Academy of Chiropractic’s
Doctors PI Program
From the Desk of:
Mark Studin DC, FASBE (C),
“Ligament Laxity and Trauma, A
Diagnosis that is Often Missed”
When dealing in trauma, damage to the ligaments is usually a missed diagnosis. Rather than re-invent the wheel, thanks to Dr. Ralph Latyschow in New Jersey who sent me this article for comment, I am sharing the entire text for your education.
The only issue that I have with this article is that the author is quoting the now outdated AMA Guides, 5th edition. At the end of the article, I will explain how to apply this according to the 6th (most current) edition of the Guides to the Evaluation of Permanent Impairment.
This entire text was taken from: http://www.chiro.org/radiology/ABSTRACTS/Accurate_Prognosis.shtml
Accurate Prognosis in Personal-Injury Cases Using George's Line
Despite the fact that every chiropractor remembers George's Line, I have found that most still do not understand its true significance. In personal-injury cases, it is the most important test a chiropractor can do when examining the patient with neck pain.
It will tell you with astonishing accuracy the condition of your patient's neck and you can know your patient's long-term prognosis after the very first examination. If you fail to accurately assess your patient's neck ligaments with the proper use of George's Line, you have probably misdiagnosed your patient, committed malpractice and severely damaged your patient's personal-injury case.
While practicing chiropractic for 20 years, I treated many car-accident patients. Now as a personal-injury lawyer, I represent car-accident victims and have read thousands of doctors' records. When the treating chiropractor does not specifically measure breaks in George's Line on both the flexion lateral and extension lateral films, it is impossible for me as the lawyer to settle the case for its true value. I will explain here in words and diagrams what you absolutely must do for every trauma patient if you expect your patient's lawyer to be able to explain the injuries to the insurance company.
The AMA's Guides to the Evaluation of Permanent Impairments uses George's Line to rate neck impairments. A moderate (3.5 mm) break in George's Line on the flexion and extension lateral X-ray films is a permanent impairment, equivalent to a post-surgical fusion of two cervical vertebra. Most chiropractors see small anterolisthesis and/or retrolisthesis on the films and ignore it or fail to appreciate its significance.
One well-known chiropractic organization lists on its Web site that the significance is a sprain with subluxation; a strain with subluxation; or possible fracture of the neural ring. You are doing your auto-accident patients a great disservice if that is all you know about George's Line, because patients who walk into chiropractic offices with breaks in George's Line generally do not have simple sprains/strains or neural arch fractures. Approximately 35 percent to 45 percent of car-accident patients have something in between, namely ligament partial rupture with translation instability that manifests as a break in George's Line on the flexion and extension films.
In 1919, A. George published "A Method for More Accurate Study of Injuries to the Atlas and Axis" in the Boston Medical and Surgery Journal, which was renamed The New England Journal of Medicine in 1928. He described his method of drawing a line on the posterior cervical vertebral bodies and looking for the key landmark, which is the alignment of the superior and inferior posterior body corners. In 1987, Yochum and Rowe published Essentials of Skeletal Radiology and described the significance of George's Line. "If an anterolisthesis or retrolisthesis is present, then this may be a radiologic sign of instability due to ... ligamentous laxity."
Modernly, the AMA Guides uses this key landmark as the basis for rating permanent spine impairments. It is extremely valuable for the treating chiropractor to have a working knowledge of ligament laxity in the cervical spine. It is a diagnosis code (728.4) recognized by Colossus that allows essentially unlimited treatment in trauma patients. Unlike sprain/strain (847.0), which causes Colossus to cut off treatment after three weeks, or subluxation (839.00), which causes Colossus to cut off treatment after 12 weeks, Colossus (and med-pay) has no arbitrary cut-off date for a patient with a true ligament laxity demonstrated on X-rays.
Since 35 percent to 45 percent of trauma patients have this injury, it is very likely you have failed to diagnose it many, many times. By failing to diagnose this injury, you have failed to accurately, thoroughly and honestly describe your patient's injuries to the claim adjusters and attorneys, who will use the facts in your patient chart as the basis for the personal-injury settlement. These people need you, the doctor, to give them all the facts so a fair settlement can be reached. The jury also needs to understand whether your patient had this injury in order to decide how much to award your patient in a trial verdict.
