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Ligament Handbook – 3rd Edition
Legal Prescription Form

Foreword 

Douglas E. Schmidt, a personal injury lawyer with over 40 years  experience in handling neck and back injuries resulting from CAD  (Cervical Acceleration/Deceleration) trauma says this: 

DMX is the single greatest medical development in my 40  year career as a personal injury lawyer. Combined with  CRMA analysis and multi-positional upright MRIs, we  now have solid objective proof of ligamentous and disc  injuries that couldn’t be objectively proved in the past. 

We have known for many years that ligamentous injury is  at the core of all Cervical Acceleration/Deceleration injuries  (CAD). However, until recently there was no objective proof  of ligamentous injuries. DMX now provides that proof. 

For the first part of my legal career as a personalinjury lawyer, we didn’t have MRIs—and, in turn, no imaginable  proof of disc injuries. When I started seeing MRI scans  proving the existence of disc injuries, I was sad for all of  those past clients who didn’t get justice because they  couldn’t prove their disc injury. 

I am now seeing case after case where my clients’  

ligamentous injuries are now objectively proven. I can’t  help but reflect on all the victims of whiplash injuries that  haven’t received the justice they deserved because there  was no objective proof of ligamentous injuries. 

Now, the good news!!! This combination of technology has  come together as the biggest single medical advancement  of my 40+ year legal career!!!

The Golden Triangle now provides objective proof of  ligamentous injury and the devastating consequences of  the accelerated degeneration that follows: 

-Digital Motion X-ray (DMX); 

-Computerized Radiographic Mensuration Analysis  (CRMA); 

-Motion MRI. 

Virtually 100% of the DMX’s that have been done on my  clients have revealed objective proof of ligamentous laxity.  (They have been carefully selected, i.e. the majority being  clients with significant symptoms lasting more than 1 year  after the car accident.) 

It is well established in the medical literature that flexion extension trauma results in accelerated degeneration of the  spine including the intervertebral discs. Until recently, that  has only been a theoretical concept based on clinical  observations. Recently, I have “circled” back and sent a  number of my client back for repeat MRIs. The results have  been astounding, showing clear proof of shockingly  accelerated degeneration of the intervertebral discs in a  matter of just a few years. See Appendixes A and B for case  examples. 

The evidence that DMX videos provides in the court room  setting is also amazing. In the very first case in which DMX  was introduced as evidence in a court trial, the jury was  obviously fascinated. They “scooched” forward on their  seat, craned their necks forward, and stared “buggy-eyed” at the screen as the DMX film played out. The result was a  jury verdict of $743,188.95 in a case where the last formal  offer before trial was only $10,000.00. See Appendix C for a  copy of the jury verdict in that case.

DMX is an amazing technological development. It is well  recognized and respected in the medical literature—but the  large majority of the medical community has virtually no  knowledge of it. It has been accepted as reliable evidence  in court in a number of cases. The courts and arbitrators have accepted DMX/CRMA in nearly 50 cases where the  Schmidt Law Firm has represented the injury victim without  a single case where it has been rejected. 

The purpose of this Handbook is to provide basic  information about the value of DMX in medical, chiropractic  and legal practice. 

Respectfully submitted, 

Douglas E. Schmidt  

Schmidt Law Firm  

952-473-4530 

schmidtlaw@visi.com

TABLE OF CONTENTS 

DMX Provides Objective Proof for the Diagnosis of Ligamentous Injuries 

  1. Ligamentous injury is at the core of all CAD (Cervical  Acceleration/ Deceleration) injuries. 
  2. CAD trauma causes stretching of cervical ligaments beyond  their anatomical limit. 
  3. Over-stretching of ligaments causes “plastic” deformity. 
  4. Many injuries of the cervical spine are ligamentous injuries  which are permanent. 
  5. “Sub-failure” (stretch only- no tear) ligamentous injuries are  serious! 
  6. Ligamentous Damage causes Instability of the Spine. 
  7. Ligament injuries produce two types of “motion segment”  impairment- translational and angular. 
  8. It’s all about motion!!! 
  9. How does DMX work? 
  10. DMX can detect ligamentous laxity that static X-rays cannot  see.
  11. DMX is respected by the chiropractic community.
  12. DMX is respected by the U.S. Government. 
  13. DMX is respected by the medical community.
  14. DMX has been accepted as reliable evidence by the courts. 
  15. CRMA can quantitatively analyze the extent of the  ligamentous laxity. 
  16. CRMA can be used to establish a percentage of impairment  rating using the AMA Guides rating system. 
  17. DMX scans can be used to provide an AMA-based disability  rating. 
  18. How we know that the ligamentous laxity was caused by  CAD trauma. 
  19. Ligamentous laxity causes accelerated degeneration of the  intervertebral discs. 
  20. When ligamentous laxity is demonstrated, later repeat MRIs  can, in some cases, objectively prove accelerated  degeneration. 
  21. DMX, and Weight-Bearing MRI can be extremely  valuable in proving major impairment hat previously  were dismissed as minor “soft tissue” injuries.
  22. Flexion-Extension MRIs provide a method for detecting  herniationsthat are not observable in conventional MRIs. 
  23. DMX provides proof of the cause of Facet Joint Injuries. 
  24. Ligamentous laxity is the primary cause of Myofascial Pain  Syndrome and trigger points. 
  25. Case studies-“Gina’s Case” and “Bruce’s Case”, provide  objective proof of accelerated degeneration of intervertebral  discs secondary to ligament damage. 
  26. The most important aspect of facet joint injuries is being  overlooked in many cases, namely the ligamentousinjury. 

Appendix A- Records from “Gina’s Case” 

Appendix B- Records from “Bruce’s Case” 

Appendix C- “Tony’s Case”-The jury verdict of $743,188.95

Ligamentous injury is at the core of all CAD  (Cervical Acceleration/Deceleration) injuries. 

It is well known that ligament damage is at the core of all Cervical  Acceleration/Deceleration injuries (CAD also known as flexion/extension injuries  or “whiplash” injuries.) 

