5293. Intervertebral Disc Syndrome

[Guest allanopie]

<H3 style="MARGIN: auto 0in">5293. INTERVERTEBRAL DISC SYNDROME

INITIAL EXAM, AMIE WORKSHEET # 1440, 1450 </H3>EXAMINATION:

The examiner should:

1. Record history of onset with or without trauma; document any treatment including surgery or chemonucleolysis. Describe present symptoms with specific reference to back symptoms such as radiating "sciatica" type pain. Specify any precipitating or relieving activities.

2. Record alignment in stance; and describe the presence of any local tenderness with or without radiation, sciatic notch tenderness, and paraspinal spasm. Examination of the motion of the back should include flexion and extension and straight leg raising and/or other tests for sciatic sensitivity. For details of examination of cervical, dorsal and lumbo-sacral spine motion, please refer to the criteria for diagnostic codes 5290, 5291 and 5292.

3. Document the results of neurological examination, with particular emphasis on deep tendon reflexes, sensory and motor tests.

DIAGNOSTIC TEST RESULTS:

X-ray of affected spinal segments, AP and lateral.

If the patient has not undergone surgery, imaging studies such as Magnetic Resonance Imaging, myelogram or CT scan may be useful to confirm presence of disc herniation.

If the patient has undergone back surgery, operative notes may be used to confirm diagnosis.

If patient has undergone surgery with no relief, then repeat imaging study may be necessary to assess local conditions post-operatively.

DIAGNOSIS:

The examiner should specify the anatomical and pathophysiological diagnosis.