A Normal X-Ray After a Crash Doesn’t Mean Nothing Happened. It Means the X-Ray Answered a Different Question.

A 28-year-old woman came to my clinic after a motor vehicle collision with persistent neck pain, right-sided C8 sensory disturbance, and right C5 to C8 motor weakness. She also had moderate thoracic scoliosis. Her case changed how I explain imaging to patients who have been told their films look fine. cureus

What does a normal X-ray after a car accident rule out?

A plain radiograph is built to answer one question: is there a fracture, dislocation, or gross loss of alignment? A normal film answers that well. For the emergency department, it is the right first question. But a normal film is a statement about bone. Ligaments, discs, and joint capsules barely register on it.

Radiographs can answer other questions when someone asks them. In her case, analysis showed reduced cervical lordosis and abnormal angular and translational motion between segments on flexion and extension views. That is alignment and motion, not fracture. cureus

Can an MRI prove the crash caused the injury?

No. MRI shows discs and ligaments well, but it cannot date a finding. A systematic review of 33 studies covering 3,110 people without symptoms found disc bulge in 30% of people at age 20 and 84% at age 80, and disc protrusion in 29% rising to 43%. A bulge on a post-crash MRI may be the collision, or it may be ten years old. ajnr

The findings are not meaningless. A separate meta-analysis of adults 50 and younger found disc extrusion, protrusion, and Modic type 1 changes more common in people with back pain than in those without. Prevalence shifts the odds without settling causation in one patient.

What happened in her case, and what does it not show?

She completed 17 visits of structured rehabilitation focused on sagittal alignment, neuromuscular retraining, and segmental motion control. At three months, her sensation and strength had normalized, her Functional Rating Index score had fallen from 23 to 3, and repeat radiographs showed more lordosis and less abnormal translation between segments. cureus

When deficits persist after a collision, alignment, segmental motion, and neurological status deserve to be assessed together.

How should imaging be used after a collision?

Imaging should answer a specific question, and the question comes from the history and exam.

1. History: mechanism, symptom timeline, and prior neck or back problems.
2. Examination: neurological screening, range of motion, and orthopedic testing.
3. Imaging chosen for a question: radiographs to exclude fracture, flexion and extension views when segmental motion matters, and MRI for neurological deficits or failure to improve.

Progressive weakness, loss of bowel or bladder control, or severe worsening pain needs urgent medical evaluation, whatever earlier films showed.

Key takeaways

• A normal X-ray rules out fracture and gross instability. It does not rule out soft tissue injury.
• MRI shows soft tissue but cannot date a finding, and degenerative changes are common without symptoms.
• After a collision with persistent deficits, assess neurological status together with alignment and motion.

About the Author: Dr. Justin Dick, DC, is a chiropractor, researcher, and owner of Clear Life Scoliosis and Chiropractic Center. He is a certified DOT Medical Examiner and holds CNMT and ARRT(N)(CT) imaging credentials.

Case source: Dick JM, Paige P. Cureus. 2026;18(3):e104584. doi:10.7759/cureus.104584.