Foreman/Croft in their classic textbook, Whiplash Injuries: The Cervical  Acceleration/Deceleration Syndrome explains this basic concept: 

Ligaments and related structures such as  the fascia and the discs are also damaged  or disrupted in CAD trauma. Both the ALL  

(Anterior Longitudinal Ligament) and the  posterior ligamentous complex  (intervertebral disc, zygapophyseal joint  

capsules, posterior longitudinal ligament,  ligamentous flavum, interspinous  ligament, and the ligamentum nuchae)  

have been shown experimentally…to rupture, either partially or completely. Ligaments of the upper cervical spine,  

such as a cruciform ligament, the suspensory and apical ligaments of the dens, and the alar ligaments also have  

been found to be ruptured or disrupted.

CAD trauma causes stretching of cervical  ligaments beyond their anatomical limit. 

CAD forces cause hyperextension and hyperflexion of the cervical spine. 

Hyperextension has been proven to cause damage to the anterior longitudinal ligament (ALL) and the facet capsular ligaments. Studies have  proven that 50-60% of the victims of chronic pain lasting more than one  year post accident have facet joint injury as the primary source of their pain.  See Lord et. al., “Chronic cervical zygapophysial joint pain after whiplash: a  placebo-controlled prevalence study,” which was published in Spine 1996;  21(15):1737-1745. 

Recent research reported in the Journal of Biomechanics reported that  injury to the apical and alar ligaments is common as the result of CAD  trauma, with damage to the alar ligaments occurring in 66% of whiplash  victims. See Fice et.al. “Investigation of whiplash injuries in the upper  cervical spine using the neck model,” Journal of Biomechanics, 45(6),  1098-1102 (2012). 

Hyperflexion has been proven to cause damage to the ligamentous flavum and the interspinous ligaments

Over-stretching of ligaments causes “plastic” deformity. 

Over-stretching, or excessive distension (hyper-elongation), of the  cervical ligaments results in “plastic” deformity instead of “elastic” deformity.

“Elastic” deformity is that which returns to its original shape, like a  rubber band. 

“Plastic” deformity is that which does not return to its original state and,  thus, results in the ligament remaining “stretched.” In other words, once  stretched, always stretched. 

A frequently used analogy is that of the plastic holder for a six-pack of  soda pop. When one pulls a can out of the plastic holder, it stretchesout  of shape and does not return to its original shape. The plastic holder will  no longer hold the can if one attempts to put it back. That is exactly  what happens with an over-stretched ligamentous injury. 

Many injuries of the cervical spine are  ligamentous injuries which are permanent. 

Plastic deformation is, by definition, permanent. Overstretched  ligaments heal with scar tissue. The following photographs show the  abnormal scar tissue formation in ligaments that have been injured due  to abnormal stretching in flexion-extension injury. 

As stated in Foreman/Croft, “The healing of ligamentous structure is  generally incomplete” (p. 183) and “plastic deformation or ligamentous  ‘sub failure’ (which is) still present after 4 months is likely to be  permanent.” (p. 185)

“Sub-failure” (stretch only-no tear)  Ligamentous Injuries Are Serious! 

Ligamentous injuries are classified in the medical literature in two  categories: 

  1. Failure Injuries-involving a total tear orrupture;  

And 

  1. Sub-failure Injuries involving a “stretching” without tear or rupture. 

Recent studies have proven that “sub failure” ligamentous injuries can be  as serious and often more serious than “failure” ligamentous injuries! A  recent article which appeared in the Journal of Biomechanics reported  studies done at the Orthopedic Bioengineering Research Laboratory of  Colorado State University where they took anterior longitudinal ligaments  (ALL) and ligamentum flavum (LF) from cadavers and subjected them to  whiplash-type trauma. The results were: 

  1. Stretch (distension) damage resulted in abnormal laxity equal to having “no ligamentous support” at all!!! 
  2. Partial injury to these ligaments resulted in laxity equivalentto “completely compromised” ligaments. 

Leahy, et al., “The Effects of Ligamentous Injury in the Lower Cervical  Spine,” Journal of Biomechanics, 15:2668-2672 (2012).

Ligamentous damage causes instability of  the spine. 

Instability of both the cervical and lumbar spine from trauma or the  resulting degeneration is recognized as a significant contributor to neck  and lower back pain and disability. Lin, “Characteristics of Sagittal  Vertebral Alignment in Flexion Determined by Dynamic Radiographs of the  Cervical Spine,” Spine, Vol. 26, No 3, pp 256-261 (2001). 

The American Academy of Orthopedic Surgeons defines instability as  “Segmental instability (which) is an abnormal response to applied loads,  characterized by motion in motion segments beyond normal constraint.”  See American Academy of Orthopedic Surgeons, A Glossary on Spinal  Terminology, 1985:34. 

Ligament injuries produce two types of  “motion segment” impairment 

translational and angular. 

The primary function of ligaments is to hold the vertebrae inplace. Ligamentous “stretch” injuries produce ligamentous laxity. Ligamentous  laxity, in turn, causes abnormal movement of the vertebrae that can be  seen on X-ray. The ligaments don’t show up on the DMX. However, the  abnormal positioning of the vertebra in the cervical spine does show upon  an X-ray. It is a simple fact that the function of ligaments is to keep the  vertebrae in their normal anatomical position. Abnormal positioning of  the vertebrae results from ligamentous laxity. Therefore, the abnormal  positioning of the vertebrae proves the damage of the ligaments, i.e.  ligamentous laxity. 

Medical literature has long ago established two types of motion segment  impairment resulting from ligamentous laxity:

  1. Translational irregularity and 2. Angular irregularity

The AMA Guides has, since 1993 recognized the concept of “Alteration of Motion Segment Impairment” (AOMSI). The AMA Guides to the Evaluation of Permanent Impairment, 4th Ed (1993) illustrated the concepts of Loss of Motion Segment Integrity, both in terms of “translation” motion and angular motion as follows:

Foreman/Croft are in total agreement. They used a similar illustration of  the same concept in 1995: 

Loss of translational motion segment integrity can result in both  retrolisthesis (the backward displacement of one vertebra in relation to  the vertebral body immediately below it) or anterolisthesis (forward  displacement). Trauma is a well-recognized cause.

