CASE REPORT: Identification and conservative management of traumatic cervical spine ligament damage AKA Alteration of Motion Segmental Integrity (AOMSI)
By Dallas Humble, DC
Abstract: This middle-aged male was injured in a vehicle collision causing him to sustain disc ligament injuries in the cervical spine. Diagnostic studies included physical examination, orthopedic and neurological testing, spinal X-Rays and Computerized Radiographic Mensuration Analysis (CRMA) with motion cervical radiographs. Typically, conservative care is initiated prior to interventional procedures, and this case study seeks to explore the proper identification of ligament laxity and usage of conservative therapy for the associated mechanical spine pain after failure of conventional procedures. He reported both short term and long-term success regarding pain reduction along with improvement in his activities of daily living after undergoing conservative chiropractic care and continued to report reduced pain scales into the immediate future. Key: Spinal X-Rays, CRMA (Computerized Radiographic Mensuration Analysis); PTSD (Post-traumatic stress disorder); PRN (as needed); VAS (visual analog scale); HVLA (high velocity low amplitude).
Introduction: The 56-year-old married male reports he was the seatbelt restrained driver of a vehicle that was traveling East at approximately 50mph when he was struck from behind by a UPS 18-wheeler. He reports impact was from the rear, right side and it spun his vehicle around 360 degrees. The patient reported he was shoved forward upon impact and recalls he experienced pain and soreness in his neck immediately following the collision.
Prior to his evaluation at our clinic, he was self-medicating his condition with over the counter Tylenol and Ibuprofen. He went to the emergency department following the accident where a CT of the head and cervical spine was performed. Medications prescribed included muscle relaxers and Ibuprofen. Physical therapy was recommended for his spinal injuries, however, he did not respond to treatment. The orthopedic surgeon recommended epidural steroid injections and facet blocks. Injuries of the cervical nerve root along with cervical strain/sprain injuries were diagnosed. On July 1, 2021, the patient presented to our office with neck pain (average 6/10 VAS to as much as 8/10), headaches (average 4/10) and trapezius pain (average 6/10 VAS). Mild paresthesia in the upper extremities in the form of tingling in the hands was noted. Additionally, he reported mid back pain (average 4/10 VAS).
Based on a functional assessment of the patient, the following effects on his quality of life were revealed at the time of his first encounter in our office when performing normal daily activities:
Pain intensity – Moderate to severe
Sleeping – Moderately interrupted
Personal Care (bathing, dressing, etc.) – Can’t perform basic personal care without assistance
Travel – Painful on short trips
Work – Can’t perform normal work duties
Recreation – Patient is athletic and can’t perform routine gym related exercises
Frequency of Pain – 75% of the time
Lifting – Can’t lift over 50 lbs. without pain increasing
Walking – Can’t walk over ½ mile without pain increasing
Standing – Can’t stand over ½ hour without increasing pain As indicated, he had increased pain with lifting, walking and even standing. He had been unable to perform any significant physical activity from the time of the crash on 6.24.21 with gradual improvement noted through September 30, 2021. He complained of not being able to function normally and perform required daily tasks such as cooking, dressing and bathing. He further stated his life had been “turned upside down” and he felt like he was suffering from PTSD after the accident. Prior History: No significant prior musculoskeletal or contributory medical history was reported. Clinical Findings (7/1/2021): He had a height of 5’7” and a measured weight of 155 lbs. Blood pressure was 105/62. Pulse was 74 BPM. Visual analysis of the cervical spine revealed pain and restriction in multiple ranges of motion including flexion, extension, bilateral rotation and bilateral side bending.
Dual inclinometer testing was ordered based on visual active range of motion limitations with pain revealing the following:
All ranges of motion are based on the American Medical Association's Guides to the Evaluation of Permanent Impairment, 5th Edition utilizing a dual inclinometer.
