Jump to content
  • Searches Community Forums, Blog and more

Search the Community

Showing results for tags 'radiculopathy'.



More search options

  • Search By Tags

    Type tags separated by commas.
  • Search By Author

Content Type


Forums

  • Coronavirus - COVID-19
    • Coronavirus - Covid-19
  • General VA Disability Compensation Benefits Claims Forums
    • VA Disability Compensation Benefits Claims Research Forum
    • Appeals Modernization Act AMA
    • RAMP Rapid Appeals Modernization Program
    • Appealing Your Veterans Compensation Disability Claims NOD, DRO, BVA, USCAVC
    • Veterans Compensation & Pension Exams
    • E-Benefits Questions
    • PTSD Post Traumatic Stress Disorder Claims
    • Entitlement - Veterans Compensation Benefits Claims
    • Eligibility - Veterans Compensation Benefit Claims
    • CHAMPVA
    • TDIU Unemployability Claims
    • CUE Clear and Unmistakable Error
    • Success Stories
    • OEF/OIF Veterans
    • VA Caregiver Benefits for Post 9/11 Veterans
    • SMC Special Monthly Compensation
    • IMO Independent Medical Opinion
    • Veterans Benefits State & Federal
    • VA Medical Centers Navigating through it
    • Medication – Prescription Drugs-Health Issues
    • VA Training & Fast letters, Directives, Regulations, Other Guidance Documents
    • MEB/PEB Physical OR Medical Evaluation Forum
    • VA Regional Offices
    • VA Disability Claims Articles and VA News
    • VA Law
  • VA Claims References
  • Specialized Claims
    • TBI Traumatic Brain Injury
    • Mefloquine / Lariam
    • Gulf War Illness
    • Agent Orange
    • ALS - Amyotrophic Lateral Sclerosis
    • MST - Military Sexual Trauma
    • Radiation Exposure from Operation Tomodachi (Japan Earthquake Fukushima Nuclear Assistant)
    • Project SHAD/Project 112
    • Vocational Rehabilitation
    • VA Pensions
    • DIC
    • FTCA Federal Tort Claims Action
    • 1151 Claims
  • Veterans Helping Veterans Podcast
    • Veterans Helping Veterans VA Claims Podcast
  • Welcome Aboard
    • Help Files - How To Use The Forum
    • Introduce Yourself
    • Test Posting Messages Here
    • Roll Call
    • Technical Support For Forum
  • Extras
    • Hiring an Attorney Discussions on S. 3421
    • Social Security Disability Questions
    • VA Scandals
    • Discounts for Veterans
    • Title 38 / 38 CFR
    • 38 CFR 3 Adjudication
    • 38 CFR 4 Schedule for Rating Disabilities
    • Federal Register Announcements
    • Active Duty MEB/PEB Physical OR Medical Evaluation Forum
  • Social Chat
  • Veterans Social Chat's Social
  • Veterans Social Chat's Topics

Find results in...

Find results that contain...


Date Created

  • Start

    End


Last Updated

  • Start

    End


Filter by number of...

