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Digitized X-Rays (CRMA)

CRMA stands for Computerized Radiographic Mensuration Analysis. Many times this process is referred to as “digitized x-rays.”

CRMA Analyzes the angles and distances between bones in the spine uses a Computer Program and Flexion-Extension X-rays. The purpose of the test is to accurately assess damage to the spine for Spinal ligament injuries



CRMA is important to patients and doctors, for patients, it visually shows them where they are injured and it can explain the patterns of pain they experience. For doctors it helps us identify injuries. These injuries must be evaluated and properly treated or the patient risk of long term impairment is increased.

AMA Guides, p. 377 (5th ed. 2001)

AMA GUIDES, P. 377 (5TH ED. 2001)

AMA Guides, Fig 15-1, p. 377 (5th ed. 2001)

AMA GUIDES, FIG 15-1, P. 377 (5TH ED. 2001)

"Inherent in most spinal sprain and strain injuries there is a biomechanical, neurological component of articular mal-position referred to Chiropractically as subluxation. Subluxation, if not addressed and merely treated with soft tissue therapeutics and/or joint immobilization forms of care, may lead to joint fixation and/or instability and loss of motor unit integrity." CRMA objectively disproves faking. Since CRMA identifies the location and extent of permanent injuries, it helps the doctor decide on a treatment plan targeted at the injured area. It is also helpful for tracking changes in a patient’s condition and for deciding when to make referrals to pain management specialists, neurologists, or surgeons. Many doctors take repeat x-rays every 3-5 years to monitor their patients’ conditions.


The mensuration method most commonly used today comes from the American Medical Association’s Guidelines for the Evaluation of Permanent Impairment (AMA Guides). It is the gold standard for impairment evaluation” And the AMA Guides also say that it would be “rare” for a patient to have motion segment alteration without trauma:

In some cases, motion segment alteration can be easily seen with motion x-rays:

However, sometimes you need a method of analysis when injuries aren’t so obvious. That’s where the AMA Guides come in. AMA GUIDES, P. 379 (5TH ED. 2001)

Doctor’s must take the right x-rays to determine whether motion segment alteration exists. Most of the time in the emergency room following a car wreck, ER doctors DON’T take these x-rays. Why not? The ER doc knows specifically what he’s looking for — broken bones — so he orders specific x-rays for that purpose. The doctor does NOT order the x-rays required by the AMA Guides because it requires forward and rear bending, which can make fractures in the neck too small to see on normal x-rays far worse. So, these bending x-rays simply aren't taken until the patient has had some time to heal. So, the tests to see if motion segment integrity is lost is performed later, because someone else treats that condition in a non-emergency situation. Also, a loss of motion segment integrity can be difficult to diagnose in the ER because tissue swelling restricts the movement necessary to obtain the proper bending x-rays required. Finally, the patient needs sufficient time to heal so that the true, permanent extent of the loss of motion segment integrity shows up.

Motion segment alteration CANNOT be diagnosed from a physical examination. So, without the proper x-rays, one just can’t say what the true extent of spinal injury is.

Once the x-rays are taken, the angles and distances between spinal bones are precisely measured and compared to a ‘normal’ spine. The American Medical Association determines what is normal:

AMA Guides, Errata p. 4 (Mar. 2002)


As shown here, in the cervical spine any difference in angles more than 11º qualifies as a loss of motion segment integrity in the cervical spine. There are other figures available in the AMA Guides to measure different kinds of spinal abnormalities, as follows:

AMA Guides, Errata p. 4 (Mar. 2002)


AMA Guides, Errata p. 4 (Mar. 2002)



Until the last 20 years or so, doctors performed mensuration by hand using x-rays, a light box, and a grease pencil. In the last 20 years, more doctors and clinics started using x-ray machines that take x-rays digitally, rather than with film (just like digital cameras have replaced film cameras).

With the computing power available today, it also made sense for doctors to use computers to perform mensuration calculations. The result is a faster, more accurate, and repeatable mensuration report. Hand-mensuration method took about 15-30 minutes, but the computerized version takes a trained technician only 30 seconds! That’s a huge time saver.

CRMA has been tested by researchers, who have confirmed it is more accurate and repeatable than hand methods. For this reason, CRMA is generally accepted in evidence-based medicine as a reliable method of assessing spine damage. Most research articles published on the spine today use computerized mensuration tools.

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