Normal (Degree) Patient (Degree)
Flexion 50 38 = 24% deficit
Extension 60 32 = 47% deficit
Right Lateral Flexion 45 18 = 60% deficit
Left Lateral Flexion 45 18 = 60% deficit
Right Rotation 80 47 = 41% deficit
Left Rotation 80 39 = 51% deficit
On evaluation for spinal functional motoricity a severe fixation of the spinal segments at C1-C2, C5-C6-T3, T5-T8 was detected. On palpation, a moderate amount of muscle tightness in the lumbar paraspinal muscles bilaterally, and a severe degree of hypertonic contraction in the suboccipital muscles bilaterally, cervical paraspinal muscles bilaterally, upper thoracic muscles bilaterally and mid thoracic muscles bilaterally was elicited. An analysis of the spinal tissues by digital palpation showed a very strong degree of pain and discomfort at C1 to C2, C5 to C6, T1 to T3 and T5 to T8 bilaterally. Severe trigger points were found at C1-C2, C5-C6, T1-T2, and T5-T8.
Muscle testing in the upper extremity was within normal limits bilaterally and all myotomes were graded +5/5 bilaterally. Hoffman's sign was negative. Deep tendon reflexes were present and equal bilaterally being rated as +1/4. There was no evidence of clonus. Dermatomes C5-T1 were within normal limits.
Right: 95, 95, 85
Left: 100, 100, 100
Nystagmus: Not present
Cranial nerves: Within normal limits
An order was placed for X-Rays of the cervical spine including flexion-extension and APOM motion views to determine if AOMSI is present. Spinal digitizing of cervical flexion-extension and Atlas Lateral Shift Analysis was also ordered on the patient. The following factors must be considered to determine if AOMSI is present: 1) flexion/extension radiographs are performed when the individual is at maximum medical improvement and are technically adequate; 2) the proper methodology is used in obtaining measurements of translation and angular motion; 3) normal translation and angular-motion thresholds consistent with the literature are used in determining AOMSI. Imaging modalities such as videofluoroscopy, digital fluoroscopy, and upright/motion magnetic resonance imaging cannot be used to establish an AOMSI permanent impairment using the AMA Guides. A number of technical factors can affect the image quality associated with measurements of AOMSI, including film centering, artifacts, poor edge resolution, endplate normal variations and spurring, and use of analog rather than digital radiography.
It should be noted that Atlas Lateral Shift analysis is sometimes warranted to evaluate the lateral translation of Atlas on Axis during lateral bending. Lateral translation is due to a tear or sub-failure of the Accessory and/or Alar ligament. Lateral shift of Atlas on Axis results in a permanently failed bio mechanical coupling of the unit. This can be a source of traumatically induced Upper Cervical Instability, Atlantoaxial Instability, or Cranio-Cervical Junction Syndrome. Overhangs of 1.7 mm or more show a poor prognosis. (2,4) This patient’s lateral shift analysis proved to be within normal limits.
Imaging Results of Functional Radiographic Analysis (Computerized Radiograph Mensuration Analysis): CERVICAL / LATERAL GEORGE’S LINE ANALYSIS
DESCRIPTION: George's Line is also known as the posterior vertebral alignment line and the posterior body line. George's line is a measure of spinal ligament integrity of the posterior longitudinal ligament and vertebral body alignment. The key landmark is the alignment and integrity of one vertebra to each superior and inferior vertebra. The normal translation or laxity of each vertebral motor unit is 0.0 to 1.0 mm. (1,10) Normally, there is a smooth vertical alignment of each posterior body corner. Interruption of a smooth curve is suggestive of ligament instability due to fracture, dislocation, trauma with ligamentous sub-failure or degenerative joint disease which can cause or aggravate spinal stenosis with resultant altered spinal biomechanics, and degenerative changes. If spinal instability is suspected due to clinical presentation, then flexion, extension or APOM Rt Lf Views are taken to determine the amount of excessive motion in the respective units.
CERVICAL FLEXION / EXTENSION ANGULAR MOTION ANALYSIS (5th & 6th Edition)
The lateral Base Lines are drawn from the inferior epiphyseal plates of each vertebra. The lines should converge on the posterior of the lateral spine view and converge at a central point. This is a qualitative analysis used to assist the physician in determining fixed flexion or fixed extension of vertebra (e). When a base line intersects with the next superior base line, this indicates fixed flexion of the inferior vertebra (e) while a base line intersecting with the next inferior vertebra indicates fixed extension of the superior vertebra. If not corrected this may leads to biomechanical dysfunction, which may assist with or lead to premature degenerative changes. (Wolf's Law).
