When a client is diagnosed with a cervical sprain or strain after a motor vehicle collision, it can be easy for the case to settle into a familiar pattern.
The client has neck pain. Initial imaging does not show a fracture or another obvious structural injury. Treatment begins. The claim is eventually characterized as a soft-tissue case.
But what if the original diagnosis does not tell the whole story?
In some cervical trauma cases, damage to the ligaments that stabilize the spine can produce Alteration of Motion Segment Integrity, or AOMSI. Because this abnormal movement may not be visible on routine imaging or to the human eye, the injury can go undetected unless the appropriate testing and measurements are performed.
For personal injury attorneys, recognizing a few potential red flags can help identify cases that may deserve a closer medical review before they are treated as routine sprain-and-strain claims.
Red Flag #1: Neck Pain Continues Longer Than Expected
One of the first reasons to take a closer look is persistent cervical pain following a collision.
While some patients recover uneventfully from a spinal injury, others continue to experience pain long after the initial trauma. When cervical ligaments have been partially torn or stretched, the affected vertebral segment may lose some of its normal stability.
The body may attempt to compensate for that excessive movement by tightening the surrounding muscles to protect the injured joint. This can result in continued muscle guarding and spasms.
For attorneys, continued symptoms should raise a simple question:
Has the underlying cause of the client’s ongoing pain actually been identified?
If the medical records continue to repeat diagnoses such as cervical strain without addressing possible ligament instability, additional evaluation may be warranted.
Red Flag #2: The MRI Is Normal, but the Client Still Has Symptoms
A normal MRI does not necessarily end the inquiry into cervical instability.
Cervical instability has historically been difficult to diagnose because traditional imaging often evaluates the spine in a neutral or stationary position. The problem with AOMSI is that the abnormality involves movement between adjacent vertebrae.
That means a patient can have signs and symptoms of cervical instability while a neutral MRI appears normal.
For an attorney reviewing the case, this distinction is important.
A normal MRI may answer one question about the cervical spine, but it may not answer whether the vertebral segments are moving abnormally when the neck flexes or extends.
If the client continues to experience symptoms despite relatively unremarkable static imaging, attorneys should determine whether the medical evaluation included appropriate motion studies.
Red Flag #3: No Flexion and Extension X-Rays Were Taken
AOMSI involves abnormal translation or angular motion between adjacent vertebrae. Detecting that movement requires evaluating the cervical spine during motion.
Flexion and extension radiographs can provide the images necessary to assess whether adjacent vertebral segments are moving beyond the criteria established for spinal stability.
If the client’s records contain only neutral X-rays, CT imaging, or an MRI, ask whether the cervical spine was ever evaluated in flexion and extension.
This is particularly important when trauma has occurred and the patient continues to report neck symptoms.
The absence of motion studies does not mean AOMSI is present. It does mean the records may not contain the information necessary to determine whether it is present.
Red Flag #4: Motion Studies Were Taken, but Nobody Measured Them
Obtaining flexion and extension X-rays is only part of the evaluation.
The abnormal movement associated with AOMSI can involve very small measurements. Historically, physicians attempted to calculate that movement manually using radiographic landmarks such as George’s Line.
Computerized Radiographic Mensuration Analysis, sometimes referred to as CRMA or DRMA, provides a method for quantitatively measuring translation and angular motion between vertebral segments.
For attorneys, the practical question is straightforward:
Were the motion X-rays simply reviewed, or were they actually measured?
A radiology report that does not mention instability does not necessarily mean that computerized mensuration was performed.
If the client has persistent symptoms and flexion-extension films exist, determining whether those images were quantitatively analyzed may be worthwhile.
Red Flag #5: The Case Is Being Treated as a Simple Sprain or Strain
The distinction between a cervical strain and a qualifying ligament injury can have significant implications.