Joined

  • Start

    End


Group


AIM


MSN


Website URL


ICQ


Yahoo


Jabber


Skype


GooglePlus


Military Rank


Location


Interests


Service Connected Disability


Branch of Service


Residence


Hobby

Found 4 results

  1. I am serviced connected for ankylosing spondylitis back in 1985. I had a C&P exam on 7-7-19 since I am asking for an increase in my cervical, thoracic, and lumbosacral ratings. After speaking with the DAV to find out progress and info on my exam, the Rep. noted sort of what I expected. Radiculopathy was noted and ROM was 0-15 for cervical, and 0-25 for back. I am currently rated as Cervical 30%, Thoracic 10%, and Lumbosacral 40%. The main question that I have is relating to the thoracic 10% and lumbosacral 40%. I am confused on these two. Is Lumbosacral separate from the thoracic/others ? Since my back ROM is at 0-25, does this mean that my thoracic might increase from the 10% to a higher rating ? I am confused how they break down my ratings from cervical at 30%, Thoracic at 10%, and Lumbosacral at 40%. Did the VA make changes to the names of the spine regions after I was rated and how they would rate each one?....because I don't see Thoracic as a region now. I only see cervical and thoracolumbar. I'm not sure how they would rate/increase me...totally confused. Also, with the radiculopathy, is this something that they will rate also ? I am currently at 90% total combined for all my disabilities. I hope this helps for someone to give me advice/answers.
  2. Hi everyone! I'm new to the page and was hoping someone here might be able to give me advice on possible next steps. I've already taken action on getting earlier effective dates for two conditions but because you never how claims are going to go I want to prepare myself should my claim not go in my favor. My story begins in 2007 when I filed my initial claim with the help of AMVETS. The entire VA claim process was very intimidating and I depended heavily on my VSO to tell me what I could/couldn't claim. He went through my STR and told me what I could claim. Ultimately, I was awarded 60% and felt extremely lucky given all the negative things that I had heard about dealing with the VA. Once I received my award I didn't revisit my VA claim until 2016. My conditions had gotten worse and after doing research online and finding the CFR I realized that I was not being compensated fairly and that I was also not being compensated for conditions that I had in service/currently had and were never claimed. I filed my intent to file and then scoured my STR for evidence of current conditions that I wanted to get SC. This post only concerns two conditions that I believe I should have an earlier effective date for so I will only mention those two below. I figure the easiest way to digest my story is by listing everything chronologically so here I go: Sep. 4, 2007: Separate from the Navy Oct. 24, 2007: File claim for chronic lower back and radiculopathy down right buttocks, also filed claim for SUI, Cystocele and Rectocele Jan. 24, 2008: Awarded service connection for lumbosacral strain 10% (claimed as lower back condition w. radiculopathy down right buttocks) Awarded SC for Urinary Stress Incontinence with Cystocele and Rectocele 20% Effective Date: Sep. 5, 2007 May.9, 2016: File Intent to file Jun. 16, 2016: File claim for increase for chronic lower back condition, file new claim for uterovaginal prolapse Sep. 6, 2016: Awarded increase for lumbosacral strain 20% (claimed as spine condition), awarded SC for radiculopathy right lower extremity (20% even though I did not claim this but it was noted during my C&P exam for increase for chronic back pain), awarded SC for uterovaginal prolapse (30%) Effective Date: May. 9, 2016 Apr-May 2017: Look through old rating decision and claims file and realize that I had claimed radiculopathy on my right side in 2007 claim. Realized that the VA mentioned my uterovaginal prolapse in their decision about my SUI and cystocele/rectocele. Aug. 30, 2017: Visit Baltimore RO with NOD in hand to request earlier effective dates for my uterovaginal prolapse and radiculopathy, they stamp it and then tell me that I need to file a new claim not a NOD. They told me that I can't appeal a decision that they haven't issued yet. They rip up my NOD (which I still have) and provide me a form 21-526ez where I request earlier effective dates. Sep.6, 2017: I receive a letter from the RO stating that I filed my NOD on the wrong form. This was confusing because I didn't file a NOD because the RO told me that I had to file a new claim for the EED. Sep. 16, 2017: They add the new claim for earlier effective dates and I can see it in E-benefits. They combine it with a current claim that I still had pending for something else. Sep. 26, 2017: (decision on uterovaginal prolapse and radiculopathy become final) Oct. 6, 