paresthesias, and weakness.  Nearly all of the patients had been all over the country consulting with all types of providers, with no relief, only to be labeled as “dysfunctional,” “histrionic,” “malingering,” or “just plain nuts.”  The average interval from the date of the car crash to the date of the surgery was 928 days.
  2. “The essential radiological feature of the cranial cervical syndrome (CCS) is lateral C1-C2 ligamentous instability,” which was detected on all patients using cervical DMX. Franck considered any laterolisthesis exceeding 2 mm. (as measured with DMX caliper software, which means that there is no adjustment for magnification) to be clinically significant.   For four years now I have been seeing on a regular basis that this is a common occurrence as a result of the whiplash event.
  3. The average measured overhang for left lateral flexion was 4.62 mm., with a range of 0-8 mm., and for right lateral flexion was 4.6 mm., with a range of 0-7 mm.
  4. The upright FONAR MRI was used as a complement to the DMX findings by visualizing the two alar ligaments and the transverse ligament using proton density sequences so that ligamentous edema and overt tears, and Chiari type 0-1 syndrome, a pathology which has important implications for the clinical expression of CCS, could be demonstrated.
  5. 34 of the 39 patients underwent the positional MRI study and Dr. Franck found that 25 (73.5%) had verified alar ligament tears. 16 had transverse ligament tears (47%).
  6. The solution for the C1-C2 instability is a procedure which involves a combination of a 3-D CT scan interfaced with a computer via an infrared camera which senses the position of specialized metallic balls placed into the surgical wound and the surgeon’s instruments, and hence the position of the patient in the room, making perfect placement of two pedicle screws through the lateral masses of C2 and into the lateral masses of C1 possible, and thereby eliminating the instability. The technology is called STEALTH Navigation, and for more information on that, you really need to read the chapter.  A 20 minute video of the highlights of one of his surgeries can be seen on YouTube- just do a search for “Joel Franck, MD,” and left click on the presentation he did at the Cranio-Cervical Symposium in 2012.  The most impressive part of the video comes when he grabs the posterior tubercle of exposed atlas with a forceps and wiggles it show how unstable the segment is, and then, after the screws are in place, he grabs it again and tries to wiggle it, and can’t, because it is no longer loose.
  7. All 39 patients underwent the C1-C2 transarticular fixation fusion, and 12 of them also underwent suboccipital cranioectomies (for the Chiari malformation).
  8. Six weeks after the surgery, the headache intensity was reduced by 96%, the neck pain was reduced by 86%, and the radiculomyelopathic complaints were reduced by 89%. Come on- when have you heard of that degree of success with a surgery?
  9. Complications were very few, mainly along the lines of infection, all of which resolved with antibiotics.
 Dr. Franck calls the headaches “postwhiplash migraines” because migraine headaches are vascular headaches.  Because the vertebral arteries go just superior to the arch of C1 before entering the foramen magnum, the side to side movement of the atlas irritates the vertebral artery by inducing repeated stretching.  He goes on to explain that the transient vertebral artery traction and compression may be causing the equivalent of transient ischemia to parts of the brainstem, cerebellum, and cerebral cortex.  And with the stabilization of the C1-C2 motion segment, the repeated stretching of the vertebral arteries is eliminated immediately.All but one of the patients involved in the study was injured in an auto crash.  The one exception was a 49 year old female who had a lifelong history of common migraine headaches, with no history of trauma, who had undergone a C5-C6 fusion surgery previously (which provided no relief for her headaches), and originally underwent the cervical DMX study to evaluate the fusion.  She was found on the study to have C1-C2 ligamentous instability, averaging 4.5 mm. bilaterally, and she requested that the transarticular fusion surgery be done.  What’s really interesting about her case is that she also underwent the FONAR upright MRI study as well, and no evidence of alar or transverse ligament damage could be found.  But four months after the surgery, she had no headaches, and near resolution of her neck pain.  Previously, she was having two headaches daily, which she rated as 10 on a pain scale of 10.  You can’t call that living- that’s called barely surviving.There’s more to this, but if I write any more, I’ll just be copying Dr. Franck’s chapter for you.  I wish Dr. Franck practiced here, as I have several patients whom I have not been able to persuade to go to Florida and end their pain.  One of the things we know about pain is that the longer it persists, the harder it is to get rid of.   In neurology, the law of facilitation tells us that the more often a message travels over a set of synapses, the easier it gets to propagate the signal.  This applies not to just motor learning, but also to the transmission of pain messages.  And we know that chronic pain can actually cause changes- permanent changes- in the central nervous system, so that even after a corrective procedure has been done, the pain might not go away.  But the fact that for most of Dr. Franck’s patients, 928 days passed before they were fixed means that there is hope for those who have this problem.  At this time, there are no neurosurgeons in our area who perform this type of surgery.  If you have patients who have lateral instability at C1-C2, killer headaches, and neck pain that won’t quit, right now he is your best option.  If a patient comes to you who has been everywhere else, spending thousands of dollars trying to find someone to help them, send them to Dr. Franck.  It’ll be their last stop (I mean that in a good way).Joel Franck, MD can be reached at the Bay Neurosurgical & Spinal Institute, 801 E. 6th St., Ste. 302, Panama City, FL  32401.  The clinic phone number is (850)914-7040. 

