Why a “Normal” X-Ray After a Car Accident Doesn’t Always Mean You’re Not Injured

If you were in an accident and your x-ray or MRI came back normal, you might feel relieved. Many times, you may also still be in pain weeks later and wondering why. Both things can be true at the same time. That’s a more common situation than most people realize. 

The spine isn’t just bones and discs 

When people think about spinal injury, they usually think about two things: broken bones and herniated discs. They show up clearly on standard imaging. 

There’s a third category that often gets missed. This injury is to the ligaments that hold the spine joints in proper alignment. These ligaments aren’t a small part of the picture. There are over 200 of them supporting the spine. The discs make up only a small fraction of that total. A car accident can stretch or tear these ligaments. The whiplash motion that everyone associates with neck pain can cause this to occur.  

Why standard imaging can miss injuries

A routine x-ray or MRI is taken with your spine in a neutral, resting position. Ligament instability doesn’t always show up that way. It shows up when the spine goes through motion. We can see this specifically in flexion (bending forward) and extension (bending backward). 

That’s why flexion-extension imaging can catch instability that a standard neutral film misses entirely. National clinical guidelines used in spine surgery decision-making, including EviCore’s musculoskeletal management criteria, define abnormal findings on flexion-extension x-rays: more than 3.5 millimeters of forward-backward slippage between vertebrae, or more than 11 degrees of abnormal angulation. These are measurable and specific numbers.  

Why this matters for your car accident claim 

Insurance adjusters lean heavily on “the imaging was normal” to argue an injury isn’t serious. If the only imaging done was a standard neutral x-ray or MRI, that argument may be incomplete. It may mean the right test for this specific type of injury was never performed. 

This is one of the reasons ongoing neck pain, headaches, dizziness, or arm symptoms after a crash shouldn’t be dismissed. Ligament injuries in the neck have been linked in published research to a wide range of symptoms beyond local pain. These may include balance problems, migraine-type headaches, and post-concussion-like symptoms. 

What to do if this sounds familiar 

If you’re still dealing with symptoms weeks after a crash and were told your imaging was normal, it’s worth asking your treating provider about a flexion-extension evaluation.  

This article was contributed by Justin M. Dick, DC, a chiropractor in Charlotte, NC with a focus in spinal biomechanics and injury documentation. Dr. Dick holds dual imaging credentials (CNMT, ARRT(N)(CT)) and has developed continuing legal education content on spinal injury biomechanics for attorneys. Learn more at clearlifescoliosis.com.