AOMSI is classified within the AMA Guides’ Diagnosis Related Estimate framework as a serious spinal impairment. Total cervical translation greater than 3.5 millimeters is described as a DRE Category IV permanent impairment carrying a 25% to 28% Whole Person Impairment rating.
That is a very different medical characterization from a temporary sprain or strain.
The issue for attorneys is not to assume that every whiplash patient has AOMSI. The issue is to make sure a potentially significant ligament injury has not been overlooked simply because the original records used a more general diagnosis.
If the symptoms, history, and clinical course do not seem consistent with a routine injury, it may be appropriate to ask whether ligament integrity was ever evaluated.
Red Flag #6: The Collision Is Being Minimized Because Vehicle Damage Was Limited
A low-speed collision should not automatically eliminate consideration of cervical ligament injury.
AOMSI can occur following motor vehicle trauma, including collisions that may be considered low speed. The forces transmitted during the event can be sufficient to damage the ligaments that stabilize the vertebrae.
For attorneys, this becomes especially relevant when an insurer attempts to equate limited vehicle damage with an inability to sustain a meaningful cervical injury.
The condition of the vehicle and the condition of the client’s cervical ligaments are separate questions.
The medical evaluation should focus on whether objective evidence of injury exists.
Red Flag #7: Nobody Has Evaluated the Client for Permanent Impairment
A client may complete months of treatment without anyone determining whether the cervical injury resulted in permanent impairment.
When the findings meet the applicable criteria for AOMSI, the AMA Guides provide a framework for assigning Whole Person Impairment.
This matters because an impairment rating gives the attorney a standardized way to communicate the severity and permanency of the injury.
Instead of presenting only:
“My client still has neck pain.”
The medical evidence may be able to establish:
The client has objectively measured abnormal cervical motion that satisfies
established criteria for a permanent spinal impairment.
Those are very different presentations of the same case.
Timing Matters
Ideally, possible cervical instability is considered during the medical evaluation rather than discovered after the claim has already been negotiated.
When trauma is suspected and symptoms continue, the treating physician can determine whether appropriate motion studies and specialized analysis should be considered.
Early identification also helps ensure that the medical records accurately describe the injury.
That documentation matters because attorneys and adjusters rely heavily on the patient’s medical chart when evaluating a personal injury claim. If the records repeatedly identify only a sprain or strain because more specific testing was never performed, the case may be evaluated on incomplete medical information.
Waiting until litigation is well underway can make the process more complicated.
A Quick Screening Checklist for Attorneys
When a client has ongoing neck complaints after a motor vehicle collision, consider reviewing the file for these questions:
- Does the client continue to experience cervical symptoms?
- Was the injury diagnosed only as a sprain, strain, or other general soft-tissue injury?
- Were the initial MRI or other static studies relatively unremarkable despite continued symptoms?
- Were cervical flexion and extension radiographs obtained?
- If motion studies were obtained, were they quantitatively measured?
- Was Computerized Radiographic Mensuration Analysis performed?
- Was ligament laxity, cervical instability, or AOMSI ever considered?
- Was the client evaluated for Whole Person Impairment under the AMA Guides?
A “no” to one of these questions does not establish that AOMSI exists.
But several unanswered questions in a client with continuing symptoms may indicate that the cervical injury deserves a closer look.
The Bottom Line
Not every whiplash case involves a permanent ligament injury.
But not every case labeled “soft tissue” is necessarily just a temporary sprain or strain either.
When a client continues to experience neck symptoms, particularly when routine imaging has not explained those symptoms, attorneys should consider whether the cervical spine has been evaluated for abnormal motion and ligament instability.
AOMSI cannot be identified simply by asking how much the client hurts. It requires the appropriate imaging, objective measurements, and application of established diagnostic criteria.
For attorneys handling cervical spine injury cases, recognizing when those steps are missing can help ensure that an overlooked injury does not become an undervalued one.
Dr. Richard Falcone provides case reviews and expert witness services for attorneys handling whiplash and cervical spine injury cases in Allegheny County, Pennsylvania.