What Boston personal injury attorneys should know about imaging alar ligament injuries
A 2015 MRI study found signs of alar ligament injury in 55% of older patients whose chronic neck pain had no other identifiable cause. For Boston and Massachusetts personal injury attorneys, that finding speaks to a familiar problem: the client who still hurts months after a car crash, but whose standard imaging reads as “normal” or “age-related degeneration.”
Why this matters for your cases
Older clients are among the hardest whiplash cases to document. Their imaging almost always shows degeneration, and insurers use it to argue that ongoing pain is pre-existing. When an older client’s chronic neck pain goes unexplained, the medical record may not reflect the true injury.
The alar ligaments are two small ligaments that connect the top of the neck (C2) to the base of the skull. They limit head rotation and side-bending, and they can be strained or torn when the head is whipped and rotated in a collision. Standard cervical MRI protocols often don’t show them clearly, so an injury can go undetected.
The study below suggests that, in older patients with unexplained chronic neck pain, the right imaging may reveal a ligament injury that a routine workup misses.
The study
Chen and colleagues at Central South University in China studied 134 elderly patients with chronic neck pain. All had a history of work or activities involving whiplash-type motion.
Every patient received a comprehensive workup: CT, standard MRI, ultrasound and laboratory testing. The researchers then split them into two groups:
• Clear-cause group (96 patients): the workup found an explanation for their pain.
• Unknown-cause group (38 patients): the workup found no explanation.
Key findings
Patients whose pain had no other explanation were far more likely to show alar ligament injury on high-resolution MRI.
|
Group |
Patients |
Alar ligament injury signs |
Rate |
|
Unknown cause |
38 |
21 |
55% |
|
Clear cause |
96 |
7 |
7% |
|
All patients |
134 |
28 |
21% |
The difference between the groups was statistically significant (p < 0.01). The authors attributed long-term neck pain and headaches to chronic whiplash ligament injury in 15.7% of all patients.
Two technical points stood out:
• High-resolution PDWI displayed the alar ligaments’ anatomy and signal clearly.
• Oblique coronal images showed the ligaments best.
The authors concluded that alar ligament whiplash injury is an important cause of chronic neck pain in elderly patients, and that high-resolution PDWI is an effective way to evaluate it.
What it means for case evaluation
A “normal” or “degenerative only” MRI report does not necessarily rule out a ligament injury. Imaging protocol matters.
When an any client has persistent neck pain or headaches after a crash and no clear explanation, consider:
1. Ask what protocol was used. A routine cervical MRI is not designed to evaluate the alar ligaments. The study used high-resolution proton-density weighted imaging with oblique coronal slices.
2. Look for the clinical pattern. Upper neck pain, headaches at the base of the skull, and pain or limitation with head rotation are consistent with upper cervical ligament involvement.
3. Document the timeline. Symptoms that began after the collision, in a client who was functioning before it, help separate a new injury from long-standing degeneration.
4. Get the right reader. Alar ligament findings are subtle. A radiologist experienced in upper cervical imaging, and a clinician who can correlate findings with the exam, make the documentation stronger.
For older clients, this research also helps answer a common defense argument: that ongoing pain is “just arthritis.” Degeneration and a new ligament injury can exist side by side.
Anticipating defense challenges
This study is useful, but it has limits that opposing experts are likely to raise. Know them before you rely on it.
• Not specifically car crashes. Patients had work or activities involving whiplash-type motion. The study does not describe motor vehicle collisions.
• Association, not proof. It is an observational imaging study. It shows ligament findings were more common in unexplained pain, not that they caused it.
• Alar ligament MRI is debated. Other studies, notably from Norway, have found high alar ligament signal in people without symptoms, and readers often disagree on grading.
• Small and regional. Only 38 patients were in the unknown-cause group. The full paper is published in Chinese, with an English abstract.
• No healthy comparison group is described in the abstract, and reader blinding is not reported.
The strongest use of this research is supportive, not standalone: it explains why a careful imaging protocol is reasonable, alongside a thorough clinical exam and a clear post-crash timeline.
How we document these injuries
Dr. Chris Quigley has focused on whiplash and automobile collision injuries since 1990. He completed a Primary Spine Care Fellowship at the University at Buffalo’s Jacobs School of Medicine and Biomedical Sciences, holds additional certification in spinal trauma, and is the author of After the Car Crash!
For your clients, that means:
• A thorough upper cervical exam that looks for ligament involvement, not just muscle strain
• Referral for high-resolution upper cervical MRI, including proton-density weighted imaging of the alar ligaments, when the clinical picture calls for it
• Clear documentation linking findings, symptoms and the timeline of the collision
• Care focused on helping your client recover
If you represent a client with persistent neck pain or headaches after a crash anywhere in Greater Boston, we’re glad to evaluate them. Our Beacon Hill office is steps from the Charles/MGH Red Line stop and serves clients from Back Bay, the West End, the North End, Downtown Boston, Cambridge, Charlestown and beyond.
Charles Street Family Chiropractic 102 Charles St, Boston, MA 02114 (Beacon Hill) (617) 720-1992 · thebostonwellnessgroup.com
Source
Chen J, Wang W, Han G, Han X, Li X, Zhan Y. MR investigation in evaluation of chronic whiplash alar ligament injury in elderly patients. Zhong Nan Da Xue Xue Bao Yi Xue Ban (Journal of Central South University, Medical Sciences). 2015;40(1):67-71. PMID: 25652377. PubMed
This article is for educational purposes for legal professionals. It is not legal or medical advice, and it does not establish causation in any individual case.