See the illustration below which shows both anterolisthesis (top left) and  retrolisthesis (bottom left) due to rupture of the capsular ligament: 

Note: Medical research has proven that overstretching of these ligaments  without tear or rupture results in almost the same amount of laxity aswith  a tear or rupture.

It’s all about motion!!! 

Most patients complain that their worst pain is with movement, and  repetitive movements that aggravate their symptoms, producing muscle  spasm, myofascial pain, and disability. It is motion that causes the  symptoms. It makes perfect sense that scanning during motion is more  likely to reveal the problem. 

In simple language, when people  

are hurt in motion, diagnostic tests  

must be done in motion to properly  

detect the full extent of 

the problem. DMX does that!!! 

As the old saying goes, “The proof is in the pudding.” Anyone who has  actually watched DMX films that show ligamentous laxity have seen that  ligamentous laxity is revealed on certain motions and not others. 

The reason is simple. Even with DMX, the viewer cannot see the  ligaments. The structural integrity of the ligaments can only be assessed by observing the movement of the vertebrae in relationship to other vertebrae. Only by using X-rays taken during movement can the accurate  and complete assessment of ligamentous integrity be done. It is only  abnormal movement of the vertebrae that reveals the ligamentous laxity  caused by the excessive stretching of the spinal ligaments. Conversely,  when the cervical spine is not moving, there is no way to assess the  relative motion of the vertebrae in relation to each other. 

For 20 years, the AMA Guides have recognized “Alteration of Motion Segment Integrity” (AOMSI) as the basis of permanent impairment of the  spine and have recognized that they cannot be determined by physical  examination. Instead, flexion-extension X-rays are required:

Motion of the individual spine segments cannot be determined by physical examination, but is evaluated with  flexion and extension roentgenograms (see Figures 15-3a  through 15-3c) AMA Guides, (5th Ed. 2001) 

But how can static X-rays show abnormality occurring in motion? It is  simply nonsense to suggest that that could happen. Instead, motion X rays are needed to show motion abnormalities!!! 

Note: During the acute phase of the injury, muscle spasm creates  hypomobility of the cervical spine. Accordingly, the abnormal  excessive motion resulting from ligament damage cannot be  expected to be revealed on digital motion X-ray. 

How does DMX work? 

The concept is quite simple. DMX is simply a “moving picture” using a series of X-rays to create a “movie.” 

X-rays were discovered in 1895 by Professor Roentgen in Germany.  

Thomas Alva Edison obtained the first patent for a moving pictureor “movie” in 1908. (A movie or motion picture is simply a series of still  photographs shown on the screen moving from one image to another with  such speed that the human brain perceives it as a moving image.) 

So why did it take so long to put 2 + 2 together, adding the X-ray and the  moving picture together? The problem was that of the excess radiation  that previously would result from taking all of the X-rays that are  necessary to create an X-ray “movie.” The problem has been solved. 

Digital Motion X-ray utilizes X-ray technology, and couples it with new  digital and optic technology in the image intensifier to create high-resolution images of the spine and skeletal system in real-time motion.  DMX can produce 2700 still X-rays with the same radiation dose as the  seven (7) view Cervical Davis series. 

DMX testing is performed while the patient is in a weight bearing standing  position and moving the body through different arcs of motion. Each arc of  motion is specific to test an anatomical structure (Specific Group of  Ligaments). Each arc of motion is a complete independent study that  focuses on the anatomical structures found in that arc of motion. 

The intended use for Digital Motion X-ray is to visualize suspected  intersegmental joint dysfunction by evaluating all 22 major cervical  ligaments with 2700 X-ray images. DMX is the only moving diagnostic test  that is performed in a weight bearing position. (This is not a “chiropractic  X-ray” designed to look for “subluxations”). 

There are two types of Ligament Injuries: 

  1. Sub-failure-When a ligament stretches or partially tears.
  2. Complete failure-When a ligament is completely severed. 

Digital Motion X-ray is the only test that will detect sub-failure ligament  injuries. MRI does not have the resolution to detect the stretching or an  elongation of a ligament. MRI can detect a complete failure, which is  commonly seen in the knee and shoulder. Sub-failure ligament injuries are  most commonly seen in the Cervical Spine, TMJ, and Wrist. 

DMX can provide valuable information about the stability of all 22 major  ligamentous structures in the cervical spine (anterior and posterior  longitudinal, facet/capsular, alar, transverse, and accessory ligaments).  The upper 30% of the cervical spine gets its stability from ligaments only.  There are NO discs in the upper 30% of the cervical spine between  Occipital C1 and C2. Digital Motion X-ray is used in demonstrating  posttraumatic instability in the neck that may be responsible for posterior  neck pain, headaches, and referred pain.

DMX provides objective proof of injury which provides substantiation to insurance companies for continued treatment. 

DMX can detect ligamentous laxity that  static X-rays cannot see. 

Because DMX can X-ray the vertebrae in motion, it is able to detect  ligamentous laxity that static X-rays cannot see. As noted by  Foreman/Croft, static X-rays don’t reveal major ligamentous injuries: 

Most of these (static X-ray) studies…fail to define movement  in a dynamic sense…deviation from the normal biokinetics  may occur somewhere between these arcs of motion, which  would not be visualized by static radiographic techniques. 

Foreman/Croft reference a study by Buonocore in which 68% of the  whiplash injuries studied by DMX were interpreted as abnormal. Another  study by Woesner and Mitts reported that DMX detected abnormalities in  35% of the plain film studies that were interpreted as normal. 

DMX is respected by the chiropractic  community. 

In 1995, Foreman/Croft stated that: 

Videofluoroscopy is important in the evaluation of ligamentous instability… several studies have indicated the  value of videofluoroscopy in the evaluation of certain types of  soft tissue lesions of the neck… clinicians trained in the interpretation of these studies are able to interpret them  reliably (p. 53).

They continue to state that: 

(Videofluoroscopy has an) important role in the diagnosis of  instability of the cervical spine and, to some extent, in determining the prognosis regarding future disability. For  example, making them has shown that the healing of a  ligamentous structure is generally incomplete; this instability  may result in early and accelerated degenerative changes  (Citing studies done by Panjabi and others). 