2017: My claim on something else is completed and they completely ignore the claim that I filed for earlier effective dates Mar. 6, 2018: VSO fills out another claim requesting EED for uterovaginal prolapse, and radiculopathy. Claim is currently at preparation for decision I believe that I'm entitled to earlier effective dates because 1) I claimed radiculopathy on my right side in 2007 and they combined it with my back pain in 2007 and issued me one rating. My symptoms are exactly the same now as they were in 2007 so why were they able to issue me a seperate rating in 2016? I was diagnosed with sciatica/piriformis syndrome in service and I have radiculopathy that originates in my buttocks and goes down my right leg. 2) I didn't claim uterovaginal prolapse because I didn't know that I could but the VA knew about it and mentioned it in their Rating Decision narrative for SC for my SUI and cystocele/rectocele. Everything that I read says this amounts to CUE because they did not "sympathetically read my claim and determine all potential claims raised by the evidence". I was told by my VSO that they were supposed to invite me to claim that condition which they never did. What do you guys think? Had the VA issued me ratings for those two conditions I would have been awarded 80% instead of 60%.
  3. If I claimed "Neck Problems" when I retired in 2009, and I was diagnosed with the symptoms of peripheral neuropathy during my C&P exam, should I have been awarded peripheral neuropathy in addition to the cervical spondylosis I was rated for? Below is the CUE I just submitted along with all the medical records. I have to say, my new VSO, the local county guy, was a big help. He said I might have a problem since I originally claimed "neck" and not "radiculopathy", so I attacked that issue head on in my claim. The claim is now in eBenefits being reviewed. Hopefully it won't be combined with my other claims, which could take a while although the VA has all the evidence and I have completed all my C&P exams. MOTION TO REVISE A PREVIOUS VETERAN’S AFFAIRS REGIONAL OFFICE DECISION ON THE BASIS OF CLEAR AND UNMISTAKABLE ERROR I am requesting a motion to revise the date of a rating decision made by the St. Petersburg, FL VA Reginal Office on February 10, 2017 concerning bilateral peripheral neuropathy of the upper extremities. I am requesting a new date of 1 May 2009. The decision in question is for myself, JustGettingStarted, VA File Number #########. SPECIFIC ISSUE CHALLENGED: Upon my retirement on 1 May 2009, I was service connected for Cervical spondylosis at 10%; however, I should have also been serviced connected for bilateral upper extremity radiculopathy (peripheral neuropathy) related to the cervical spondylosis. This motion alleges specific errors of fact or law and why the result would have been different were it not for those errors: ERROR: The VA recognized symptoms of bilateral radiculopathy in my upper extremities during a peripheral nerve C&P exam conducted on 20 July 2009 but failed to provide service connection or a rating. In this case, the VA failed to give a sympathetic reading to the filing by determining all potential claims raised by the evidence, applying all relevant current laws and regulations. Moddy v. Principi, 360 F.3d 1306 (Fed. Cir. 2004). In addition, the VA failed to apply the applicable, existing regulations or statue at that time. Look v. Derwinski, 2 Vet. App. 157, 163-64 (1992). FACTS: 1. In 2008, when preparing for my retirement physical, I claimed "neck" problems. My miliary doctor clarified "cervical disc herniations with radicular symptoms" on the same document (Attachment 1). 2. In my 2009 C&P exam it is stated “A Bone, Hand, Joint, Peripheral Nerves, and Spine Worksheet should be completed for this patient” (Attachment 2). Both the Peripheral Nerve and Spine worksheets say to see the Bone Worksheet (Attachment 3). On the Bone worksheet, the examiner states “bilateral hand numbness”, “numbness in the dorsum of her forearms”, and “pain radiates into the bilateral arms”. All are symptoms of bilateral upper extremity radiculopathy. It is also noted that I was taking Motrin and Neurontin for the nerve pain (Attachment 2). 3. On 5 Dec 2016, I had a C&P exam for peripheral neuropathy that states “Chronic neck pain radiating to the left arm and right hand numbness since 2000”. (Attachment 4). After this exam, I was service connected for left and right upper extremity radiculopathy and rated 20% bilaterally. 