NOTE: Pictures will be posted shortly
The diagnosis of cervical ligament laxity (728.4)is determined by measuring the translation instability of each vertebral motion segment in the neck. First, take the extension lateral X-ray film and look for possible breaks in George's Line. At each level you see a possible break in the line, draw the following lines of mensuration: a line on the lower vertebra's superior end plate; a line perpendicular to the end plate line so that it intersects with the posterior superior corner of the vertebra upon which you drew the end plate line; and a line perpendicular (90 degrees) to the end plate line so that it intersects with posterior-inferior corner of the vertebra above. Also measure the distance between lines two and three in millimeters. (See Figure 1) This gives you a measurement of what we might call the retrolisthesis on the extension film.
Now, take the flexion lateral X-ray film and repeat steps one through four at the same vertebral level(s) as you drew on the extension film. (See Figure 2) This gives you a measurement of what we might call the anterolisthesis on the flexion film. The critical step is to add these two measurements together. The sum of these two numbers is the total translation at that vertebral motion segment, which is a measurement of the ligament laxity or ligament instability at that level.
For example, let's use C4-5 to illustrate what this means. You measured how much the body of C4 slides backward in relation to C5 on the extension film. You measured how much the body of C4 slides forward in relation to C5 on the flexion film. When you added them together, you know exactly how much excess motion (translation) there is at the C4-5 joint because of traumatic ligament partial rupture. This is a direct measurement of how much damage or partial rupture there is to the anterior longitudinal and posterior longitudinal ligaments in your patient's neck.
Total translation of greater than 3.5 mm in the cervical spine is a DRE Category IV permanent impairment of 25 percent to 28 percent whole person in the AMA Guides. This is the same percentage of impairment for a patient who has had spine surgery to fuse two vertebrae. The physiological result of this excessive movement is that the body tries to stabilize the injured joint by splinting the muscles to guard the injured joint. These chronic muscle spasms continue for several years until degenerative arthritis can stabilize the joint. The neck joints with partial ligament ruptures will develop DJD within a few years (visible on X-rays within seven years).
These patients are the ones who never heal. After the first six months of treatment following the car accident, you will find that these patients get about two to three weeks of relief after each chiropractic treatment because you have stretched the tight muscles (which are guarding the joint from excessive movement) and adjusted the adjacent restricted vertebra. Unfortunately, the patient is then right back where they started with excessive vertebra motion.
Within two to three weeks, the muscles go into spasm again, the patient experiences painful neck muscles, and they are back in your office for another treatment. This pattern often continues for two or three years until the two vertebra start to fuse together by the process of DJD, the result of which is a chronic stiff neck for which the patient will always need a chiropractor in order to maintain as much range of motion and function as possible.
If you examine your patients' neck X-rays in this manner and there are no measurable translation instabilities present, you can generally assure them that they have a simple sprain/strain and/or chiropractic subluxations that will probably heal completely within a few months. Patients with simple sprain strains (no ligament partial ruptures) get well and stay well. Patients with ligament partial ruptures do not.
I have a lot of issues with the above commentary. First, the comment on when DJD Starts is inaccurate based upon current literature. Secondly, pain does not go away fro 2-3 weeks after an adjustment. It calms down until you re-stress the joint. Third, you MUST x-ray digitize your patient to get an accurate read. You cannot "eye-ball" an xc-ray and there is also a second component called angular deviation that cannot be seen with the "naked eye." You must,must,must take the course CONNECTIVE TISSUE PATHOLOGY and SPINAL TRAUMA PATHOLOGY that are part of the Trauma Qualification to fully understand this issue as it is critical to a relationship with lawyers and medical specialists to fully understand the pathology.
The other issue I have with the above article, as I mentioned at the start of this consultation, is that although it was last updated on 3-28-2010, it reflects older versions of the AMA Guides. When evaluating impairment in the 6th edition, on page 578, it states that to have AOMSI (Alteration of Motion Segment Integrity), an impair-able diagnosis, there must be either a 20% forward or backwards translation. This is not a combined number; each much meet the test. The Guides go on to say that in addition, if there is angular motion greater than 11 degrees on the adjacent vertebrate in flexion, that too is impair-able. Should the AOMSI be present, you then must go to page 570 of the AMA Guides, or look up the chart in the handouts associated with the Impairment Rating Course I offer online, and go to the section “Motion Segment Lesion.” You need to identify if there are single or multiple levels and if radiculopathy is present or absent. Those are the variables that will drive the impairment. The difference in the 6th edition is not if there is AOMSI present, but if AOMSI has caused any functional loss qualified by diagnostic findings.