DMX has been approved by the Council on Chiropractic Practice:  Vertebral Subluxation in Chiropractic Practice Guidelines, 3rd Ed, Council  on Chiropractic Practice, 2008, p 318: 

Videofluoroscopy may be employed to provide motion views  of the spine when abnormal patterns are clinically suspected.  Videofluoroscopy may be valuable in detecting and characterizing spinal kinesiopathy associated with vertebral  subluxation. 

DMX is respected by the U.S Government. 

The AHQR (Agency for Healthcare Research & Quality of the U.S.  Department of Health & Human Services) recommends DMX in two  separate practice guidelines. The Guideline: Vertebral Subluxation in  Chiropractic Practice states: 

Videofluoroscopy may be employed to provide motion views  of the spine when abnormal motion patterns are clinically  suspected. Videofluoroscopy may be valuable in detecting  and characterizing spinal kinesiopathology associated with  vertebral subluxation.

The Guideline: Management of Whiplash Associated Disorders  states: 

Videofluoroscopy screening may be useful in and for evaluating for cervical instability injuries. Motion MRI (kinetic MRI) has been shown to demonstrate significant differences in biomechanical function between normal patients and injured patients following rear-end, low-impact  motor vehicle collisions. 

DMX is approved by the FDA. The FDA has classified the dynamic motion  X-ray system with a device classification name of “image-intensified  fluoroscopic X-ray system”, a regulation number of “892.1650”, assigned a  510(k) number of “k943272”. The machine has been classified as a “class  ii” device. Section 892.1650. Image-intensified fluoroscopic X-ray system,  and is a device intended to visualize anatomical structures by converting a  pattern of x-radiation into a visible image through electronic amplification.  This generic type of device may include signal analysis and display  equipment, patient and equipment supports, component parts and  accessories. 

The Centers for Medicare and Medicaid Services further support the  appropriateness of fluoroscopy as an examination technique utilized to  determine biomechanical abnormalities (subluxation). (Source: Medicare  Coverage Database; LCD for Chiropractic Service (manual spinal  manipulations) (l15759). 

DMX is respected by the medical  community. 

Digital motion X-ray is well accepted and acknowledged in the medical  community as well. 

The American Academy of Pain Management’s Practical Guide to Clinicians, 5th Edition states:

…digital motion radiography is currently a valuable diagnostic method in evaluating painful hyper-mobility and  instability of capsular and axial ligaments in the cervical  spine. 

The American College of Occupational Medicine’s Practice Guidelines, 2d  Ed. 2004 (American College of Occupational and Environmental Medicine)  states: 

If probable ligamentous injury with persistent, pain, consider  fluoroscopically directed flexion study. 

Respected medical doctors (MDs) have publicly proclaimed DMX to be a  valuable diagnostic tool. John H. Bland, M.D., Professor of Medicine,  University of Vermont, in his book entitled Disorders of the Cervical Spine  (1987), said: 

Video fluoroscopy is the most valuable technique in analyzing  cervical spine motion. The stability of the cervical spine depends on bony structures  only to a minor degree; stability depends to a major degree  on the ligamentous structures.

Such injury is not always detected on static plain film X-rays  (standard roentgenograms). The next best medically reasonable diagnostic tool for determining ligamentous injury (a biomechanical source of pain) is the fluoroscopic  exam. 

Robert Baily: Professor of Orthopedic Surgery, University of Michigan in  The Cervical Spine (1974), chapter 3, Dynamic Anatomy and  Cineradiography of The Cervical Spine said this: 

Video fluoroscopy shows abnormal secondary to soft tissue  (ligamentous) damage. Stability is dependent on ligaments.

Ruth Jackson, M.D., Instructor of Orthopedic Surgery at Baylor University,  in her book entitled The Cervical Syndrome (1977) said: 

Video fluoroscopy shows areas of limited or unstable motion  resulting from ligamentous and capsular injuries. 

DMX has been accepted as reliable evidence  by the courts. 

It seems foolish to even suggest that there might be any question as to  whether the courts would accept a DMX as reliable evidence. It has now  been 118 years since Dr. Wrench had discovered X-rays as a technology  

that could be useful in the detection and diagnosis of various physical  conditions. In 1908, Thomas Alva Edison obtained the first patent for a  “moving picture” which simply moves a series of still photographs past the  human eye with such speed that it appears to be “moving.” DMX simply  combines technology that has been respected for more than 100 years. 

Accordingly, the courts have acknowledged DMX as reliable evidence. In  Graftenreed v. Seabaugh, 268 s.w.3d 905 (Ark. Ct. App. 2007) the Arkansas  Court of Appeals made these statements: 

Generally, a chiropractor is qualified to testify in a personal  injury action concerning matters within the scope of the profession or practice, and may testify as to the permanency  of an injury, as well as its probable cause. DMX evidence is  reliable, and is accepted by the chiropractic and medical communities. Appellant argues that DMX technology does  not meet the Daubert standard because it has not been proven to aid in diagnosing or treating any injury and that  DMX gives no more information than standard X-rays. Appellant also asserts that the scientific community has not generally accepted the use of DMX is for diagnosing or treating any injury or ailment. We disagree. Here, there is no question that this evidence was prejudicial  to Appellant’s position, however, we cannot say that it was  unfairly prejudicial. Appellant next argues that the trial court  erred in admitting the DMX evidence because there was no  proof as to which accident caused the ligament damage  referred to in the radiologist report. According to Appellant,  even if the DMX has indicated injury, there was no proof that  it was caused by the January 2001 accident. * * * there is  more than sufficient evidence to let the jury decide whether  Ms. Woods’ injuries were caused by the 2001 accident. Appellees presented testimony that her symptoms began  immediately after the wreck; that they continued over several years; that the 2003 accident did not exacerbate  them; and that the pain and problems she was experiencing  at the time of trial were the same as those that began right  after the 2001 wreck. 

Other cases that support the admissibility of fluoroscopy. See Hughes v.  Denny’s Restaurant, 328 so.2d 830 (Fla. Supreme Court 1976); Destin v.  Sears, Roebuck & Co., 803 s.w.2d 113 (Mo. Dist. Ct. App. 1990); Cognata,  et.al. v. Weishaupt, et.al., bc243305 (Ca. Los Angeles County Superior  Court 2002). 