4. Peripheral neuropathy is supported by a long medical history documented in military medical records to include MRIs (Attachment 5). These records were available to the VA during my rating decision in 2009. In summary, the path to this error is very clear. My medical records from 2000 to present clearly show signs of bilateral upper extremity radiculopathy supported by x-rays and MRIs. I claimed this as a neck problem when I retired in 2009 and it was clarified to include “radiculopathy” by my military doctor. In 2009, the VA ordered exams for Peripheral Nerves, Spine, Hands, and Bones. When rated in 2009, somehow the radiculopathy was overlooked when it became part of my Bone exam and not reported separately on the Peripheral Nerve exam. The symptoms continued after this exam and I had the radiculopathy properly rated in 2016 by a VA examiner who states I had the symptoms since 2000 based on the medical records provided to him. The VA clearly should have provided service connection and a minimum 20% rating for both right and left upper extremities based on all the medical information that was on hand during the 2009 C&P exam. This request for a new rating date of 1 May 2009 for bilateral upper extremity radiculopathy (peripheral neuropathy) at 20% and meets all qualifications for Clear and Unmistakable Error: - The VA had all evidence in hand, including military medical records and a C&P exam, when they did not provide for service connection and a rating for peripheral neuropathy in 2009. - The statutory or regulatory provisions extant at the time were incorrectly applied when the VA failed to determine all potential claims raised by the evidence at hand. - The error was the sort which, had it not been made, would have manifestly changed the outcome at the time it was made. - The determination is based on the record and the law that existed at the time of the prior adjudication in question. I request your favorable consideration in this matter. JUST GETTING STARTED 17 July 2017 Five attachments 1. Military separation physical 2. 2009 VA C&P exam for Peripheral Nerve and Spine 3. 2009 VA C&P Bone exam 4. Excerpt from 2016 VA C&P exam 5. Military medical records, peripheral neuropathy
  4. Hello everyone, I am just curious at what I looking at for compensation. I am currently SC 20% for back and 10% for right radiculopathy. I am looking to get SC for left radiculopathy and an increase in my back. Thoughts please. My thoughts. I get SC for bilateral readiculopathy @ 10% each and back stays the same at 20%. my goal is to get 30-40% for back. Important sections are in bold to cut through the silt.... LOCAL TITLE: C&P EXAMINATION STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: AUG 07, 2015@08:00 ENTRY DATE: AUTHOR: EXP COSIGNER: URGENCY: STATUS: COMPLETED Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire Name of patient/Veteran: Indicate method used to obtain medical information to complete this document: [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] No If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other: 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No Thoracolumbar Common Diagnoses: [ ] Ankylosing spondylitis [ ] Lumbosacral strain [X] Degenerative arthritis of the spine [ ] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture Diagnosis #1: Degenerative joint disease, lumbar spine, with bilateral sciatica ICD code: 721.3, 724.3 Date of diagnosis: 2003 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): 35 y/o male on active Marine Corps service 1998-2002 as enlisted aviation operations specialist. Currently works full-time as office manager, doing mostly desk work and sometimes teleworking from home. Gets his medical care usually via the VA, but also has a private doctor. Approx 2000 he injured his back while doing heavy lifting on his ship. Since then he has had recurrent back pain that has now become continuous. Currently while sitting at rest he says his low back pain is about 7 out of 10. If he sits for an hour, or walks or does yard work for about 45 min, then the pain gets up to 9-10 and takes several hours to return to baseline with rest. With the pain flares he describes reduced range of motion and weakness but not incoordination. The pain often radiates down the back of both legs, and also sometimes causes tingling and numbness. No bowel or bladder difficulties. No back surgery. Current meds: ibuprofen, vicodin, baclofen, gabapentin. Also uses an electrical stimulator intermittently. Has seen a chiropractor and physical therapy with modest temporary relief. Currently walks for exercise. In the past year has had to take off from work about 12 days because of back pain. b. Does the Veteran report flare-ups of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: If he sits for an hour, or walks or does yard work for about 45 min, then the pain gets up to 9-10 and takes several hours to return to baseline with rest. With the pain flares he describes reduced range of motion and weakness but not incoordination. The pain often radiates down the back of both legs, and also sometimes causes tingling and numbness. c. Does the Veteran report having any functional loss or functional impairment of the thoracolumbar spine (back) (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words. If he sits for an hour, or walks or does yard work for about 45 min, then the pain gets up to 9-10 and takes several hours to return to baseline with rest. With the pain flares he describes reduced range of motion and weakness but not incoordination. The pain often radiates down the back of both legs, and also sometimes causes tingling and numbness. 