Do doctors miss instability?

Disclosure:

Medical Disclaimer: The content shared in this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay seeking it because of something you’ve heard on this podcast.

Legal Disclaimer: Similarly, the legal information provided is not a substitute for legal advice. Laws and regulations can vary widely by jurisdiction, and the application of the law depends on the specific circumstances of each situation. Please consult a licensed attorney for personalized legal advice pertaining to your case.

Welcome back to the Forensic Chiropractor podcast.

A lot of my podcasts cover ligament damage.  I covered objective evidence of spinal ligament damage on lots of my podcasts.  I covered what these injuries are like for patients.  The ligaments inability to completely heal after damage and the ongoing dysfunction.  I want to talk about spinal ligament damage and cover a case report published in the Korean Spine Journal in 2015 titled Delayed or Missed diagnosis of Cervical Instability after Traumatic Injury: Usefulness of Dynamic Flexion and extension Radiographs by Chang Gi. 

Missed or delayed diagnosis of spinal instability can lead to serious injuries.  These serious injuries ranges from ongoing pain, musculoligament dysfunction, and neurological compromise as serious as paraplegia.  Today’s study showed that there is delay or missed diagnosis of cervical spine instability in up to 20% of cases.  That seems crazy that 1 out of every 5 patients with cervical instability don’t know they have it do to missed or delayed diagnosis. 

I think I understand how cervical instability is missed so frequently.  I do not know how many people understand instability and how to assess for this.  While doing IMEs I read a lot of radiology reports on cervical x-rays with flexion and extension and they typically report no instability seen.  There are rarely any measurements given from the x-rays.   I will also see a diagnosis of cervical instability with no measurements done to verify this. 

  Today’s study brought up another reason for delayed imaging.  When a patient is in a lot of pain flexion and extension x-rays may not show what we need.  If there is a significant amount of pain that is limiting flexion and extension movement the x-rays will not show us instability.  If there is a high level of uncertainty about cervical spine damage static imaging should be done prior to flexion and extension imaging. 

In my office I almost always do x-rays from trauma patients to assess for fractures and other damage.  If disc damage or neurological compromise is noted I will almost always get an MRI.  If the examination shows decreases in cervical range of motion, I will wait to get flexion and extension x-rays.  This waiting is likely part of the reason for the 20% of instability diagnosis being missed or delayed.

Today’s study covered 4 patients with missed cervical instability several days to weeks following traffic collisions.  All of these patients had neck pain without neurological deficits.  All of these patient had initial imaging without flexion and extension.  On imaging only one of these patient had any findings and that was a spinous process fracture. 

To summarize these 4 patients all had a MVC with neck pain and basically negative imaging.  The first case was a 57-year-old female in a rollover MVC.  She had multiple fractures in her extremities and a C5 spinous process fracture.  The spinous process fracture did not involve the lamina.  She had a cervical spine MRI that showed posterior ligament signal changes making suspicion of ligament damage more likely.  Conservative treatment was done for 9 weeks with little to no progress with her neck pain.  After 9 weeks they did the flexion and extension x-rays to assess for instability.  She had severe cervical instability at C5-6 and underwent A C5-6 fusion. 

The second patient was a 46 year old man who was in a MVC.  He had neck pain after the MVC and following x-rays, a CT scan and an MRI he was diagnosed with cervical sprain.   Again his MRI showed subtle high signal in the posterior ligaments that increased the suspicion of ligament damage, but flexion and extension x-rays were not taken.  His neck was not improving and after 7 weeks flexion and extension x-rays were taken.  These flexion and extension x-rays showed severe instability at C5-6 and he had a C5-6 fusion. 

The third and fourth patients were a 61 year old man and his 56 year old wife who were in the same MVC.  They both came to the emergency room with mild neck pain.  X-rays and CT scans showed a loss of cervical lordosis, but no other acute findings.  They were placed in cervical collars and underwent conservative treatment (they do not say what type of treatment).  No MRI imaging was done.  There neck pain persisted and the symptoms got worse over time.  3 days after the MVC flexion and extension x-rays were taken and both of these patients had severe instability at C4-5 and both of them had fusions at C4-5. 

All 4 of these patients had severe instability that required surgical fusion.  All of these patients had lots of imaging done that did not show instability.  2 of them had MRIs with high signal in the ligaments indicating ligament damage.  All 4 of them were sent away for conservative treatment.  The symptoms persisted and eventually up to 9 weeks later flexion and extension x-rays were taken.  All of these patients were so bad that surgery was needed. 

This study stresses the fact that MRI, CT and static x-rays did not act as a crucial diagnostic modality for these patients. This study stresses the importance of flexion and extension x-rays with persistent neck pain with normal  static x-rays.  This study reported that there are 3 main reasons for delayed or missed diagnosis of cervical instability.  The first is misinterpretation of imaging.  The second is no flexion and extension x-rays were taken.  Third was limited neck motion while doing flexion and extension x-rays. 

This study shows that a lot of patients in the emergency room have limited cervical spine range of motion make it not only difficult to get flexion and extension x-rays, but can lead to a lot of false negative tests.  This is one reason it is important for physicians to consider doing flexion and extension x-rays with patients days to weeks after an injury once range of motion improves, but symptoms persist. 

Real world

Now for a real world example.  I have a few thoughts for today’s real world example.  The first is for providers and billing.  Although billing has a large impact on litigation and attorneys.  If the patient just had x-rays and CT scans in the emergency room should I take x-rays again when they come to my office.  I know if I do often I will get the claim denied.  A lot of insurance companies do not like to pay for imaging especially if it was just done.   The thing insurance companies do not understand is the different types of imaging and perhaps why more x-rays were taken.  Today’s study is a great justification to take flexion and extension x-rays even if the patient just had static x-rays, CT and MRIs.  I have had adjusters and even attorneys ask why I would take flexion and extension x-rays since the patient already had an MRI.  They assume that MRI is the best type of imaging and all pathology will be seen on the MRI, and that I am overbilling and there is no way more x-rays are needed and they surely couldn’t show anything that the MRI did not show.  This study has been helpful to try to explain that  there is still an important place for x-rays even if an MRI has been done. 

The second thought I have for a real world example would be with my IMEs.  My job on an IME is to find objective evidence of an injury if it exists and to give an opinion on causation.   Objective evidence is often best done with imaging.  I have a lot of IME patients that have had multiple imaging studies done, but no flexion and extension x-rays to assess instability.  I have had some of these patient who have had the flexion and extension x-rays done with no measurements done.   If the neck pain has persisted for weeks to years without instability assessment then it is long overdue and needs to be done.  I will often taken the flexion and extension x-rays for an instability assessment.  Often if instability is seen on flexion and extension x-rays taken years later causation can be more difficult.  Prior podcasts have talked about causation with ligament damage.  It can be more difficulty, but not impossible. 

The third thought I have for a real world example is that most people do not understand this topic.  A lot of physicians do not seem to understand this topic or how to measure for instability.  A lot of attorneys do not understand this topic and how significant it can be for patients.  Insurance companies do not seem to understand this topic either.  Today’s study is another way to help educate others on ligament damage.  Cervical instability is missed a lot or at minimum the diagnosis is delayed.  It is a serious injury that we can show objectively. 

THANKS