Using Dislocation Codes

Dislocation Codes

When it comes to the kind of devastating trauma which whiplash causes to the ligaments of the cervical spine, don’t let the insurance companies off the hook by using the equivalents of diagnoses which they have trained their people to ignore, such as the chiropractic subluxation codes (which the value drivers list ranks between a scrape and a bruise) or the general sprain codes, 847.0, 847.1, and 847.2.  The insurance companies will give their equivalents no more respect than they gave these codes, so why use them?   There are much better codes to use which do a much better job of conveying the severity of the injuries.Use the M codes for Medicare, as they are intended to be used.  For all other insurance companies, especially including the auto insurance companies, use the S codes whenever possible, as they are intended to convey information concerning trauma.If you were at my seminar, I presented the ICD-10-CM conversions for the ICD-9-CM codes I have been using up until now.  Here they are again.  First, the old codes:
  • 847.0   Cervical Sprain/Strain
  • 847.2 Lumbar Sprain/Strain
  • 728.4  Laxity of Ligament
  • 738.2 Acquired deformity of the cervical spine
  • 728.5 Hypermobility syndrome of the cervical spine
  • 718.88  Instability of joint, vertebrae
  • 738.4 Acquired spondylolisthesis
  • 723.2  Cervicocranial syndrome
The new codes:
  • 728.4= M24.20 Disorder of ligament, unspecified site
  • 738.2=  M95.3  Acquired deformity of the neck
  • 728.5= M35.7  Hypermobility syndrome
  • 718.88= M24.8  Other specific joint derangements of unspecified joint, not elsewhere classified
  • 738.4= M43.00  Spondylolisthesis, site unspecified, or M43.10  Spondylolisthesis, site unspecified
  • 723.2= M53.0 Cervicocranial syndrome
 The old sprain/strain codes for the cervical spine were always pretty disappointing.  When I heard that there was going to be a new system in place with five times more codes than the original, what I was hoping to see was separate and very specific codes for each of the cervical ligaments, i.e. a code for the left alar ligament, a code for the right alar ligament, a code for the anterior longitudinal ligament specific for the C5-C6 level, and a separate code for the anterior longitudinal ligament for the C3-C4 level, etc.  Well, that didn’t happen.  While there is one code (M48.32) that I found which is specific for the “interspinous ligament, traumatic, cervical region,” the root code “S13.4…” is meant to be “all inclusive for anterior longitudinal ligament, atlas ligaments, atlanto-axial, atlanto-occipital, and whiplash disorder.”  So much for exact specificity, right?  The correct way to use the S13.4 code is as follows:0 = S13.4XXA Sprain of ligaments of cervical spine, initial encounter-or-S13.8XXA  Sprain of joints and ligaments or other parts of neck, initial encounter;847.1= S23.3XXA  Sprain of ligaments of thoracic spine, initial encounter,-or-S23.8XXA  Sprain of other specified parts of thorax, initial encounter;847.2= S33.5XXA  Sprain of ligaments of lumbar spine, initial encounter.See what I mean?  You end up using the equivalent of the old sprain/strain codes even though the DMX study you ordered showed you definite, objective proof of demonstrable damage to very specific ligaments in the cervical spine.Like Captain Binghampton in McHale’s Navy, whenever McHale and the boys of the PT 73 used to out-fox him, used to say, “I could just scream.”But, I found a solution to this whole mess, so let me explain it to you.Over a hundred years, the original chiropractors stole the word “subluxation” from the medical dictionary and gave it a new meaning, and used it and used it until they owned it.  