Diagnosis of Acute Spinal Ligament injury
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Hello, everyone. For those of you who are tuning in and expecting to see Dr. Mark Studin, you probably realized already I am not him. My name is Dr. Don =Capoferri. I. am gonna talk to you a little bit today about diagnosis of acute ligament injuries. And I’m excited to do that. I want to thank ChiroSecurfe for the opportunity to share this information with everybody today. And why don’t we go ahead, go to the slide.
Okay. So a little bit about me. First of all, I am, I’m a practicing chiropractor. I’m in my 40th year of doing that. Hopefully you’re looking at that picture and thinking he’s way too young to be practicing 40 years. I am a fellowship trained chiropractor through the State University of New York at Buffalo.
And that fellowship is in spinal biomechanics and trauma. A lot of the information I’m going to be sharing with you today came from that program. Particularly proud of that. Number one, I was the first one and number two, the medical school sponsoring a fellowship for chiropractors is a statement of increased cooperative.
Also have a fellowship in neuro-radiology spine and MSK radiology. I’m a diplomat of the American medical legal academy of medical legal professionals. And that’s the flavor I’m going to be coming at you with. I live in the medical legal world, 24 7. And that’s the slant we’re going to take on this.
However, the information I’m going to share, certainly as clinically applicable to any type of injury, any type of patient that you have regardless of how they pay. I’m also an adjunct professor at Cleveland university in the clinical science department, which basically means. I go ahead and teach diagnosis.
Again, I want to thank ChiroSecure. I want to thank Dr. Weinstein for helping put this together and also want to thank Dr. Mark Studin. He’s been a mentor and a coach for me for almost 13 years now. I really appreciate him. Do I switch the slides or let’s see. Yes. Okay. So we’re talking about acute spinal ligament injury today.
For those of you who haven’t done much studying of spinal ligaments, the ligaments are the stabilizing forces of the skeleton of our body. I attended a seminar once with a PhD in spinal biomechanics. Some of you are surprised as I am, that there is such a thing as a PhD in spinal biomechanics, but there is a fascinating man and his analogy of the spinal ligaments was like the suspension cables on a suspension bridge, a disaster happens without them, or when they’re coming.
So I’m going to talk about the ligaments today and when a ligament is compromised let’s go back. Let’s take a step back a second. Let’s talk about joints of the body. There’s a counterbalance of mechanism with the joints of the body. You have muscles, which are your movers, and then you have ligaments, which are your restraining bolts, if you will.
So when a muscle. Is injured. And we call that a strain. S T R a I N a it’s difficult to move the joint when they ligament is injured, oftentimes especially once the spasm associated with that injury reduces there is excessive movement that has. And I was trained in chiropractic school in the early, late seventies, actually early eighties and all the focus of range of motion still today, mostly is on restricted range of motion.
But in my opinion, hypermobility of a joint, particularly of the. Is way more dangerous and life impacting ultimately than restriction of motion. So let’s dive into this just a little bit, but we’re not going to get very deep. This is I’ve been told this is a 20, maybe a 25. Presentation. So my hope today is to maybe inspire somebody on this call to dive a little bit deeper into studying the ligaments especially for those that operate like I do in the medical legal arena.
So what you’re seeing on the screen there is a, on the left is a report from the software that I use. To assess ligament damage. And on the left side, you see a cervical spine assessment. And on the right side, you see a lumbar spine assessment. Those reports come out of a software, which I’m going to talk about in a little bit called SIM Virta S Y M V E R T a.com.
And you can go to there if you like, but SIM Virta is, in my opinion, the premier software for assessing. Ligament injury in the spine. We take the x-rays flection and extension x-rays there’s always a reference line on there so we can tell the software distance, like this point to this point is so many millimeters, and then we plot what I like to call GPS.
On each vertebrae, each corner of the body of E of every vertebrae, starting at the top end plate of T1 and ending at the occiput on either side of the mastoid vertebra mastoid bone, and then the software does its job. And what it’s assessing is how each vertebrae responds to the one above and below when the person flexes and.
And this is a sample of one of the reports. So there are two major types of excessive movement that occur with ligament injuries, particularly in motor vehicle crashes, front end or rear end collisions. Now side impacts are a little bit different, but front and rear end collisions, which is the majority of them.
One of the pathologies that we see is called angular deviation, and it’s depicted there on the picture, on the left-hand side as one vertebrae angulating over the other. That pathology comes from a compromise. Of the interspinous ligament mainly, and that’s depicted on the screen there also the super spinus ligament, and that would be the ligament that runs from tip to tip over the spinus processes.
And the picture is showing a gross compromise of that ligament, complete tear. I’ve been doing this for a very long time and I’ve never had one of those come in my office. If you work with sprain strains a lot, then you already know this, but there are three grades of sprain and S P R a, I N always refers to the ligament.
The first grade of sprain is overstretching now ligaments because they are the tension cables of our joints are pre-stressed. So they already have a degree of tension. And if they are stretched slowly as in baseball players or basketball players or football players going out to warm up prior to competition that’s called history, SIS.