DESCRIPTION: A motion segment of the spine is defined as two adjacent vertebrae, an intercalated disk, and the vertebral facet joint. Loss of motion segment or structural integrity is defined as abnormal back-and forth motion (translation) or abnormal angular motion of a motion segment with respect to an adjacent motion segment, in the flexion view only. The angular loss of integrity is defined as a difference in the angular motion of two adjacent motion segments greater than 11 degrees at C2-C7, which qualifies as AOMSI in both the 5th and 6th edition or the AMA Impairment Guides. All abnormal or ratable findings should be clinically correlated to determine if they are producing an active spinal instability. (1,3,4,8,9)
These finding can help the treating provider to better determine the severity and location of any cervical ligament injury and well as grade the severity of the sprain (ligament Injury). (5) The results can be utilized to determine proper course of treatment (Medical, Chiropractic, Pain Management, Spine Surgery, Physical Therapy), as well as make better determination for such things as return to play parameters in contact sports (11), or to determine if the patient has a surgical stabilization need. (12)
DESCRIPTION: Translational motion is measured by determining the anteroposterior motion of one vertebra over another. Loss of motion is defined by translational motion that is greater than 3.5 mm in the cervical spine using DRE Cervical Category IV, loss of motion segment integrity may be assessed as 25%-28% Impairment of the Whole Person AMA Guides 5th Edition. A translation of 1 mm or more is considered abnormal. (1,10) All abnormal or ratable findings should be clinically correlated to determine if they are producing an active spinal instability. (4)
These finding can help the treating provider to better determine the severity and location of any cervical ligament injury and well as grade the severity of the sprain (ligament Injury). (5) This report can improve the providers ability to determine the need for more advanced imaging. (6) The results can be utilized to determine proper course of treatment (Medical, Chiropractic, Pain Management, Spine Surgery, Physical Therapy), as well as make better determination for such things as return to play parameters in contact sports (11,12), or to determine if the patient has a surgical stabilization need.
1.Interruptions of the George's Line at C3/C4 are indicative of ligamentous instability or sub failure.
2.Ligamentous instability is indicated in the cervical spine with the measurements.
3.Cervical motion study indicates Angular Motion Segment Integrity change at C5. The impairment of thecervical region is due to ratable Loss of Motion Segment Integrity and is ratable at 25% for cervicalspine (AMA Guides, Fifth Edition, Errata). This patient’s digital analysis reveals Loss of MotionIntegrity at C5=11.12° yielding an impairment estimate based on plain film forensics at 25%. MotionSegment Integrity Angular variation is abnormal at C4. This patient’s digital analysis revealsC4=10.24°. Motion Segment Integrity Translational variation is abnormal at C4-C5, C5-C6. Thispatient’s digital analysis reveals C4-C5=1.3mm, C5-C6=1.74mm. These abnormal measurementsindicate spinal ligament damage/sub-failure and clinically significant ligament injury.
4.Abnormal translation or angulation finding on flexion/extension studies are highly suggestive ofligament and connective tissue damage. These findings are considered clinically significant. Anymeasurements over 1 mm of translation and/or over 7° angular variation, are considered to be clinicallysignificant and in excess of normal motion of the cervical spine.
Conservative treatment rendered: Conservative care was initiated despite the availability of other medical procedures.
1. The patient was placed on an initial care plan of 3x/week graduating down to 1x/week over the next 3 months with a significant reduction in symptoms noted. He maintained palliative care for an additional 3 months to ensure proper healing and achievement of MMI was obtained.
2. 24 chiropractic visits was administered during the first 3 months of care. Instrument adjusting cervical spine was utilized with the Arthrostim adjusting intrument. HVLA (high velocity low amplitude) spinal adjustments were performed to the upper thoracic spine, applied A-P. No HVLA spinal adjustments were delivered to the cervical spine.
3.Therapeutic procedures including ice/heat applications, muscle stimulation, myofascial release to the trapezius musculature and eventual therapeutic exercises to the cervical spine were performed.
