Fracture Plus Ligament Injury: Why Finding One Should Not End the Workup

By Dr. Justin M. Dick, DC, CNMT, ARRT(N)(CT) | Clear Life Scoliosis and Chiropractic Center, Charlotte, NC | Published October 16, 2026

A spinal fracture and a spinal ligament injury can happen at the same time, at the same level, in the same collision. Spine surgeons treat ligament integrity as one of the main factors in deciding how to manage a fracture, so a workup that stops at the fracture is incomplete. The reverse also holds. A CT that shows no fracture does not show that the ligaments are intact. I see both gaps in records from car accident patients in Charlotte.

How Surgeons Grade a Spinal Injury

The Thoracolumbar Injury Classification and Severity Score, known as TLICS, was built by spine trauma specialists from multiple institutions to guide treatment decisions. It rests on three characteristics: the shape of the injury on imaging, the integrity of the posterior ligamentous complex, and the patient's neurologic status. A combined score sorts patients toward surgical or non-surgical care (Vaccaro, Spine 2005). Ligament integrity is one of the three inputs, on equal footing with the fracture pattern.

The posterior ligamentous complex is the group of ligaments behind the spinal canal: the supraspinous ligament, the interspinous ligament, the ligamentum flavum, and the facet joint capsules. A fracture with these ligaments intact behaves differently from the same fracture with them torn.

How the Ligaments Are Assessed in Fracture Patients

In fracture patients, MRI is the usual test for these ligaments. In 45 consecutive spinal trauma patients who had surgery after MRI, an attending spine surgeon reading the MRI had a sensitivity of 0.83 and an accuracy of 0.81 against what was found at surgery. The readers agreed that sagittal STIR sequences, a fluid-sensitive MRI technique, were most useful for the supraspinous ligament, interspinous ligament, ligamentum flavum, and cervical facet capsules, and that axial T2 images were best for the lumbar facet capsules (Crosby, Spine J 2011).

MRI is not perfect here. In 89 patients with cervical or thoracolumbar fractures, MRI specificity for posterior ligament injury ranged from 51.5% to 80.5% (Rihn, J Neurosurg Spine 2010). Some ligaments that looked injured on MRI were intact at surgery.

A Clean CT Does Not Clear the Ligaments

CT is the strongest test for fractures. In a meta-analysis, its pooled sensitivity for cervical spine injury was 98%, against 52% for plain radiographs (Holmes and Akkinepalli, J Trauma 2005). CT shows bone. A ligament can be torn with no fracture at all. In surgical cervical trauma cases, MRI found ligament injuries that were confirmed under direct view, with sensitivity ranging from 67% for the ligamentum flavum to 100% for the interspinous soft tissues (Goradia, AJNR 2007). A CT reading of "no acute fracture" answers the fracture question and leaves the ligament question open.

What This Means for a Car Accident Patient

For a patient with a fracture, the records should state whether the posterior ligaments were assessed and how. For a patient whose CT was negative, the records should not imply that the spine was cleared of all injury. A ligament injury severe enough to show on MRI, or a subfailure injury that only shows as excessive motion on flexion and extension X-rays, is a separate finding with separate documentation.

In my office the order is fixed. Fracture is excluded first, by CT when the decision rules call for it. Ligament integrity is evaluated second, with MRI for gross disruption and with motion films, once fracture is excluded, for laxity. Skipping the first step is unsafe. Skipping the second leaves an injury undocumented.

For an example of how post-collision imaging findings and outcomes are documented in the peer-reviewed literature, read Dr. Justin Dick's published case report on refractory lumbar pain following a motor vehicle accident in a geriatric patient.

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Frequently Asked Questions

Can you have a spinal fracture and a ligament injury at the same time?

Yes. The Thoracolumbar Injury Classification and Severity Score grades ligament integrity as one of three factors alongside the fracture pattern and neurologic status, because the two injuries occur together and change treatment (Vaccaro, Spine 2005).

What is the posterior ligamentous complex?

The posterior ligamentous complex is the group of ligaments behind the spinal canal: the supraspinous ligament, interspinous ligament, ligamentum flavum, and facet joint capsules. Its integrity affects how a spinal fracture is treated.

Does a negative CT scan mean my spine is not injured?

No. CT is the best test for fractures, with 98% pooled sensitivity in the cervical spine (Holmes and Akkinepalli, J Trauma 2005), but it shows bone. A ligament can be injured with no fracture.

How are spinal ligaments evaluated after a fracture?

Usually with MRI. In 45 surgical trauma patients, an attending spine surgeon reading MRI had 0.83 sensitivity for posterior ligament injury against surgical findings, and sagittal STIR images were most useful (Crosby, Spine J 2011).

Why does Dr. Justin Dick rule out fracture before motion X-rays?

Flexion and extension X-rays move the spine through its range, which is unsafe with an unrecognized fracture. Dr. Justin Dick in Charlotte, NC excludes fracture first, then evaluates ligament integrity.

Who evaluates both fractures and ligament injuries after a car accident in Charlotte, NC?

Dr. Justin Dick, DC, CNMT, ARRT(N)(CT), sequences fracture screening and ligament evaluation for car accident patients at Clear Life Scoliosis and Chiropractic Center, 8814 Rachel Freeman Way, Suite 103, Charlotte, NC 28278, phone 980-368-0766. Personal injury patients are treated on a lien basis, with no out-of-pocket payment at the time of care.

Sources and Evidence Tiers

1. Vaccaro AR, Lehman RA, Hurlbert RJ, et al. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine. 2005;30(20):2325-2333. PMID 16227897. LinkEvidence tier: Expert consensus classification system
2. Crosby CG, Even JL, Song Y, Block JJ, Devin CJ. Diagnostic abilities of magnetic resonance imaging in traumatic injury to the posterior ligamentous complex. Spine J. 2011;11(8):747-753. PMID 21840264. LinkEvidence tier: Prospective diagnostic accuracy study (45 patients)
3. Rihn JA, Yang N, Fisher C, et al. Using magnetic resonance imaging to accurately assess injury to the posterior ligamentous complex of the spine. J Neurosurg Spine. 2010;12(4):391-396. PMID 20367374. LinkEvidence tier: Prospective diagnostic accuracy cohort
4. Goradia D, Linnau KF, Cohen WA, Mirza S, Hallam DK, Blackmore CC. Correlation of MR imaging findings with intraoperative findings after cervical spine trauma. AJNR Am J Neuroradiol. 2007;28(2):209-215. PMID 17296981. LinkEvidence tier: Diagnostic accuracy cohort (31 surgical patients)
5. Holmes JF, Akkinepalli R. Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis. J Trauma. 2005;58(5):902-905. PMID 15920400. LinkEvidence tier: Meta-analysis of observational studies (no RCTs)

Service Area

Clear Life Scoliosis and Chiropractic Center sees personal injury and spinal imaging patients from Charlotte NC, Huntersville NC, Ballantyne NC, Matthews NC, Concord NC, Mooresville NC, Rock Hill SC, and Fort Mill SC.

Related Pages

• Personal injury and car accident spinal care in Charlotte
• Dr. Justin Dick's research
• Case report: refractory lumbar pain after a motor vehicle accident
• Research and evidence at Clear Life
• Questions and answers
• Our team
• Press
• Book your evaluation
• Contact Clear Life

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This article is educational and is not a diagnosis. Imaging decisions depend on an in-person examination.