The importance of Magnetic Resonance Imaging to evaluate the integrity of the lumbar posterior ligament complex post trauma.

Abstract: Posterior ligamentous complex(PLC), consisting of the supraspinous ligament, interspinous ligament, ligamentum flavum, and the facet joint capsules is thought to contribute significantly to the stability of the lumbar spine. There has been much debate on whether Magnetic Resonance Imaging(MRI) is specific and sensitive in diagnosing pathology to the PLC. The objective is to determine the necessity of MRI imaging for evaluating the integrity of the lumbar posterior ligament complex post trauma.

Key Words: Magnetic Resonance Imaging(MRI), interspinous ligament, posterior ligament complex, low back pain, ligament laxity, electromyography, impairment rating

A 41-year-old male, presented to my office for an examination with complaints of low back pain with numbness, tingling and weakness into the left lower extremity after he was the restraint driver in a motor vehicle collision approximately three and a half months’ post trauma. He rated the pain as a 3/10 on a visual analog scale with 10/10 being the worst and the pain and noted the pain as being present most of the time.  He stated that he was on pain killers daily and this helped manage his daily activities. Without pain killers his pain levels are rated 8/10 being present most of the time. The pain killers stated by the patient are Oxycodone and Naproxen.
He reported that the pain would be aggravated by activities which required excessive standing, repetitive bending, and lifting. He further noted that in the morning the pain was increased and his left leg would be numb and weak for about the first hour.

The patient stated that his care to date had been managed by a pain management clinic and that he had minimal improvement with treatment which has included physical therapy and massage therapy. He reported the pain clinic next recommended steroid injections which he refused. He states there has been was no imaging ordered and that an Electromyography(EMG) had been performed. He was told the test was negative for pathology.

Prior History: No significant medical history was reported.
Clinical Findings: The patient is 6’0” and weighs 210 lbs.

Physical Exam Findings:

Cervical Spine:
Cervical spine range of motion is full and unrestricted. Maximum cervical compression is negative. Motor and other regional sensory exam are unremarkable at this time.

Thoracic Spine:
Palpation of the thoracic spine region reveals taught and tender fibers in the area of the bilateral upper and mid thoracic musculature. Thoracic spine range of motion is restricted in flexion, extension, bilateral lateral flexion, and bilateral rotation. Regional motor and sensory exam are unremarkable at this time.

Lumbar Spine:
Palpation of the lumbosacral spine region reveals taught and tender fibers in the area of the lumbar paraspinal musculature. Lumbar spine range of motion is limited in flexion, extension, bilateral lateral flexion and bilateral rotation. Extension restriction is due to pain and spasm. Straight leg raise causes pain at approximately 50 degrees when testing either side in the left low back. There is no radicular symptomatology down the leg. Kemp’s maneuver recreates pain in the L4 region on the left. No radicular symptoms are noted. The patient is able to heel and toe walk. Regional motor and sensory exam is unremarkable at this time other than L4, L5 and S1 dermatomes having decreased sensation with light touch.

Muscle testing of the upper and lower extremities was tested at a 5/5 with the exception of the left quadricep tested at a 4/5.  The patient’s deep tendon reflexes of the upper and lower extremities were tested including triceps, biceps, brachioradialis, patella, and Achilles and all were tested at 2+ bilaterally except the left patellar reflex was 1+.

RANGES OF MOTION EVALUATION

All range of motions are based on the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 5^th Edition¹ and performed by a dual inclinometer for the lumbar spine.

   Range of Motion      Normal         Examination         % Deficit

Flexion	60	48		20
Extension	25	12		52
Left Lateral Flexion	25	16		36
Right Lateral Flexion	25	18		28

A lumbar MRI reveals;
1)    Mild disc bulges at T11-T12, T12-L1, L1-L2 and L5-S1
2)    Low disc signals indicative of disc desiccation at T11-T12, T12-L1, L1-L2, L2-L3, L3-L4 and L4-L5
3)    Retrolisthesis of 2mm at L3-L4
4)    Mild ligamentous hypertrophy at L1-L2, L2-L3, L3-L4, L4-L5 and L5-S1
5)    L4-L5 has a Grade 1-2 tear of the interspinous ligament with mild inflammation
6)    L5-S1 has a Grade 1 interspinous ligament tear with mild inflammation

After reviewing the MRI I ordered lumbar x-rays to rule out ligament laxity.

X-RAY STUDIES

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