CRMA can quantitatively analyze the extent  of the ligamentous laxity. 

CRMA is Computerized Radiographic Mensuration Analysis, or CRMA. It is  also called “digitized X-ray.” The term “mensuration” simply means “the  measurement of geometric quantities.” Medical and chiropractic doctors  have, for nearly 100 years, been measuring the translational and angular  malpositioning of vertebrae.

CRMA means to measure radiographics (X-ray) using a computer. Thus  CRMA provides for accurate, computerized measurement of the  malpositioning of vertebrae due to ligamentous laxity. 

CRMA is a valuable tool to chiropractic and medical practitioners. It assists  in arriving at a differential diagnosis and establishing an appropriate  treatment plan. 

For patients, it provides substantiation for pain that might otherwise be  labeled as “secondary gain,” “somataform disorder,” or just the old fashioned terms of “faking” or “malingering.” 

For lawyers and their clients, it is a “blockbuster” development. It  provides objective proof of ligamentous injury that has been the major  cause of chronic pain and disability in CAD injuries. 

CRMA can be used to establish a percentage  impairment rating using the AMA Guides rating  system. 

For 20 years, the AMA Guides have recognized “Alteration of Motion Segment Integrity” (AOMSI) as the basis of permanent impairment of the  spine and have recognized cannot be determined by physical examination.  Instead, flexion-extension X-rays are required: 

Motion of the individual spine segments cannot be determined by physical examination, but is evaluated with flexion and extension roentgenograms (see Figures 15-3a through 15-3c) AMA Guides, (5th Ed. 2001), pg. 379. 

But how can static X-rays show abnormality occurring in motion? It is  simply nonsense to suggest that that could happen. Instead, motion X rays are needed to show motion abnormalities!!!

DMX scans can be used to provide an AMA based disability rating. 

The AMA Guides to the Evaluation of Permanent Impairment, 5th Ed.  (2000), p. 392, states that Alteration of Motion Segment Integrity (AOMSI)  results in a 25-28% impairment rating in each of the following cases: 

Alteration of Motion Segment Integrity or bilateral or multilevel radiculopathy; alteration of motion segment integrity is defined from flexion and extension radiographs as  at least 3.5 mm of translation or one vertebrae on another,  or angular motion of more than 11 degrees greater than at each adjacent level

But what about translation at lesser levels? What about angular  irregularity less than 11 degrees? Assessments of impairment levels less  than that specified in the AMA Guides is appropriate. As stated in  Foreman/Croft: 

To adopt 3.5 mm of translation as the minimal criterion for  anterior subluxation is to leave the majority of mild to moderate instability unclassified. 

Translations greater than 2.0 mm have been determined toindicate  ligamentous disruption. See Looby,”Spine Trauma,” Radiologic  Clinic of North America, Vol 49, No 1, pp. 129-163 (2011). 

In another study, measurement of 1 mm translation and/or 7  degrees of angular variation has been considered to be clinically  significant and indicative of abnormal flexibility of the cervical  spine. See Spine, Vol 3:256-261 (2001).

It, therefore, makes perfect sense that translations less than 3.5  mm. should result in impairment ratings as follows: 

3.5 = 25 

3.0 = 20 

2.5 = 15 

2.0 = 10 

1.5 = 5 

And angular irregularity should result in impairment ratings as  follows: 

11 degrees = 25 

10 = 20 

9 = 15 

8 = 10 

7 = 5 

It is true that the AMA Guides does not recognize these numbers,  affirmatively or negatively. However, the above numbers are a  totally logical conclusion based on the literature. 

How do we know that the ligamentous laxity  was caused by CAD trauma? 

The causal connection between the trauma and the ligamentous laxity is  probable for each of the following reasons: 

  1. If the patient was asymptomatic before and immediately acutely  symptomatic after the trauma, the causal connection should be  clear. 
  2. Motion segment alteration is extremely rare in the absenceof  trauma. The AMA Guides states:

When routine X-rays are normal and severe trauma is absent, motion segment alteration is rare; thus,  flexion and extension X-rays are indicated only when  the physician suspects motion segment alteration  from history are findings on routine X-rays.

AMA Guides, 5Ed. 2001, pg. 379. 

  1. If the DMX shows ligamentous laxity that is present at  specific levels and not generally throughout the spine,  it is highly probable that the laxity is traumatic rather  than the result of natural. As stated in Lin, “characteristics of sagittal vertebral alignment in  flexion determined by dynamic radiographs of the  cervical spine,” Spine, Volume 26(3), pg. 256 – 261.

The aging changes of the cervical spine should be  similar at each level, if no trauma affects a specific  level. 

Lin cites numerous articles supporting this concept. 

  1. If the ligamentous laxity occurs in whole or in part in  the upper cervical spine, that is an additional  indicator that the laxity is trauma-induced because  laxity due to non-traumatic degeneration typically  occurs at the lower cervical levels rather than the  upper levels. See Dvorak, et.al. Clinical validation of  functional flexion/extension radiographs of the  cervical spine. See also Spine, 18(1), pp. 120-7(1976). 
  2. If the ligamentous laxity is centered at the C4-5 joint,  it is likely due to trauma. It is well recognized thatthe  C4-5 joint is the single most vulnerable of the cervical  spine joints and the location at which ligamentous  laxity is most likely to occur. Accordingly, if the ligamentous laxity includes that joint, it is an additional indicator that the laxity was caused by traumatic forces.

Ligamentous Laxity Causes Accelerated  Degeneration of the Intervertebral Discs. 

The concept is quite simple. Biomechanical studies have established the  following principles: 

-Ligaments of the primary source of stability and human spine. 

-Ligaments, and intervertebral discs work together, in tandem, to  provide stability to the spine. 

-Loss of ligamentous support, ligamentous laxity, places increased  stress on the intervertebral discs, resulting in accelerated  degeneration of the intervertebral disc. 

