Introduction: Spinal Ligament injury is well documented to be one the most common injuries in a trauma. It is also well documented that,
depending upon the grade (seriousness) of the injury, they can take up to 2 years to heal and have different treatment protocols. Yet it seems
few doctors attempt to accurately grade the injury according to medical guidelines even where specific guidelines exist. The crude and varying
methods to assess the injury provided little consensus. This study shows that precise accurate grading of spinal ligament injury can be best
obtained by advanced computerized methods for measuring x-rays, while conforming to current AMA injury guidelines. One Hundred random
cases of spinal injury were assessed by usual visual inspection of stress x-rays by radiologists, then re-assessed by computer measurement.
Results: Significant spinal ligament injury was accurately revealed by computer measurement that was missed by the standard
radiological reads.
Conclusion: Assessing spinal ligament injury by computer measurement significantly improves diagnosis and grading of ligament injury.
Keywords: Spinal Ligament Injury; Intersegmental Motion Spinal insstability; Alteration of motion segment integrity (AOMSI)
Abbreviations: AMA: American Medical Association; AOMSI: Alteration of Motion Segment Integrity; CRMA: Computerized Radiographic
Mensuration Analysis
Introduction
While some patients recover uneventfully from a spine injury,
a significant number will have pain which may last indefinitely
[1,2]. The risk of developing chronic pain will be increased if
a physician is unable to find a physical cause of pain in these
patients [3,4]. X-ray, CT, and MRI scans are routinely ordered
to aid physicians in evaluating a patient, but these imaging
techniques are often unable to clearly show the real source of pain
adding uncertainty to what the correct diagnosis and ultimately
the proper course of treatment is [2].
After spinal trauma, the ligaments in the spine may be
damaged causing ligamentous instability resulting in abnormal
intersegmental motion. Excessive joint motion caused by
spinal ligament sprains is a cause of acute spine pain and is a
significant risk factor for developing chronic pain [5,6]. Serious
intersegmental motion problems are routinely missed in standard
X-ray and CT interpretations by board-certified radiologists. In a
related study showing the need to improve accuracy in current
radiologist’s reads, Taylor et al. [7] concluded that there is a need
to reduce the subjectivity of reading medical images and improve
agreement of the diagnosis between physicians [7]. They state,
“The study reinforces the need for radiologic specialists to reduce
missed diagnoses, misdiagnoses, and medico-legal complications" [7]. Spinal ligament injuries will remain problematic unless
findings can both be systemized and quantified in a consistent,
logical, and accurate manner.
The American Medical Association’s (AMA) Guides to the
Evaluation of Permanent Impairment [8] can be used as a reference
by providing a standardized, objective approach when evaluating
disability and impairment [8]. The “Spinal Injury Model” includes
a diagnosable condition of “joint laxity” called alteration of motion
segment integrity (AOMSI) where exact spinal radiographic
mensuration is used to identify the severity of joint instability.
This spinal impairment caused by spinal ligament injuries is
identified not through physical examination but by measuring
stress X-ray images (flexion and extension). Since this evaluation
uses standardized, objective radiographic mensuration criteria
and precisely measured stress X-rays, it produces an opportunity
to minimize the adversarial nature of the injury tort arena when
attempting to rule in or rule out AOMSI. When the provider feels
that there may have been a spinal ligament injury, AOMSI criteria
are used to rule in or out any spinal ligament injury by measuring
spinal radiographic hypermobility and are critical findings on all
spinal impairment examinations. Thus, the most precise image
measurement procedure is required to enable physicians to most
accurately diagnose and effectively treat patients with pain from
spinal ligament injuries.
Computerized Radiographic Mensuration Analysis (CRMA) is
an accepted procedure in the National Guidelines Clearinghouse
that can provide the most useful clinical information and can be
easily utilized to more accurately identify clinically significant
ligament instabilities. Information provided by CRMA can assist
doctors in determining more focused and effective treatment
plans by improving the understanding of the pain source in the
patient being treated and can significantly reduce the missed
diagnosis, misdiagnoses, and medico-legal complications
associated with this injury. In the study conducted by Taylor
et al. [9] they showed the effectiveness and reliability of an
intersegmental motion exam using plain radiographs when
combined with CRMA technology [9]. The physicians’ level of
agreement on the presence of spinal instability increased from
17% to 77% following minimal training with CRMA because it
dramatically increased their ability to locate abnormal spinal
motion [9].
The focus of the current experiment was to test a boardcertified
radiologist’s ability to identify the most serious levels of
ligament instability (joint laxity) in standard cervical and lumber
weight-bearing stress X-ray studies without the use of CRMA.
Case Selection
The purpose of this case selection process was to provide trauma cases that would normally be read by a radiologist. The cases of 100 patients who were previously sent to an outpatient imaging center for a requested CRMA intersegmental motion study were randomly selected from two outpatient medical imaging centers. In this experiment, 53 cervical and 47 lumbar cases were used. Besides having spine pain associated with a car accident, there was no other criteria required for a patient to be included in this study. There was no circumstance where a patient was ruled ineligible to be in this experiment.
Experimental Methods
To assess a physician’s ability to identify ratable amounts
of intersegmental motion in X-ray studies, the cases of trauma
patients were reviewed by a board-certified radiologist. The
X-ray studies provided contained the analysis of five view
cervical series or five view lumbar X-rays, which included both
flexion and extension films. The involvement in a motor vehicle
accident and associated pain was the only history supplied to the
radiologist. With this history, the radiologist was asked to use
all normally used methods to help determine abnormal spine
movements.