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Forward Flexion (0 to 90): 0 to 60 degrees Extension (0 to 30): 0 to 20 degrees Right Lateral Flexion (0 to 30): 0 to 20 degrees Left Lateral Flexion (0 to 30): 0 to 20 degrees Right Lateral Rotation (0 to 30): 0 to 30 degrees Left Lateral Rotation (0 to 30): 0 to 30 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes (please explain) [ ] No If yes, please explain: Difficulty bending forward to reach. Description of pain (select best response): Pain noted on exam and causes functional loss If noted on exam, which ROM exhibited pain (select all that apply)? Forward Flexion, Extension, Right Lateral Flexion, Left Lateral Flexion Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): Mild-moderately tender over lumbar spines and paralumbar muscles. b. Observed repetitive use Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: Per patient history, pain, weakness, fatigability or incoordination could significantly limit functional ability during flare-ups or when the joint is used repeatedly over time. However I am unable to quantify the degree of reduced range of motion during the flare-ups because I don't observe them, and the patient's description is a widely variable estimate and also depends on subjective factors such as individual pain tolerance. It would be speculation for me to quantify an additional range of motion loss that might occur during flare-ups or repeated use. d. Flare-ups Is the exam being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [ ] The examination is medically consistent with the Veteran's statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss during flare-ups. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: Per patient history, pain, weakness, fatigability or incoordination could significantly limit functional ability during flare-ups or when the joint is used repeatedly over time. However I am unable to quantify the degree of reduced range of motion during the flare-ups because I don't observe them, and the patient's description is a widely variable estimate and also depends on subjective factors such as individual pain tolerance. It would be speculation for me to quantify an additional range of motion loss that might occur during flare-ups or repeated use. e. Guarding and muscle spasm Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [X] Yes [ ] No Muscle spasm: [X] None [ ] Resulting in abnormal gait or abnormal spinal contour [ ] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: Localized tenderness: [ ] None [ ] Resulting in abnormal gait or abnormal spinal contour [X] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: Guarding: [ ] None [ ] Resulting in abnormal gait or abnormal spinal contour [X] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: f. Additional factors contributing to disability In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Interference with sitting 4. Muscle strength testing -------------------------- a. Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Hip flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Knee extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle plantar flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle dorsiflexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Great toe extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 b. Does the Veteran have muscle atrophy? [ ] Yes [X] No 5. Reflex exam -------------- Rate deep tendon reflexes (DTRs) according to the following scale: 0 Absent 1+ Hypoactive 2+ Normal 3+ Hyperactive without clonus 4+ Hyperactive with clonus Knee: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Ankle: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ 6. Sensory exam --------------- Provide results for sensation to light touch (dermatome) testing: Upper anterior thigh (L2): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Thigh/knee (L3/4): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Lower leg/ankle (L4/L5/S1): Right: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Foot/toes (L5): Right: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent 7. Straight leg raising test ---------------------------- Provide straight leg raising test results: Right: [X] Negative [ ] Positive [ ] Unable to perform Left: [X] Negative [ ] Positive [ ] Unable to perform 8. Radiculopathy ---------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [X] Yes [ ] No a. Indicate