Foreman/Croft reports that injuries to the anterior longitudinal ligament  and intervertebral discs typically produce immediate symptoms, whereas  delayed instability is not uncommon in injury to the other spinal ligaments  of the cervical spine. (359) They report that “ligaments heal with scar  tissue, which is less elastic, less resilient, less pliable, and less resistant to  shear and tensile forces than the original tissue” adversely affecting  mobility and extensibility and causing altered biomechanics of the spine.  They note that “the lack of motion at one level will be compensated for by  hypermobility at adjacent levels, which in turn usually will result in  degenerative disc disease and osteoarthritis sometime in the future.” 

Foreman and Croft cite studies by the eminent Dr. Ruth Jackson and Ehni  who explain the biomedical aspects of the process of accelerated  degeneration as follows:

Acute injury (sprain) of the joint produces synovial effusion,  histamine release, capsular ligament is stretched or tore,  bleeding, and associated clinical disabilities. Some of this is  visible and palpable in joints in the extremities, such as the  ankle and knee, but not in those of the spine. With repetition  of the traumatic process and with chronic stress and the joint  from sharing and other forces, as the disc fans and the superior facet moves cephalad under the inferior facet of the  vertebra above, a chronic synovial reaction becomes established, which extends to the underlying articular cartilage. The cartilage undergoes fibrillar change, softens  and becomes rough and eroded. Stresses in the capsule and  periosteum result in marginal osteophytosis, which may  encroach on the underlying nerve root. A loose body may  develop in the joint cavity, or an austere olefinic process may  fracture of life rear loosely attached in or near the foramina.  The facetal bone may thicken or hypertrophy, and the laminae may do so as well, but not to the same degree as  seen in the lumbar spine. Degenerative enlargement of facets  with irritative compression of one or more cervical roots may occur… 

They note that the zygapophyseal joint is particularly susceptible to this  accelerated degeneration process. 

Numerous medical journals have established that whiplash injury causes  changes that predispose the victim to “premature degenerative disc  disease.” See The Neurology of Trauma 1992; 10(4):975-997; Injury 1993;  24:549-550. See also Journal of Bone Joint Surgery 1974; 56A:1675- 1682(reporting a study that found that 39% of whiplash victims had  accelerated degeneration at 5 years post-injury).

The concept is quite simple. Biomedical studies have established the  following principles: 

-ligaments are the primary source of stability in the human spine. 

-ligaments and intervertebral discs work together, in tandem, to  provide stability to the spine. 

-loss of ligamentous support, ligamentous laxity, places increased  stress on the intervertebral discs, resulting in accelerated  degeneration of the discs. 

Delayed instability of the spine due to ligamentous laxity is recognized in  the medical literature. DMX is a valuable tool in detecting delayed  instability of the ligaments. See Cusic, Clinical Biomechanics, Vol. 17, No 1,  pp. 1-20 (2002) 

When ligamentous laxity is demonstrated,  repeat MRIs can, in some cases, objectively  prove accelerated degeneration. 

We have known for many years that CAD injury predisposes the victims to  accelerated degeneration. Previously, that concept has only been a  hypothetical one as it relates to any given patient/client. Recently,  however, the lawyers at the Schmidt Law Firm have discovered that, in  some cases, there is objective, irrefutable proof of highly accelerated  degeneration in some of the clients who have been found on DMX to have  significant ligamentous laxity. One of those cases is presented below. In  “Gina’s Case,” a 14 year old, previously healthy girl was found to have the  equivalent of 30 years of accelerated degeneration that had occurred in  only 2 years!!!

The combination of DMX, CRMA, and  Motion MRI can be extremely valuable in proving major impairment in cases that previously were dismissed as minor “soft tissue” injuries. 

DMX provides objective proof of the existence of both translational laxity  and angular laxity in ligaments. 

CRMA provides a scientifically reliable method of accurately measuring or  quantifying the exact amount of laxity in each category. 

Weight-Bearing Flexion/Extension MRI provides a method of proving  the existence of accelerated degeneration. 

Together, they form the “Golden Pyramid” of Objective Proof of ligamentous injury. 

Motion MRIs provide a method of detecting  herniations that are not observable in  conventional MRIs. 

SUMA MRI has developed a new technology that may be as revolutionary  as Digital Motion X-rays, namely “Motion MRIs.” This procedure involves  taking MRIs in a number of positions, or stations, throughout the flexion extension cycle. Remarkably, it has been shown that some herniations will  be revealed at one station but not others. Some will be revealed at one  station, then disappear at other stations, and reappear at yet others.

The bottom line is that Motion MRIs can reveal herniations that would not  be detected by other forms of MRIs. 

DMX provides proof of the cause of Facet  Joint Injuries. 

Recently, authoritative and reliable medical research has established that  the primary cause of chronic pain in the victims of CAD trauma is injury to  the facet joint. Reliable biomedical research has established that facet  joint pain is primarily due to injury to the capsular ligament and to some  extent of the anterior longitudinal ligament. Research is also established  that injury to the synovial fold may be a secondary cause. See  Yogandando et al., Biomechanics of the Cervical Spine, Journal of  Biomechanics (2001). 

The internal facet joint injury provokes pain in the medial branch nerve.  Radiofrequency neurotomy (RFN) provides relief of pain in the medial  branch nerve by coagulating the nerve so that it no longer transmits the  pain message to the brain. However, RFN procedures do absolutely nothing to cure the underlying injury in the facet joint. 

Now, as Paul Harvey would say, the other side of the story: DMX now provides a method of proving damage to the capsular ligament and  the anterior longitudinal ligament!!!

Ligamentous laxity is the primary cause of  Myofascial Pain Syndrome and trigger points. 

Chronic muscular symptoms of myofascial pain syndrome with trigger  points are the result of the muscle overload resulting from the muscles  working excessively to compensate for ligamentous laxity. Foreman/Croft  states that muscles heal within “a few weeks” leaving “myofascial pain  disorders” in which the muscles serve as the “end organs” of the “long term manifestations…of late whiplash” (p. 15, 384). 

Case studies-“Gina’s Case” and “Bruce’s  Case” provide objective proof of accelerated  degeneration of intervertebral discssecondary  to ligament damage. 