They used it to describe a vertebra which had lost its correct anatomical alignment and was pinching on a spinal nerve- the ol’ bone out of place scenario.  What the word means in its medical context is very interesting, especially in relation to our current situation.  Dorland’s Medical Dictionary defines “subluxation” as an “incomplete or partial dislocation.”  A dislocation is a dislocation, whether it is partial, incomplete, or complete, and certain things are implied when the word is used.  It means that two adjacent joint surfaces have lost their anatomical alignment, and this can only occur when the ligaments, which gives the ultimate integrity and stability to the joint, have been disrupted by being stretched beyond their elastic ligaments.  The damage to the ligaments is permanent, and they will never regain their original resting length.  Blood vessels which service the ligament, and the surrounding muscle, are also torn, so there is internal bleeding, or hemorrhage.  The resulting inflammation is painful, and results in myospasm in the short term, and scar tissue invasion in the long term.  The joint is forever changed.  That’s why Krakenes stated, “Lateral shift of the atlas on the axis greater than 1.7 mm. is considered subluxation and associated with poor prognosis for whiplash injury.” (Krakenes J., Kaale, BR, Moen G, Nordli H, Gilhus, NE, Rorvik J.  MRI Assessment of the Alar ligaments in the Late Stage of Whiplash Injury- Structural Abnormalities and Observer Agreement.  Neuroradiology 2002, July:44(7);617-24).  There is no doubt that Dr. Krakenes was using the word “subluxation” in its medical sense, and not in the chiropractic sense.In the insurance industry’s Colossus system, and other systems, dislocation is given a great deal of weight.  It ranks tenth on the scale of twelve, with twelve being the greatest degree of injury.INJURY TYPES IN ORDER OF WEIGHTED VALUE (from low to high)
  1. Superficial (Pain)
  2. Abrasion
  3. Chiropractic subluxation
  4. Contusion
  5. Sprain/Strain (Spine)
  6. Ligament/Tendon (Extremities)
  7. Laceration
  8. Crush/Extensive soft tissue/De-Gloving
  9. Bulge/Prolapsed discs/Herniated discs
  10. Dislocation (CCS)
  11. Fracture
  12. Penetrating wound
Notice that #5 and #6 specifically describe ligament injuries, which gives those injuries more weight, but it is still only in the mid-range.  But at #10, there sits dislocation.  And as has already been stated, you cannot have dislocation without ligament injury- in fact, it is the injuries to the ligaments that the term “dislocation” describes.  Note that I placed “CCS” in parentheses next to dislocation, because I want to emphasize that Craniocervical Syndrome (aka cervicocranial syndrome, it really doesn’t matter which part of the word comes first, it’s all the same thing) is probably the most egregious example of the results of ligament subfailure, and the sloppy instability it causes.  One diagnosis you should use whenever it applies is M53.20:  The Cervicocranial Syndrome.  If you didn’t get my write up about Joel Franck, MD, in Newsletter #4, about the incredible transarticular fusion surgery he does to correct C1-C2 lateral instability, please let me know, and I will send it to you.With that in mind, let’s call these injuries to the cervical spine which are most commonly caused by auto collisions what they are- dislocations!  What’s really cool about this is that the new ICD-10-CM system gives a series of dislocation codes which are specific to each cervical and lumbar level:
  • S13.111A  Dislocation of C0/C1 vertebrae, initial encounter
  • S13.121A  Dislocation of C1/C2 vertebrae, initial encounter
  • S13.131A  Dislocation of C2/C3 vertebrae, initial encounter