The measurements obtained by CRMA determined the
severity of the spinal unit’s motion according to the impairment
criteria established in the AMA 5th Edition guidelines. According
to the AMA 5th Edition guidelines, spinal instability is ratable
in the cervical spine when translation in one vertebra is larger
than 3.5mm or has angular motion greater than 11°. Ratable
impairment of the lumbar spine occurs when there is a translation
greater than 4.5mm in one vertebra on another or when angular
motion exceeds 15° at L1-2, L23,
or L3-4 levels, is greater than
20° at the L4-5 level, or is greater than 25° at the L5-S1 level. The findings determined by CRMA would eventually be used
to determine the accuracy of the physician’s ability to diagnose
spinal ligament injuries in stress X-rays.
Results
The board-certified radiologist’s reports of the selected X-ray
studies showed no studies having significant amounts of spinal
instability indicative of spinal ligament injuries. No findings of
abnormal joint play were found and no units of qualified AOMSI
integrity were reported.
However, CRMA determined from the same X-ray series
that there were a combined 199 motion units that showed
abnormal joint laxity in all 100 patients. In 24 patients, there was
a total of 29 findings, 22 cervical and 7 lumbar, of ratable spinal
motion abnormalities that exceeded the mensuration threshold
for AOMSI according to the widely accepted AMA 5th Edition
guidelines. Of the ratable cervical spine findings, 12 resulted from
excessive translation and 10 were due to angulation. There was
1 patient with 2 ratable cervical spine translation findings. There
were 2 patients with abnormal angular motion and translation
in the cervical spine. There were 2 ratable lumbar findings due
to translation and the other 5 were from excessive angulation.
There was 1 patient that had excessive lumbar translation and
angular motion present.
Discussion
This study was designed to test a radiologist’s ability to locate
spinal ligament injuries in trauma cases. Spinal ligament injuries
are an often overlooked physical cause of today’s well publicized
chronic spinal pain and impairment problem. According to
research, many patients with chronic spinal pain do not have
a pathoanatomic diagnosis, but rather have a diagnosis of nonspecific
mechanical neck or back pain [10].
Even with advanced and improved imaging technology, the
most problematic area in diagnosing ligamentous injuries is
the subjectivity of the imaging study professional read. Taylor
et al.’s [9] study showed that the subjectivity is so large that
one professional radiologist frequently says there is significant
pathology on the study while another report suggests that there is
nothing of any significance at all [9]. Without a separate specialty
analysis performed through CRNIA technology, these conditions
would have gone misdiagnosed or undiscovered.
All the different types of medical imaging techniques are
commonly accepted diagnostic procedures that have been
utilized for decades. Some have claimed that X-ray, CT, and MRI
scans are generally not useful in the evaluation of chronic low
back pain [2,11]. But this is because spinal ligament injuries are
mostly missed due to inadequate radiographic interpretation
[12,13]. When evaluating conditions causing spine pain, their
effectiveness is limited by how the image is assessed. These
imaging techniques often fail to identify any potential source of
pain or cause some gross abnormality, which is not actually the
cause of the patient’s pain, to be confused with the real source
of pain [14]. Intersegmental motion problems are missed by
radiologists because there is no way to accurately quantify
abnormal spinal motion in these cases by simply looking at films with the human eye which is a common practice today. Without
an intersegmental motion study via CRMA, plain radiographs
aren’t being used to their fullest potential when diagnosing spine
injuries.
Based on the current level of knowledge used in diagnosing
spinal ligament injuries today, there are no indications that any
other radiologist would have gotten any significantly different
results than the physician that was a part of this study. In
agreement with the results of Taylor et al.’s [9] study, there is
no evidence supporting that more or different radiologists
would have been able to accurately and consistently identify
spinal ligament injuries. The accuracy in diagnosing spinal
ligament injuries is just not feasible without the level of
precision computers can obtain in its measurements. Taylor et
al. [9] showed in their study that intersegmental joint laxity is
most accurately measured with the use of computer assisted
technology [9]. However, most radiologists do not have access to
CRMA technology that can assist them in diagnose severe levels
of joint laxity most accurately and consistently.
Conclusion
Even with guidelines already established, there is still no resolution of determining who is injured and to what level of severity. The obvious path to more effective treatment of spinal pain lies with improving the accuracy of diagnostic techniques. The understanding of AOMSI is of little value if the findings are inherently being missed in most if not all radiographic reads. The CRMA procedure offers a standardized spinal misalignment and intersegmental motion criteria for reporting AOMSI and other abnormal states of the spinal motion unit. CRMA also enables spinal ligament injuries to be reported in a manner that all professions can utilize for more accurate diagnosis and better treatment rationales. The margin of error in intersegmental motion measurement and the wide range of disagreement would be significantly reduced, allowing for a much more accurate assessment of the degree of spinal ligament injuries. Therefore, CRMA should be a critical tool used to rule in or rule out any patient suspected of having a spinal ligament injury that is causing impairment and either acute or chronic pain. This study shows the incredible need for a separate and distinct intersegmental motion study to be performed by an educated and trained board-certified radiologist using CRMA technology. A logical and systematic approach to a standardized spinal ligament evaluation procedure should include a separate CRMA procedure. No provider should be without this assessment. This line of study will require more research in the future, but CRMA technology can be used to reduce the number of patients with spinal ligament injuries that are undiagnosed or misdiagnosed.
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Figure 1: Clinical photographs for clinical scenario (age 18).
Figure 2: Radiograph for clinical scenario (age 18).
Figure 3: Study casts for clinical scenario (age 18).
Figure 4: Commonly used treatment options for clinical scenario (age 18).
Figure 5: Preferred treatment options for clinical scenario (age 18).
Table 1: Preferred treatment options for clinical scenario (age 18).