It has been recognized for decades that whiplash trauma and injurycauses  long-term accelerated degeneration of the spine. However, that concept  has been largely theoretical—until now. In several cases, the Schmidt Law  Firm has “doubled back” and sent clients for repeat MRIs of the cervical  spine. The results have been amazing! Two such cases are presented  here.

Gina’s Case

Gina was injured in a car crash as a 14 year old. Her MRI, done shortly  after that collision, was totally normal. Two years later, and $32,000 of  chiropractic and medical treatment, as well as physical therapy and  massage therapy, and she was still symptomatic. However, DMX showed  significant ligamentous laxity. 

CRMA showed translational instability of 3.5 mm, sufficient to establish an  AMA rating of 25%. It also showed angular instability of 12.5%, also  sufficient to establish another AMA rating of 25%. 

Repeat MRIs then showed significant desiccation and bulging of her  intervertebral discs—proof of accelerated degeneration. 

This evidence formed the basis of a claim that Gina’s cervical spine, in a 14  year old that was totally healthy before her car accident, had “aged” the  equivalent of 30 years in the course of only 2 years!!! Her medical doctor  then reported the following: 

It should be noted that MRIs of Gina’s cervical spine which  were performed on September 17, 2011, were unremarkable with the exception of the 25 degree cervical lordosis that was  noted. The finding of cervical lordosis indicates that the ligamentous laxity which is noted on the recent DMX studies  was present at that time. That ligamentous damage would  not be expected to show on static MRIs. However, it is apparent that Gina has, in the intervening 2 years experienced significant degeneration of her cervical spine which is an expected result of the ligamentous damage. 

It is well established in the medical literature that the ligaments of  the spine and the intervertebral discs work in tandem to provide  stability to the spine. When the ligamentous are stretched and  damaged creating ligamentous instability, excessive stresses are imposed on the intervertebral discs which cause accelerated  degeneration of the discs. These studies provide objective evidence  that Gina’s ligamentous instability has resulted in significantly  accelerated degeneration, as evidenced by the disc desiccation and  bulging. 

It should also be noted that these studies provide objective  evidence to support my diagnosis of myofascial pain syndrome.  Myofascial pain syndrome is the result of overload imposed on the  skeletal muscles in the neck and back as a result of the ligamentous  laxity. Simply put, myofascial trigger points result from the fact  that the muscles are working overtime to compensate for the  ligamentous laxity. 

The result was objective proof of disc desiccation and bulging discs  which occurred over a 2 year period. Simply put, Gina’s  ligamentous injury had produced laxity which imposed abnormal  stresses on the intervertebral discs, causing grossly abnormal  degeneration. In the course of only 2 years since her whiplash injury, Gina’s neck had “aged” or “degenerated” the equivalent of 30-40 years! 

For more detail regarding Gina’s case, see Exhibit A.

Bruce’s Case

Bruce’s case is even more dramatic. Bruce was injured in a car accident  when he was 45 years old. His MRI showed some generalized  degeneration, mostly mild desiccation and some facet arthrosis which  would be typical and expected for a 45 year old with a history of doing  physical labor while working as a carpenter/fix-it-man, but nothing  significant. 4 years later, a DMX showed major ligamentous laxity-much  more than would occur naturally, especially when considering that he  totally stopped doing any significant physical work after his accident. 

Again, repeat MRIs showed dramatic accelerated degeneration with 3  large herniations and impingement on the nerve roots at all 3 levels: 

MRI of the Cervical Spine dated 12/17/13 (SUMA) with the  following elements: 

(1) Left paracentral posterior disc herniation (4mm) at C3/4; 

(2) Broad-based posterior disc herniation at C5/6(6mm) and  C6/7 (4mm); 

(3) Annular bulge at C2/3 and C4/5; 

(4) Dehydration of the discs as noted above; 

(5) Mild loss of disc height; 

(6) Straightening of the normal lordosis; 

(7) Moderate stenosis of the bilateral intervertebral neural  foramina at C5/6 and C6/7 with impingement of the bilateralC6  and C7 nerve roots

(8) Moderate stenosis of the left intervertebral neural foramen at C3/4 with impingement of the left C4 nerve roots; and

(9) Mild central canal stenosis at C3/4, C5/6 and C6/7. 

Based on this new MRI, his medical doctor concluded that he had  experienced the equivalent of 30 years of degeneration since his motor  vehicle collision: 

It is well established in the medical and biomedical literature that  injuries of the type that Mr. Bruce experienced in the November  18, 2008, motor vehicle accident produced ligamentous deformation which is plastic in nature so that it does not return to  its prior condition, thus producing instability of the cervical spine  as now documented on Mr. Bruce’s DMX studies. Further, the  ligamentous instability then results in placing stresses on the intervertebral discs, thus producing advanced changes that are  quite dramatic and have occurred in just 3 years. In this case, Mr. Bruce’s degeneration cannot be explained by normal aging process. On contrary, this degeneration is the equivalent of 30 years of degeneration due to normal aging. 

The most important aspect of facet joint  injury is being overlooked, namely the  underlying ligamentous injury. 

Recently, trial lawyers have come to realize that facet joint injuries are  perhaps the most important aspect of spinal injuries. Medical research has  established that facet joint injury is the primary cause of 60% of the cases  of chronic pain lasting more than one year post injury. 

Radiofrequency Neurotomy (RFN) has become increasingly recognized as  a form of treatment that can provide major relief to the victims of facet joint  pain.

The medial branch nerve transmits the pain signals from the facet joint to  the brain. RFN, also referenced as radiofrequency ablation or rhizotomy,  involves coagulating the medial branch nerve which, in turn, blocks the pain transmission from the facet joint and provides relief from the facet  joint pain. 

RFNs have been determined to be successful in 90% of the cases where the  patients are properly pre-selected. However, the beneficial effects of RFN  only last somewhere between 8-15 months—and then the pain returns. That is true because the RFN does nothing to heal, cure or improve the  injury to the facet joint. 

The RFN procedure can then be repeated indefinitely. Studies show that  the repeat procedure will be successful more than 90% of the time in cases  where the first RFN was successful. 

