Hello Berta and Manning01,
Here is what I received from the VA:
Your compensation claim was processed under the Fully Developed Claim Program.
What We Decided.
We determined that the following condition was related to your military service, so service connection has been granted:
DECISION : DDD lumbar spine (previously rated as compression fracture residuals, L1 and T12) Percent Assigned: 20% Effective Date : June 12, 2013.
+ Previous Rating Decisions, and all evidence contained therein
+ VA Form 21-0820 Report of General Information, dated June 12, 2013
+ Private treatment records, Rockcastle Regional, from June 30, 2008 through June 18, 2013
+ VA Form 21-526EZ Application for Disability Compensation and Related Compensation Benefits, dated June 28, 2013
+ VA Form 21-4138, Statement in Support of Claim, received June 28, 2013
+ Veterans Claims Assistance Act (VCAA) Letter, dated July 15, 2013
+ VCAA Notice Response, received August 21, 2013
+ VA Examination, Lexington, dated February 13, 2014
REASONS FOR DECISION
Service connection for DDD lumbar spine (previously rated as compression fracture residuals, L1 and T12).
We have assigned a 20 percent evaluation for your thoracolumbar spine based on:
+ Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees. (I can't even tie my shoes, they stay laced)
+ Localized Tenderness not resulting in abnormal gait or abnormal spinal contour. (I walk with a limp from the pain on my left back and hip)
+ Combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees
+ Intervertebral disc syndrome with no incapacitating episodes during the past 12 months (I have missed over 23 days this year because of my back)
ADDITIONAL Symptom(s) include:
+ Painful motion upon examination
+ X-ray evidence of arthritis
Here are the Radiology/Doctor's Reports -
EXAM DATE: 6/18/13
EXAMINATION: LUMBAR SPINE, 5V (Does anyone know what 5V means?)
HISTORY: LOW BACK PAIN, LEFT HIP PAIN
There is progressive disc space narrowing at L3 - L4 where there was a disc herniation in MR lumbar spine 6/30/08.
Mild facet degenerative changes at L4 - L5 and L5 - S1. Probably chronic minimal loss of height at the upper end of plate of L1.
Moderately severe disc space narrowing at L3 - L4. This is where there was a disc herniation in MR lumbar spine 5 years ago.
EXAM DATE: 7/03/13
EXAMINATION: MR LUMBAR SPINE
HISTORY: LOW BACK PAIN
The current evaluation was correlated with recent lumbar spine x-rays 6/18/13, lumbar spine x-rays, MR 6/30/08.
As noted recently, the primary locus of disc degenerative changes is at L3 - L4. At that level, there was a herniation in June 2008.
As a result of developing facet arthropathy, from the posterior direction within the foramen on the right at L3 - L4, exacerbated by the
presence of the chronic broad-based disc protrusion, there is now right neuroforaminal stenoisis looking at sagittal image 10, compared with previous sagittal image 10. Another bulging disc at L4 - L5 is stable.
Additionally, seen at the upper margin of the image, there is a new disc protrusion at T10 - T11. This is seen in sagittal T2 weighted image 5.
No new findings within the lumbar spine. As a result of the chronic bilateral broad-based disc protrusion at L3 - L4 and the evolving facet arthropathy at that level, there is right sided foraminal stenosis of a greater degree than in the 6/30/08 MR of the lumbar spine. This is a matter of degree.
In the lower thoracic spine however, incompletely visualized in the current examination, new since 6/30/08, there is what appears to be a broad-based disc protrusion near the midline at T10 - T11.
EXAM DATE: 6/30/08
EXAMINATION: MRI LUMBAR SPINE
HISTORY: LOWER BACK PAIN
There are bilateral large herniations within the neural foramina at L3 - L4, right greater than left, associated with superior extrusions across the midline within the canal. The rest of the examination is normal.
Significant herniations with mass effect on the neural foramina, bilateral, right greater than left, at L3 - L4, in addition to left mechanically significant superior midline and bilateral paracentral extrusion at the same level with the canal. neurosurgical consulation may be beneficial.
The current evaluation is correlated with lumbar spine x-rays.
When I had my C & P exam, the first thing the P.A. said to me was, " Do you have your medical records and reports with you" ! She didn't take into consideration the chronic constant pain (7 - 8) I am in. Nor the inability to sit or stand for longer than 15 minutes at a time. I can no longer lift weights over 15 - 20 pounds. I have already missed 23 days this year.
I am lost on what I should do or what my next step is. Do I have a case In appeal ?