PATIENT was involved in a car crash. She was involved in the crash when her head was in a flexed position. According to the Journal traffic injury prevention 2015 with a paper titled “out of position rear impact tissue level investigation using a detailed finite element neck model” the authors concluded “the incorporation of ligament laxity in the upper cervical spine was essential to predict range of motion and traumatic response, particularly for repositioning of the neck model prior impact”. The results of this study identify a higher potential for injury and out of position rear collisions and identical at risk locations based on ligament distractions”. The treatment I recommended was chiropractic and rehab with the ultimate goal of trying to restore and stabilize the sagittal alignment of the cervical spine. The diagnosis is loss of the cervical curve, cervical kyphosis, facet irritation, and ligamentous instability as well degeneration. According to the Journal injury 2015 in a paper titled “long-term outcomes of individuals injured in a motor vehicle crashes a population-based study” the authors concluded “Traffic injuries are significantly associated with the long-term reduced health-related quality of life.” This is another recent study that shows that car crashes can lead to significant chronic conditions that can greatly impact the patient’s quality of life. What the study does not show, is what pathologies are causing a decreased quality-of-life. In the report below for Kris, I will go over her pathologies and what the research and my clinical experience have shown and why those injuries are associated with pain and disability.

Loss of the cervical sagittal alignment: Based on her x-rays, PATIENT has a loss of the cervical lordosis (1). This is a pathology that has been shown in many biomechanical studies to occur from motor vehicle crashes (2), such as the one PATIENT was involved in. This pathology has been shown to lead to increased pain, increased disability, muscle spasms, arthritis, and even central nervous system disturbances as well as vascular disturbances (3-8). The literature as well as my clinical experience suggests that once a kyphosis develops, it will progressively get worse (9-11). If PATIENT did have a loss of curve before the crash, , this would only increase further injuries from occurring , as her neck would’ve been in weaker state (12). Having this abnormal sagittal alignment will also affect her activities of daily living. Because the neck is weaker and more susceptible to injury it cannot redistribute certain stresses and that can use a certain structures of the spine. I have encouraged her to stay active as long as she is not flexing her neck. As well the journal Emergency Radiology 2002; 9:249-253 authored by Giuliano, they looked at 100 asymptomatic patients in 100 patients after a car crash within 12 to 14 weeks. The author showed that only 4% of the asymptomatic individuals have a loss of the cervical lordosis, in 98% of the car crash patients had a loss of cervical lordosis. This study shows as well as the biomechanical literature that patients involved in car crashes suffer from a loss of the cervical lordosis.

• Cervical instability: PATIENT was diagnosed with cervical instability at several levels. Cervical instability according to the AMA guidelines is diagnosed when a measurement in the cervical spine is over 3.5 mm of translation and or 11° of angulation(13). The definition of instability according to White and Panjabi Clinical Biomechanics of the Spine text is defined as“The loss of the ability of the spine under physiologic loads to maintain relationships between vertebrae in such a way that there is neither damage nor subsequent irritation to the spinal cord or nerve roots, and, in addition, there is no development of incapacitating deformity or pain due to structural changes.”

The purpose of the flexion extension x-rays is to determine if the ligaments, which hold bones in place that surrounds the central nervous system, are holding the bones together minimizing the amount of movement into the spinal canal. According to her reports she has multiple levels of instability in the mid cervical spine(14-16). She also has a increase ADIs space which could be damaged the transverse ligament. Since she was improving well with care I do not make referral to a neurosurgeon as the conservative treatments were helping. We also see that when she’s in extension ADIs space minimizes back to more neutral position. Based on the instability in certain ranges of motion we can clearly see how this can affect her activities of daily living, especially if she puts her head into the position of further instability.

According to the Croft CAD guidelines, PATIENT s a grade “3” based on her clinical findings. Being a grade three would validate approximately 76 weeks of care. However having instability and a loss of the cervical curve as can lead to further pathologies if left untreated. This is why I still recommend care in my office and her doing traction at home.