Personal injury cases involving RFN treatment have been successful in  producing some rather large jury verdicts for several reasons: 

(1) RFN procedures, including the test injections, cost approximately $10,000-$12,000. If they need to be repeated, the projected cost of future  medical expenses will be well in the six figure range, thus significantly  increasing the potential size of the jury verdict. (Note: If a 35 year old will  need RFNs for life, and has a life expectancy of 44.6 years, then the future  projected medical expenses would be $490,600.00); and 

(2) The fact of successful treatment with RFN provides strong  evidence of the existence of the facet joint injury. (If the pain goes away  with treatment of the facet joint, that proves that the facet joint was the  cause of the pain.) 

In most cases, the fact that RFNs do absolutely nothing to heal or cure the underlying injury is completely overlooked. In many cases, the  lawyers produce absolutely no evidence to establish the nature and extent  of the underlying injury.

The answer can be found in the biomedical research. The primary cause of  facet joint injury is damage to the capsular ligament. See Yoganandan,  “Biomechanical analyses of whiplash injuries using an experimental  model,” Accident Analysis and Prevention, Vol 34, No 5, pp. 663-671  (2002). 

Here, the missing link often is supplied by the DMX. In those cases where  the DMX shows damage to the capsular ligament, objective proof exists to  confirm the existence of the capsular ligament injury and, thus, the  underlying injury which has been causing the pain in the medial branch  nerve. Because the ligamentous laxity that causes the facet joint pain also causes accelerated degeneration of the spine, patients who are candidates for RFN treatment can be expected to get worse over time because of this accelerated degeneration. 

Then, when subsequent MRI scans provide evidence of the accelerated  degeneration which results from the existence of the ligamentous laxity which,  in turn, places more stress and stain on the intervertebral disc structure, the full  consequences of the injury are brought to light. 

Respectfully submitted,

Douglas E. Schmidt  

Schmidt Law Firm

Appendix A-GINA’S CASE- 

A CLASSIC EXAMPLE OF HOW DMX & MULTIPLE  POSITION MRI CAN ESTABLISH PERMANENT  LIGAMENTOUS DAMAGE 

  • Serious ligamentous injuries have been dismissed as “soft tissue sprain/strain” injuries  of minimal consequence because of the lack of  objective proof.
  • We now have that proof of the ligamentous  damage!!! DMX provides that objective proof.
  • We also now have objective proof of  accelerated degeneration resulting from  ligamentous laxity!!!

Gina’s Case is a classic example.

BEFORE DMX: 

  • Gina was a 14 year old girl who sustained a  whiplash injury.
  • After 2 years of treatment, by DC, MD, PT and  Massage ($32,000.00), she continues to  experience major pain and disability.
  • The MRI was “unremarkable” in all aspects. -The Chiropractic diagnosis was “sprain/strain.”
  • The MD diagnosis was “ligamentous injury” with no objective proof.
  • The offer of settlement was only $2,000.00  more than the medical bills.

THE DMX STUDY PROVIDED

SUBSEQUENT MRI SCANS PROVIDED  OBJECTIVE PROOF OF ACCELERATED  DEGENERATION DUE TO LIGAMENTOUS LAXITY: 

-Multi-positional MRIs at SUMA show  accelerated degeneration, i.e. multiple disc  bulges and disc desiccation. 

BOTTOM LINE-MAJOR ACCELERATED DEGENERATION: 

  • Ligamentous injury to a 14 year old girl,  previously healthy, has resulted in two  impairments of her cervical spine, each rateable  pursuant to AMA Guides at 25% of the whole  body. 
  • Proof of accelerated degeneration of her spine. 
  • Her spine has aged the equivalent of 30-40  years in 2 years!!!

Appendix B- Bruce’s Case 

Bruce’s case is even more dramatic than Gina’s in objectively proving accelerated degeneration secondary to ligamentous injury. 

Bruce was injured in a car accident when he was 45 years old. His MRI  showed some generalized degeneration, mostly mild desiccation and some  facet arthrosis which would be typical and expected for a 45 year old with  a history of doing physical labor while working as a carpenter/fix-it-man, but nothing significant.

4 years later, a DMX showed major ligamentous laxity-much more than  would occur naturally, especially when considering that he totally stopped  doing any significant physical work after his accident. 

IMPRESSION for patient BRUCE: 

  • Damage to the posterior longitudinal ligament is indicated byan  anterolisthesis at C3 on C4. 
  • Damage to the capsular ligament is indicated by intervertebralforaminal  encroachment of the facet joint at C3-C4 bilaterally. 
  • Damage to the alar and accessory ligaments is indicated by an overhang ofthe  lateral mass of C1 to the left. 

Again, repeat MRIs showed dramatic accelerated degeneration with 3  large herniations and impingement on the nerve roots at all 3 levels: MRI of the Cervical Spine dated 12/17/13 (SUMA) with the  following elements: 

(1) Left paracentral posterior disc herniation (4mm) at C3-4; 

(2) Broad-based posterior disc herniation at C5-6 (6mm) and  C6-7 (4mm); 

(3) Annular bulge at C2-3 and C4-5; 

(4) Dehydration of the discs as noted above; 

(5) Mild loss of disc height; 

(6) Straightening of the normal lordosis;

(7) Moderate stenosis of the bilateral intervertebral neural  foramina at C5/6 and C6/7 with impingement of the bilateralC6  and C7 nerve roots

(8) Moderate stenosis of the left intervertebral neural foramen at C3/4 with impingement of the left C4 nerve roots; and 

(9) Mild central canal stenosis at C3/4, C5/6 and C6/7.

Continuation 

Appendix C-Tony’s Case 

In the first case in the upper Midwest in which DMX was  offered into evidence, the result was amazing. 

The case was LUCI V. PARROT which was tried to a jury  in St. Croix County, Wisconsin. (Hudson, Wisconsin is  the county seat.) 

The last offer before trial was $10,000.00. 

The jury verdict at end of trial was $743,188.95  DMX video was played to the jury, 

Their eyes were “bugged;” 

They were leaning forward in their seats to look;  and

They asked to see it replayed! 

Doug Schmidt says, 

“It was the most powerful and persuasive single piece of evidence  that I have ever seen in a courtroom in over 40 years of trial experience.”