symptoms' location and severity (check all that apply): Constant pain (may be excruciating at times) Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Intermittent pain (usually dull) Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Paresthesias and/or dysesthesias Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Numbness Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe b. Does the Veteran have any other signs or symptoms of radiculopathy? [ ] Yes [X] No c. Indicate nerve roots involved: (check all that apply) [X] Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve) If checked, indicate: [ ] Right [ ] Left [X] Both d. Indicate severity of radiculopathy and side affected: Right: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe Left: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe 9. Ankylosis ------------ Is there ankylosis of the spine? [ ] Yes [X] No 10. Other neurologic abnormalities ---------------------------------- Does the Veteran have any other neurologic abnormalities or findings related to a thoracolumbar spine (back) condition (such as bowel or bladder problems/pathologic reflexes)? [ ] Yes [X] No 11. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest ----------------------------------------------------------------------- a. Does the Veteran have IVDS of the thoracolumbar spine? [X] Yes [ ] No b. If yes to question 11a above, has the Veteran had any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months? [ ] Yes [X] No 12. Assistive devices --------------------- a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No 13. Remaining effective function of the extremities --------------------------------------------------- Due to a thoracolumbar spine (back) condition, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc.; functions of the lower extremity include balance and propulsion, etc.) [X] No 14. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [X] Yes [ ] No If yes, describe (brief summary): Able to sit for the interview. Gait is normal. Limits his back ROM due to pain. b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided 15. Diagnostic testing ---------------------- a. Have imaging studies of the thoracolumbar spine been performed and are the results available? [X] Yes [ ] No If yes, is arthritis documented? [X] Yes [ ] No b. Does the Veteran have a thoracic vertebral fracture with loss of 50 percent or more of height? [ ] Yes [X] No c. Are there any other significant diagnostic test findings and/or results? [X] Yes [ ] No If yes, provide type of test or procedure, date and results (brief summary): MRI,SPINE LUMBAR W/O CONT. Exm Date: MAR 20, 2015@19:14 INDICATION: Back pain radiating down the right more than left leg. COMPARISON: Lumbar spine MRI 2/11/2003. Lumbosacral spine x-rays 1/14/2014. TECHNIQUE: MRI of the lumbar spine including: sagittal and axial T1 and fast-T2. Sagittal fast-STIR. FINDINGS: This report assumes five lumbar-type vertebral bodies. Lumbar spine alignment is preserved. Vertebral body heights and disc space heights are preserved. Normal disc signal. No developmental narrowing of the spinal canal. Diffusely abnormal T1-dark marrow signal, similar to 2003. The tip of the conus medullaris is at L1; the conus medullaris and nerve root of the cauda equina have an unremarkable appearance. At L1-2, no spinal canal or neural foraminal narrowing. At L2-3, no spinal canal or neural foraminal narrowing. At L3-4, no spinal canal or neural foraminal narrowing. At L4-5, diffuse disc bulge. Minimal spinal canal narrowing. Mild bilateral facet arthropathy. Minimal bilateral neuroforaminal narrowing. At L5-S1, disc bulge with small superimposed central protrusion. Bilateral facet arthropathy with small posteriorly oriented in facet joint cyst on the right. Mild bilateral neural foraminal narrowing, left greater than right. Within the limits of this examination, no infrarenal abdominal aortic aneurysm. Impression: 1. Minimal multilevel facet arthropathy without evidence of neural impingement. 2. Persistent diffusely abnormally dark T1-marrow signal. This is nonspecific but can seen with smoking, anemia, hematopoietic or hyperplastic marrow or marrow dyscrasias; neoplastic lymphoproliferative conditions would be unlikely to remain stable in appearance since 2003. 16. Functional impact --------------------- Does the Veteran's thoracolumbar spine (back) condition impact on his or her ability to work? [X] Yes [ ] No If yes describe the impact of each of the Veteran's thoracolumbar spine (back) conditions providing one or more examples: Avoid heavy lifting. 17. Remarks, if any: -------------------- Veteran was informed that this evaluation is for compensation and pension purposes only, and he/she is to return to his/her treating clinician for regular medical care.
×
×
  • Create New...

Important Information

{terms] and Guidelines