Rear-End Accidents at Moderate Speed
Injuries After a Rear-End Accident
Your client was rear-ended five months ago at moderate speed. She has been seen in the Emergency Room, by her PCP, by her chiropractor, by a physical therapist, and by a neurologist. Plain films and a cervical MRI revealed only minor information about her status, and she is telling you that in addition to frequent headaches and neck pain, her head still “doesn’t feel right,” and it’s affecting all aspects of her life. She’s been given a different story about her case at every step along the way, and she keeps saying, “I just wish I knew what’s wrong with me.”
Contrary to popular opinion, the ability of a spinal MRI to identify the degree of ligament damage in the neck is fairly limited. Fortunately, there is a diagnostic study available which can provide objective proof of permanent ligament injury in the spine. It’s called digital motion x-ray (DMX).
For decades now, we have known what happens at each joint, including the spinal joints, when a person moves. It’s pretty simple: Joints are formed when two bones come together. The bones are held in place by strong, non-elastic connective tissue structures called ligaments. When your clients are involved in car crashes, strong forces travel through their bodies and up the spine to the neck and head. The ligaments in the upper cervical spine are the most brittle ligaments in the body, and they were never meant to withstand these forces. As a result, they are abruptly stretched, and when they are stretched, they never regain their original length, so there is slack in the ligament, and now the joint is unstable. These are not “self-limiting injuries.” Because of the close proximity of the central nervous system- the brain stem and the spinal cord- this is absolutely critical to the health of the rest of the body. When bone bangs into spinal cord, bad things happen.
A DMX study records the motion of the spine as it moves in all directions, and what the interpreter looks for is unusual and excessive gapping between the bones, which indicates that the ligaments have been stretched out and injured. There are 22 major ligaments in the neck, and all of them can be visualized in this way. The medical literature is full of reference articles which address the abnormalities which can be found in ligaments. Ligaments have fairly specific pain referral patterns, and when a torn ligament is found which matches up with pain in a specific area, then a definite cause-and-effect relationship can be established.
While the DMX study is very good for identifying ligament injuries, it is useless for detecting injuries to the intervertebral disc. If damage to most of the ligaments at one level can be identified, then medical necessity for a cervical MRI can be established. It’s hard to believe that if serious trauma damages most of the ligaments at one spinal level, that the disc got away unscathed, because, after all, it’s actually just a highly specialized ligament. By the same token, the MRI is not capable of doing a credible job in detecting ligament injury. So the two diagnostic studies are not contradictory, but complementary.
Identifying ligamentous injury after a car accident
Identifying ligamentous injury is not only essential in formulating a patient’s correct diagnosis so that they can get proper treatment, it has the effect of increasing the cash value of a personal injury case. The computer programs used by the insurance industry (Colossus and its knock-offs) place a higher value on the diagnosis codes which describe ligament injury than they do for disc injury, and so does the universally accepted medicolegal textbook, the AMA Guide to Evaluation of Permanent Impairment, 6th Ed., in terms of impairment rating and resultant disability. This is not artificially inflating the case by manipulating the codes; rather, it is just a case of accurately presenting the truth concerning the severity of a person’s injuries. It is fair to say that before DMX studies were available, whiplash victims have been grossly under-diagnosed. About 1 million people get whiplashed each year in car crashes, and the most conservative estimates tells us that about 33% of them end up with chronic pain, despite their doctor’s best efforts. Most studies indicate that the percentage is a lot higher than that. And these people are your clients.