They do very well. And for a time after that warming up, they will maintain that elongate. Posture until the activity stops and somewhere between 12 and 24 hours later, they’ll go back to their original tension. What happens in an injury is the time is shortened. The suddenness of it is called strain rate the suddenness of the forces.
That are applied to that ligament are so quick that it actually stretches and has internal tearing. That’s called a sub failure. That’s grade one. So the ligament is stretched or lax. Okay. The medical medical term is called ligament laxity. The grade two is a partial, a Volusion of. And that’s where their significant tearing in the internal structure of that ligament.
And then a grade three is what depicted there. That’s complete avulsion. My experience is a spinal injury that experiences a complete avulsion. Usually it doesn’t make it to a chiropractor’s office. They would go right from the scene of whatever caused that be the motor vehicle crash, a fall off a roof or whatever, and taken to the emergency room.
Admitted and have orthopedic surgery to secure that that injury. I want to explain a little bit about the report on the right. This is an angular deviation report and it starts, this is the cervical spine one. I believe it starts at two, three and goes down to and extending from your left to your right.
Bars, those black bars rent represent the degrees of angular motion of the segment that it represents. Then you see two vertical lines that are in color. One is green and one is red. The green line, according to the current scientific consensus, that is the published literature is seven degrees. So if that vertebrae angles more than seven degrees from the one below, it that’s considered a pathology and that’s important in the clinical realm.
Certainly you want to take that into consideration. I believe when you’re applying, whatever technique you use to to treat this individual above that, I believe C2 three at three 50. Some angular motion that doesn’t reach that green line. So it hasn’t reached the pathology line that would be considered within normal limits.
But then on the bottom you see a black line that extends all the way past green. So past the pathology threshold and past red. Now the red line is an administrative line that represents the threshold to qualify for. Whole person impairment of that particular motor unit, the level, I believe is what that is.
That plays a big role in the medical legal community, particularly in the legal community. The AMA guides, particularly the fifth edition, which is what my state uses gives that a 25%. Whole person impairment. So you can see 25%, whole person impairment. That’s a significant issue. That a person has sustained.
And the sad thing is, and I don’t have time to go delve into all the literature that substantiate this, but ligaments don’t heal. They don’t heal in children or infants. They don’t heal in adults or old people like me. They scar, they took typically scar and they’re less function. After that, which is why the AMA guides give that such a high impairment rating moving forward this person’s likely to experience a spondylosis at that level, possibly bone sparing, maybe ultimately fusion and that surgical fusion, or it could end up in surgical fusion.
But if left alone, that is likely to go ahead with that. Cool. And then a SIM Virta study or another software study done months or years or decades down the road. You’ll notice instead of excessive motion, there’ll be very little motion at that joint at all. Even in the absence of any disc herniations, which typically is what personal injury attorneys are looking for from chiropractors this is a significant life impacting injury.
This person. So angular deviation is one of the path ologies that we detect with ligament study. The next one is called translation. Now translation is an angulation of one vertebrae on the other. It is sliding and the joint that controls that is the Fossette joint. And there’s a much tighter pathology threshold when it comes to translation because it’s much more agreeable.
To the human body. You see the green line is set at 0.6 millimeters. Now research has come out recently that it has adjusted that tight 0.6 threshold that comes from Penn jobbies research. But then you see the red line at 3.5 millimeters in the cervical spine for translation, pathology and qualifying for the 25.
Whole person impairment, very significant injuries even in the absence of disc herniations. So angular, deviation, and translation demonstrable. Now the point here, if you do medical legal work, that should be your mantra is what your patient’s attorney is looking for. Is you to be able to demonstrate the injuries that this person has and a software like this, like SIM Virta is very demonstrable.
A lot of times when I’m doing my wrap up report, some people call it a narrative or a four corners report at the end. If this is the most significant part of my patients in. These reports get embedded right into their report. So it’s the monster trouble for the legal community for the jury or whoever is taking a look at this.
There’s a picture of the Fossette now how this injury actually occurs is you see that on the left-hand side is depicted for you. What’s called the Fossette capsule within that, those striations that you see. Is a synovial joint which means it has fluid in it. And that allows one vertebrae to glide over and under the other one, while research has found out that when that capsule is stretched out as in a hyper flection hyperextension injury and then retracts it often tears.
And when it does tear, you will see. A lot of fluid in that joint. And that’s what the pick did on your right. That is an axial MRI. Actually, it’s a lumbar spine MRI and the yellow arrow is pointing to a DEMA swelling, excess fluid in the facility. And that white that you see there is a very bright white signal and bright white, typically on a T2 MRI means acute injury in contrast to the Fossette on the left, that does not have a yellow arrow point into it.
That’s an Fossette joint with a touch of arthropathy in it. No. But it is deteriorating to an extent. So you, in one picture, see left side, as you’re looking at it, that would be the patient’s right side and arthritic, or If I set joint with a touch of arthropathy that’s old. And then on the, as you’re looking at it on the right side, patient’s left, you see a Fossette joint.