4. Prior to being placed at maximum medical improvement the patient had persistent severe neck symptoms to as much as VAS 8/10, with continued tingling in the fingertips. Identification of AOMSI in the cervical spine allowed proper treatment to be performed at specific levels and intervals. His upper extremity paresthesia improved 50% in the first 4-6 weeks and completely diminished in 8-10 weeks. He continued chiropractic care reaching MMI, approximately 1 visit every 2-4 weeks with properly administered therapeutic exercises, myofascial release and chiropractic adjustments as needed (PRN). 1 year/4 months post collision, and 1 year/3 months after initiating conservative care at our clinic, he reports only slight (1/10 VAS) spinal complaints.
5. After initiating care at our clinic, no other interventional procedures were performed, although over the counter medication usage persisted until pain level decreased. Due to improvement in symptoms and functional status, pain management injections was not considered. The patient was given at home active care consisting only of cervical stretches/stabilization/strengthening exercises and has been told to return to this office should any unresolved symptoms reoccur.
Conclusion: While chiropractic care is safe even in the presence of ligament damage, herniations and radicular symptoms, it was explained that ligament injuries are permanent in nature and will require ongoing rehabilitative care for the maintenance and integrity of the affected joint. In the case of this patient, a 25% permanent impairment of whole person was given for the AOMSI at C5-6. Due to significant ligament damage involvement, the provider decided to utilize low force procedures although HVLA spinal adjustments to the cervical spine could be considered safe when administered correctly in this case. While previously theorized, care can be active, passive, pharmaceutical, interventional, or conservative in nature, but ongoing pain management therapy is often required for permanent ligament conditions. There is clear benefit to the patient population to be able to avoid surgical intervention due to risks, costs and ongoing prescription medication usage. Also, avoiding opioid usage is a high priority in today’s environment. Long term conservative care utilizing instrument spinal adjusting and targeted therapy significantly reduced subjective reporting of pain, increased activities of daily living, and allowed the patient to avoid spinal injections or surgical intervention. Considering that various interventional procedures including the failures and cost associated with each, it is important that providers work in an interdisciplinary environment such that the safest, and in this case the most effective, therapies are utilized first to reduce risk to the patient, maximize benefit and reduce costs. In this case study, the patient utilized an initial emergency room visit and a chiropractic physician. Utilizing chiropractic as conservative care enabled this patient to regain function and decrease pain while reducing costs and risks that are associated with medications and interventional procedures. Competing Interest: There are no competing interests in the writing of this case report. De-Identification: All of the patient’s data has been removed from this case.
1. Measurements over 1mm Translation and/or over 7° Angular Variation are considered to be clinically significant and in excess of normal flexibility of the cervical spine. (SPINE 2001, February; 26(3): (256-261), Lin, Tsai, Chu and Chang (the 1mm was rounded up) In the lumbar spine the same 1mm or translation is being accepted as normal. Wang S, et al., Spine. 2008 May 15;33(11):E355-61
2. Lateral shift of Atlas on Axis greater than 1.7mm 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 Jul;44(7):617-24, PCCRP Official X-ray Guidelines of the ICA, WCA, FSCO, CCP, pg. 331, Table 1.
3. A motion segment of the cervical spine is defined as two adjacent vertebrae, an intercalated disk, and the vertebral facet joint. Measurements of more than 11° Angular Variation and/or greater than or equal to 3.5mm Translation (Loss of Motion Segment Integrity) by definition constitutes ligament damage which results in permanent instability and calculates a whole person impairment of 25% to 28%. (Guides to the Evaluation of Permanent Impairment, Fifth Edition, 2000.) DRE Category IV. A diagnosis of AOMSI in the cervical spine by translation measurements requires greater than 20% anterior or greater than 20 posterior relative translation of one vertebra on another, on flexion extension radiographs, respectively, or and angular motion of more the 11° greater than each level on the flexion radiograph. AMA Guides 6th Edition Page 578.
4. Spinal instability for purposes of this report is defined as “excessive motion identified with testing” that is clinically correlated through examination or other testing means to be causing a motor, sensory or pain problem at that specific level.
