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Chronic Whiplash and MRI, Is it diagnosed correctly?

Chronic Cervical Pain Patients Show Abnormal Alar Ligament
Motion vs. Control in Motion MRI
abstract from March 2010 Advocate Article
Richard H. Adler, Attorney at Law

Patients with chronice neck pain from trauma need to obtaining a proper diagnosis. this requires a comprehensive physical examination and the use of imaging studies such as a MRI to better understand the structures and potential pathologies of the cervical spine.Static MRI's have inherent limitations and does not reveal all causes of pain. A MRI for example, is not useful in showing facet-generated pain or alar ligament stretch injuries.

Providers have long known that the association of positive structural damage in the cervical spine on C-MRI is low compared to the number of patients with chronic pain. Insurers are always ready to claim that without “objective imaging findings” treatment of chronic cervical pain is not reasonable and necessary. This is mantra  often used to deny payment based on the lack of imaging findings, The medical comunity has known that a MRI is not the ‘be all, end all’ for injury proof. For example, the work of renowned researchers, Drs. Barnsley, Bogduk, and Lord1 have demonstrated that injury to the facet joint, though not seen on C-MRI, is a musculoskeletal pain generator. More recently, other causes of chronic neck pain have been discussed involving injury to the alar ligaments.

The percentage of trauma patients progressing to chronic pain varies widely. On average 30% [range 11% - 42%] of people with cervical acceleration/deceleration injuries develop chronic whiplash associated disorders.2 A recent study on whiplash associated disorders in Finland revealed3 11.8% of patients experienced symptoms three years after the accident.

Upper cervical whiplash injuries have been documented to cause upper cervical syndrome which is characterized by such symptoms as balance distributance, dizziness, visual problems and jaw pain.4 The cranial cervical juncture, the alar and transverse ligaments provide much of the stability in the cervical spine with the alar ligament restraining rotation of the upper cervical spine. In these segments abnormal motion patternscan be the result of a stretch/sprain or rupture of the alar ligament.

In a current Finland study, researchers investigated the difference in movement patterns of the upper cervical spine in cervical acceleration/deceleration trauma patients using a controlled group that included 10 male and 15 female patients with matched controls for sex and age.5 All patients suffered from some combination of severe neck pain, upper and lower limb dysfunction, loss of balance, and/or numbness of the tongue. All the Patients participating in the study did so after an average of 7 years from the original injury and were still experiencing symptoms. None of the control subjects had any history of neck pain, trauma, or inflammatory diseases such as rheumatoid arthritis. The focus of the study was on a top section of the spine, specifically at C0-C2 region. The atlas axix also known as C1 and C2, are the top 2 vertebra in the cervical spine. The researchers used dynamic (motion) kine magnetic resonance imaging (dMRI) to analyze movement between C1 and C2 during side-bending and then assessed instability of the C0 and C1 joints. To insure control and proper movement of the spine and prevent injury physical therapist were used. The results showed significant differences between the whiplash patients and the non-whiplash control group: there was abnormal movement in the alar ligaments in 92% of trauma patients vs. only 24% in the control subjects. Motion MRI images taken while side-bending revealed widening of the C0-C1 joint, this is an indication of unstable joints from a stretched alar ligament in seven patients and one control subject. Additionally, there was abnormal movements in the C1-C2 were found in 56% of whiplash patients vs. 20% of the non-whiplash controlled group.

In summary, the researchers noted cervical acceleration/deceleration patients with long standing chronic neck pain had more abnormal signals from the alar ligaments and greater movement distributances in the C0-C2 level in the dMRI than the controlled group:
This is the first comparative MRI study to our knowledge to use dMRI among whiplash patients and controls. The results show that whiplash patients with long standing symptoms have both more signals from the alar ligaments and more abnormal movement in the dMRI at the C0-C2 level than controls.”
This study raises a question of whether static MRIs can rule out potential pain generators such as traumatic insult to cervical ligaments. For the physician who is trying to better understand and diagnose their trauma patient’s chronic cervical pain, ligament injuries are an area worthy of greater attention. Your patients injuries are real and Ader and Giersh have the knowledge and advocacy abilities to prove it.


1 Barnsley L, Lord SM, Wallis BJ, Bogduk N. The prevalance of chronic cervical zygapophysial joint pain after whiplash. Spine 1995; 20:20-5

2 Barnsley L, Lord S, Bogduk N. Whiplash Injury. Pain 1994;58:283-307.

3 Miettinen T, Leino E, Airaksinen O, Lindgren K-A. Whiplash injuries in Finland: The situation three years later. Eur Spine J 2004; 13:415-8.

4 Radanov BP, Dvorak J, Valach L. Cognitive deficits in patients after tissue injury of the cervical spine. Spine 1992;17:127-31.

5 Lindgren, Karl-August, et al. Dynamic kine magnetic resonance imaging in Whiplash patients and in age - and sex - matched controls. Journal of the Canadian Pain Society. Nov/Dec 2009



The previous Article source was written by

Richard H. Adler, Attorney at Law

We at Cedar River Medical Massage consider Richard Adler one of the Great LOCAL personal Injury Attorneys.

Chronic Cervical Pain Patients Show Abnormal Alar Ligament 
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