That’s been recently injured. Another thing, the legal community, if for those of you who operate in the medical legal word are looking for is age dating. So that Adima typically would last for six, eight weeks, and then start to dark. So we can age dated according to the date of the incident. Of course, it’ll start to turn gray and then ultimately we’ll end up like the joint on the other side with arthropathy and.
For those of you who haven’t paid much attention to the Fossette, I’m really talking to myself here. A translation is a Fossette injury. And in my opinion, the Fossette joint is to use an old term, the redheaded stepchild of the personal injury world. It is oftentimes significantly injured in motor vehicle crashes in sports injuries.
And it is often ignored. The diagram that you see on the right is the typical pain pattern associated with the facets at each one of those cervical spine levels. Another great use for this kind of software study is it helps guide pain management doctors being in the medical legal world.
I work very closely. Neurosurgeons. I work very closely with pain management professionals. So I will send my biomechanical study to help them narrow down what Fossette joints they might need to inject, or at what levels they might need to do a medial branch block to see if that’s the pain source.
Another good use of this, particularly the translation pathology is it helps neurosurgeons guide. Surgical planning. There’s always a question that they have a weather, particularly in the cervical spine or lumbar spine that they can do an artificial disc. The emphasis on replacing a disc with an artificial disc is to preserve motion.
But if there’s significant ligamentous instability, like you see on the study there on the left-hand side if that’s the level they’re considering doing the surgery that would exclude the possibility of putting an artificial disc in that patient because of the ligamentous instability. So they would most likely move in more of a fusion direction.
Most of not most all of the neurosurgeons that I work with, I have. That we consult with and refer to on a regular basis, always look for this biomechanical report so they can help their surgical planning. Okay. So age dating of ligament injuries. This is a partial list of what I use to help age date, really any injury disc herniations ligament injury.
So the first is that osteophytes and or bone spurs also called bone spurs. The first evidence of a bone spur is at six months. And you have the research paper underneath that research was published in 2006. If you want to take a screenshot of that that still might be behind the paywall. So you have to, you might have to buy that.
I’m not sure. Generally speaking, I don’t use research. That’s more than three to five years old, unless it’s become, what’s called canonized. That means it’s so widely cited, widely used and is actually the research is now appearing in textbooks. So that’s the case with the ones on here that are more than three to five years old.
But if you see an osteophyte at that level, Typically that’s at least six months old. Now, for me, in the context of what I do a lot of consulting with law firms that may or may not help the attorney’s case just cause there are bone spurs on there. I am often consulting on a case where the imaging was done.
Six, 12 months, 24 months after the incident loss of disc height. Usually it takes 12 months to start seeing loss of. Now you can see that on a plain film, lateral x-ray, you don’t need an MRI for that. And this article will take you through a process for those of you who are like me, who like to measure things and have numbers that they can talk to people about.
It’ll take you through the process of how to accurately measure disc height, because a lot of times an emergency room. Person looking at an x-ray or even sometimes orthopedic surgeons will just eyeball it and say, yeah, loss of disc height at C5, C6, and then I’ll measure it and see that’s not the case.
Lastly endplate sclerosis. Endplate sclerosis is a hardening and of and scar tissue forming within the bone marrow, adjacent to either the superior or inferior in play to the vertebral. And that is almost always a result of either an old infection or excessive mobility of the joint, just beyond the end plate, either inferior to the inferior end plate or superior to the superior in play.
So biomechanical findings in the absence of these acute indicators are most likely acute. Then you can back that up by getting an MRI. And particularly the gold standard for determining acute Adima in a ligament, in a joint or in a disc is a stirrer view. Stir stands for short talent version of recovery, and it is a fat suppressed view.
So those two yellow arrows are pointing to a high signal, white signal. The Fossette joint of the that’s the top arrow and also in the interspinous space, the bottom arrow at C6 C7. And that stir view is from the patient that. Did the SIM Virta software studies on. So we could be, we’re able to tell tell the attorney, tell the patient that this is an acute injury and this happened in the motor vehicle crash of so many weeks ago.
Okay, now, Symverta.com take a screenshot of that. I feel go look around, as I said, it gives you more information than just. Ligament injury or a whole person impairment. It gives you biomechanical studies. Like you see here allows you to determine compensations in the spine versus primary lesions.
You do that by the size of those black lines. And so Symverta provides for me, ligament assessment. Helps me with AMA guide impairments, biomechanical analysis, a diagnosis of a primary lesion versus a compensation. It helps with collaboration with spine surgeons, pain management professionals, physical therapists, and I manage all my patients this way.
So that study, you’re looking at. Their frequency of care is not reduced until the biomechanical lesions originally diagnosed improve their pain might be zero and that’s, I’m not a pain physician. So I celebrate with them, but that’s not why I’m treating them. I’m treating the improved biomechanics of their spine.
So I think that’s all we got Dr. Weinstein back to. Oh, yes. I forgot about that. Join us next week for Dr. Mike Miscoe. I think he’s a doctor. He will be doing the presentation next week.