CAD GUIDELINES

Grades of severity of CAD injury:

Grade I minimal, no limitation of motion, no ligamentous injury, no neurological findings

Grade II slight, limitation of motion, no ligamentous injury, no neurological findings

Grade III moderate, limitation of motion, some ligamentous injury, neurological findings

present

Grade IV moderate to severe, limitation of motion, ligamentous instability, neurological findings

present, fracture or disc derangement

Grade V severe, requires surgical management/stabilization

Frequency and duration of care in CAD trauma:

Daily 3x/w 2x/w 1x/w 1x/mos. TD TN

Grade I 1w 1-2w 2-3w 4w – 9w 17

Grade II 1w 4w 4w 4w 4 mos. 25w 29w

Grade III 1-2w 10w 10w 10w 6 mos. 56w 76w

Grade IV 2-3w 16w 12w 20w

Grade V Surgical stabilization necessary — chiropractic care is postsurgical

Activities of daily living.

I have taken the time to discuss what the research shows will happen with a lost the sagittal

alignment as well as instability. However, this can affect people in many different ways. The

spine from the side view is supposed to act as a shock absorber. When the sagittal alignment

changes the spine can no longer act as a shock absorber and the stress that is transmitted

through the spine is no longer normally redistributed. This abnormal alignment will cause

increased stress on the different areas of the fine making it harder for the patient to do tasks

through the normal activities. PATIENT does like to stay active which I have encouraged her to

continue to do as there are many health benefits to exercise. However some activities that are

associated with exercising like jumping or looking down can put her spine in a more susceptible

position, potentially increasing the likelihood of pain and flareups. The same can be true for her

cervical instability. This is an injury as I mentioned above that left untreated will get worse and

her spine is already in weaker position because the normal lordosis is not been restored,

making her more susceptible to further injuries and pain.

I have mentioned that PATIENT can go to a physiatist for possible injections to minimize her

pain. She did not want to do that as she did not want to get her spine injected with a form of

medicine and she was not convinced that it would help her heal. At this point, she has decided

to stop treatment as she is afraid of incurring any more bills since the insurance company at

fault has not paid for any of her treatment so far. She is doing traction at home which is going

to help keep yourself active to have encouraged her to continue with care here until we can

restore the curve and minimize degenerative process that most likely will occur.

PATIENT has done well with care from a pain perspective but I’m still concerned with the long-

term consequences of her injuries as they can lead to chronic problems and disability. The

future treatment would still have been to three times a week which would consist of specific

chiropractic adjustments traction, physical therapy and home treatment. This would average

approximately $120-150 a visit. This is considered reasonable necessary and falls within the cat

guidelines as well as the research I have attached in this report. As you can see we did make

good structural changes to her sagittal cervical curve but she is not with in a normal range. (18-

19)

1)2) Whiplash produces an S-shaped curvature of the neck with hyperextension at lower

levels. Spine volume 22, number 21, PP 2489 – 2494.3) Decreased vertebral artery hemodynamics in patients with loss of cervical lordosis. Med

sci monit 2016.4) Impact of cervical sagittal alignment parameters on neck disability. Spine volume 41

2016.

5) Apoptosis of endplate chondrocytes in post- laminectomy cervical kyphotic deformity. Eur Spine J 2013

6) Straightened cervical lordosis causes stress concentration: a finite element model study. Australa phy Eng Sci Med 2013

7) spinal kyphosis causes demyelination and aroma loss in the spinal cord. Spine 20058) cross-sectional study of neck pain and cervical sagittal alignment in Air Force pilots.

Aerospace medicine and human performance 20159) cervical radiographic parameters in one and two level anterior cervical discectomy and

fusion. Journal of neurosurgery spine 2016.10) Sagittal and balance the risk factor for adjacent segment Pathomechanics after

multilevel fusion. Spine 201611) cervical spondylotic myelopathy associated with kyphosis or sagittal sigmoid alignment.

Journal of neurosurgery spine 2009.12) Preinjury cervical alignment affecting spinal trauma. Journal neurosurgery 200213)

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