  • S13.141A  Dislocation of C3/C4 vertebrae, initial encounter
  • S13.151A  Dislocation of C4/C5 vertebrae, initial encounter
  • S13.161A  Dislocation of C5/C6 vertebrae, initial encounter
  • S13.171A  Dislocation of C6/C7 vertebrae, initial encounter
  • S13.181A  Dislocation of C7/T1 vertebrae, initial encounter
  • S33.101A Dislocation of unspecified lumbar vertebra, initial encounter
  • S33.111A Dislocation of L1/L2 vertebrae, initial encounter
  • S33.121A Dislocation of L2/L3 vertebrae, initial encounter
  • S33.131A Dislocation of L3/L4 vertebrae, initial encounter
  • S33.141A Dislocation of L4/L5 vertebrae, initial encounter
It should go without saying that if you use these codes, you should have a working familiarity with the ligamentous anatomy at the level you use, so that you can defend your choice of coding.And, remember, you can’t use these codes unless you can provide objective proof of the injury, and the DMX study is the only way you can do it.   I’m sure that there some naysayers out there who would like to argue that the dislocation code for the subaxial joints is only for a situation like perched facets, or the C0-C2 codes are only for injuries like a vertical dislocation of C1 on C2, or a complete failure of the transverse ligament leading to a pathological change in the atlanto-dental interval, but I beg to differ.  The situations I just described are best referred to as “luxations,” which means a complete loss of congruence of adjacent joint surfaces, and are far more serious than subluxations (in the medical sense).  But if you really look at the reality of what happens when there is a laterolisthesis of C1 on C2, or anterolisthesis/retrolisthesis from C2-T1, you will have to come to the conclusion that these injuries fit the definition of medical subluxation.  Yes, I know that there are subluxation codes which are very much like the dislocation codes, and they are meant to describe hypermobility, but when ligaments are subjected to subfailure, let’s call it what is- dislocation. (I don’t think that the writers of the codes had a solid understanding of the nature of the injuries.  I mean, after all, there is a code for “cervical disc displacement, high cervical spine,” an area which does not have discs).  Otherwise, the Colossus system, and other systems like it, will continue to downgrade our diagnoses and give them short shrift.  Let me be clear- our patients who have been injured in motor vehicle collisions have been under-diagnosed for far too long.  A diagnosis code which does not convey the true severity of their injuries is not a diagnosis code you should be using.If you refer a patient to me for a cervical DMX study, and you use the S13.4 series codes on the medical necessity form, I want you to know that after I read the film and write the report, and document anterolisthesis/retrolisthesis/laterolisthesis in excess of 20%, the insurance claim form I fill out will list these injuries as dislocations.  When you get my report, make sure that you comment on this in your notes, and then adjust your coding accordingly in your billing software.   Remember, if it’s not found in your medical notes, it doesn’t exist.
Email Us For a Response

How Can We Help?

Bold labels are required.

Contact Information
disclaimer.

The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.

close

Privacy Policy

Lara Law Firm

Tucson Office
177 N. Church Ave.
Ste. 909
Tucson, AZ 85701

Phone: 520-276-4727
Phone: 520-577-0707
Fax: 520-577-0709
Tucson Law Office Map

Tucson Office
5151 E. Broadway Blvd.
Ste. 1601
Tucson, AZ 85711

Phone: 520-210-4010
Fax: 520-577-0709
Map & Directions

Phoenix Office
2 N. Central Ave.
Ste. 1801
Phoenix, AZ 85004

Phone: 602-833-2343
Fax: 520-577-0709
Map & Directions