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Szabo, T., Welcher, J., Anderson, R., Rice, M. et al., Human Occupant Kinematic Response to Low Speed Rear-End Impacts, paper no. 940532 SAE (Society of Automotive Engineers) "Human Occupant Kinematic Response to Low Speed Rear-End Impacts," SAE Technical Paper 940532, 1994
Croft AC: The case against "litigation neurosis" in mild head injuries and cervical acceleration/deceleration trauma. J Neuromusculoskeletal System, 1(4): 149-155, 1993
Croft AC, Swenson RS, Tarola GA, Vernon H: Grand rounds: Symptoms following a motor vehicle accident. J Neuromusculoskeletal System 3(4):203-210, 1995
Croft AC, Freeman MD: Correlating crash severity with injury risk, injury severity, and long-term symptoms in low velocity motor vehicle collisions. Med Sci Monit 2005 11(10):RA316-321
Croft AC, Philippens, MMGM: The RID2 biofidelic rear impact dummy: a validation study using human subjects in low speed rear impact full scale crash tests. Neck injury criteria (NIC). 2006 SAE World Congress, Technical Paper Series 2006-01-0067, April 3-6, Detroit, MI, 2006
Croft AC: Human subjects exposed to very low velocity frontal collisions. Journal of Biomechanics 39 (Supplement 1) S146, 2006
Croft AC, The Neck Injury Criterion (NIC): Future Considerations. 44th Annual Proceedings of the Association for the Advancement of Automotive Medicine, Chicago, IL, October 1-4, 2000, 519-521
Croft AC, Haneline MT, Freeman MD: Differential occupant kinematics and head linear acceleration between frontal and rear automobile impacts at low speed: evidence for a differential injury risk. International Congress on WAD, Berne, Switzerland, March 9-10, 28, 2001
Freeman MD, Nicodemus CN, Croft AC, Centeno C: Significant spinal injury resulting from low-level accelerations: a case series of roller coaster injuries. Cervical Spine Research Society 29th Annual Meeting, Monterey, CA, Nov 29-Dec 1, 2001
Croft AC, Haneline MT, Freeman MD: Differential Occupant Kinematics and Forces Between Frontal and Rear Automobile Impacts at Low Speed: Evidence for a Differential Injury Risk, International Research Council on the Biomechanics of Impact (IRCOBI), International Conference, Munich, Germany, September 18-20, 2002. 365-366
Functional Overlay Method of X-Ray evaluation following RTA, (Opinion):
Despite the fact that every person who was initially trained as a chiropractor remembers George's Line from Roentgenology, most still do not understand its true significance. In personal-injury cases, it is the most important test a spinal manipulation health care professional can do when examining the patient with neck pain. This is done using the functional overlay method of x-ray evaluation of the cervical spine.
This measures with astonishing accuracy the condition of a patient's neck and the patient's long-term prognosis after the very first examination.
When the treating doctor, chiropractor, osteopath, physical therapist or other spinal manipulator does not specifically measure breaks in George's Line on both the flexion lateral and extension lateral cervical films, it is impossible to assess or to settle the personal injury case for its true value.
Fact: The AMA's Guidelines 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 (if taken) and ignore it or fail to appreciate its significance.
Clinical Practise Opinion: The functional overlay method of evaluation of the cervical spine can measure with accuracy, changes in functionality of cervical ranges of motion in neutral lateral, flexion and extension - post trauma initially and following 3-6 months of spinal manipulation following RTA with neck pain.
One well-known chiropractory organization lists that the significance is a sprain with subluxation; a strain with subluxation; or possible fracture of the neural ring. An RTA patient is done a great disservice if that is all that is known 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 MVA/RTA patients who present for care have something in between, namely ligament partial damage leading to pain 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 Guide to Impairment uses this key landmark as the basis for rating permanent spine impairments. It is extremely valuable for the treating spinal manipulator or if it is a regulated chiropractor to have a working knowledge of ligament laxity in the cervical spine. It is a ICD-9 diagnosis code (728.4) recognized by Colossus that allows essentially ongiong treatment in RTA trauma patients. Unlike an ICD-9 Diagnosis of sprain/strain (847.0), Colossus 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 that a chiropractor or other practitioner has failed to diagnose it many, many times. By failing to diagnose this injury, the chiropractor has failed to accurately, thoroughly and honestly describe a patient's injuries to the claim adjusters and attorneys, who will use the facts in that patient's chart as the basis for the personal-injury settlement. I may point out that clinical practise is one of three tiers of what is defined as Evidence Based Practice.
These people need their spinal manipulation health care professional or chiropractic doctor to give them all the facts so a fair settlement can be reached after a RTA with neck damages. The court also needs to understand the patient had this injury in order to decide how much to award the patient in a settlement verdict.
Functional Overlay Method of Measuring Ligamentous Laxity and Recovery following Spinal Manipulation or Chiropractic Treatment in CADS. 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 we see a possible break in the line, drawing the 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 Below) This gives 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.
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. 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.
Another method is to mark the anterior inferior and anterior superior margins of the vertebrae on neutral lateral, flexion and extension films at the presentation of the patient, followed by remensuration at three months and, if needed, six months. Clinically, there should be less anterior or retrograde translation following RTA chiropractic care or spinal manipulative care as in this clinician's case. The second method is this clinicians preferred method, as it is more accurate to overlay the films and gives an exact measurement of translation either anterior or retrograde, and shows the reduction in movement post-treatment.
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 spinal adjustment appointment because you have rapid-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 again spasm, the patient experiences painful neck muscles, and they are back in the chiropractor's or spinal manipulation professional's office for treatment. This pattern often continues for 2-3 years until the two vertebrae start to fuse together by the process of DJD, leaving a chronically stiff neck for which the patient will always need a spine manipulator in order to maintain as much functional range of motion as possible.
A patients' neck X-rays which are evaluated in this manner and when there are no measurable translation instabilities present, you can generally assure them that they have a simple sprain/strain and/or spinal subluxations that will probably heal completely within a few months. Patients with simple sprain strains (no ligament partial ruptures) get well and stay well - some with periodic future care. Patients with ligament partial ruptures do improve somewhat, and those with more significant partial ruptures approaching 3.5mm, simply do not.
Complied from opinion from practice and additional, main compilation from legal opinion of Dr Steve Eggleston, DC, Esq - Doctor of Chiropractic, Personal Injury Attorney
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"This is an informational video about what happened to a vehicle occupant historically during Biomechanical Research and Testing of live human subjects, and elements of which possibly may be similarly repeated in another low-speed collision.
Of note: Some persons are resilient and can go through a low speed collision and endure it without suffering any apparent adverse musculoskeletal (spinal) effects. *However this is not always the case. To be clear, we are not making any claims about the probabilities of you or another person's specific injuries or need for future chiropractic or medical care. These are purely educational videos." This clinic is licenced to show this video.
- Dr Leah Remeika-Dugan, Doctor of Chiropractic Degree 1997, Expert - Association of Personal Injury Lawyers, UK
Disclaimer: This video content has been produced by a third party to be helpful, but is for general educational purposes and it does not intend to imply that specifics are prescriptive for a particular patient's case. Please discuss your case with a competent and qualified doctor of chiropractic, spinal manipulative practitioner, or other health care professional.