5. For purposes of understanding the importance of this report. “Ligament sprains commonly occur and can be quite debilitating, frequently causing persistent joint instability, prolonged pain, and progressive degeneration. A sprain is defined [3,26] as an acute injury to a ligament or joint capsule without dislocation. Sprains are classified by severity based upon clinical examination or imaging. Grade I sprains are mild stretches with no discontinuity of the ligament and no clinically detectable increase in joint laxity. Grade II sprains are moderate stretches in which some fibers are torn. Enough fibers remain intact so that the damaged ligament has not failed. These grade II sprains produce detectable laxity at the joint. Grade III sprains are severe and consist of a complete or nearly complete ligament disruption and result in significant joint laxity.” J Orthop Res. 2002 Sep;20(5):975-83. Healing of subfailure ligament injury: comparison between immature and mature ligaments in a rat model.
6. For purposes of this report, it has been found in research that translation abnormalities have be found to be highly sensitive and highly specific in their ability to rule in or rule out the need for MRI analysis for disc protrusion/herniation. This report can improve the providers ability to determine the need for more advanced imaging. Kim CH, Hwang JM, Park JS, Han S, Park D. Predictability of severity of disc degeneration and disc protrusion using horizontal displacement of cervical dynamic radiographs: A retrospective comparison study with MRI. Medicine (Baltimore). 2018;97(25):e11098.
7. A motion segment of the lumbar spine is defined as two adjacent vertebrae, an intercalated disk, and the vertebral facet joint. Measurements of Angular Variation greater than 15° at L1-2, L2-3, L3-4, greater than 20° at L4-5 or greater than 25° at L5-S1 and/or greater than or equal to 4.5 mm Translation (Loss of Motion Segment Integrity) by definition constitutes ligament damage which results in permanent instability and calculates a whole person impairment of 20% to 23%. (Guides to the Evaluation of Permanent Impairment, Fifth Edition, 2000.) DRE Category IV. A diagnosis of AOMSI in the lumbar spine (l1-5)by translation measurements requires greater than 8% anterior or greater than 9% posterior relative translation of one vertebra on another, on flexion extension radiographs, respectively. In the lumbosacral spine , it requires great than 6% anterior or greater than 9% Posterior relative translation on flexion or extension radiographs. The angular finding remain the same as in the previous edition (AMA 5th Edition)
8. “Motion of individual spine segments cannot be determined by a physical examination but is evaluated with flexion extension radiographs.” AMA Guides to the Evaluation of Permanent Impairment 5th Edition Page 383. This means that it is impossible to determine the level and severity of excessive spinal motion in physical examination and must be determined with the assistance of objective and quantifiable imaging results.
9. Radiographic examination has been long considered the “Gold Standard” for spinal instability evaluation. Ferrari, S., Manni, T., Bonetti, F. et al. A literature review of clinical tests for lumbar instability in low back pain: validity and applicability in clinical practice. Chiropr Man Therap 23, 14 (2015)
10. Wang S, et al., Spine. 2008 May 15;33(11):E355-61
11. Cervical Spine Injuries and the Return to Football https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445180/ Ligamentous injuries Lateral roentgenograms that more than 3.5 mm of horizontal displacement of either one vertebra in relationship to another or more than 11° of rotation than either adjacent vertebra represent an absolute contraindication. With regard to lesser degrees of and rotation, further participation enters the realm of trial by battle, and these situations can be considered relative contraindications depending on such factors as level of performance, physical habitus, and position played.
12. https://www.evicore.com/-/media/files/evicore/clinical-guidelines/solution/msk--advance/2020/evicore_spinesurgery_eff02142020_pub101519.pdf “The determination of medical necessity for the performance of cervical fusion with and without discectomy is always made on a case-by-case basis.” Flexion-extension plain X-rays demonstrate instability and include ANY of the following: ¡ >3.5 mm sagittal plane translation ¡ >20% sagittal plane translation of vertebral body width ¡ >11 degrees relative sagittal plane angulation. Pg 8 Lumbar Spine Page 85: Dynamic segmental instability documented by flexion-extension plain X-rays OR comparison of a supine and upright image, with a difference in translational alignment between vertebrae greater than 3 mm between views ¡ Grade II or higher spondylolisthesis (i.e. instability)defined as at least 3 mm of anterolisthesis of the upper vertebra in relation to the lower vertebra, either isthmic (i.e. secondary to a posterior arch stress fracture) or degenerative type.