lumbosacral Results Of C&p Exam. What Is Your Take On This?

[pilgrim01]

After retirement I was denied for a condition of numbness/tingling down my right leg to my right foot. They said it was not diagnosed, etc. I filed a RECONSIDERATION for Lumbar Condition with Radiculopathy. I received another C&P exam on Jan 4th, 2010. Well I got the results of my latest C&P exam today. The QTC doctor stated:

NEUROLOGICAL EXAM:

The lumbar spine sensory is impaired. The examination of the sacral reveals no sensory deficits of S1. The modality used to test sensory function was touch. There is no lumbosacral motor weakness. L4: Sensory deficit of right lateral thigh. There are signs of Lumbar Intervertebral Disc Syndrome. The most likely peripheral nerve is the Sciatic Nerve. The IVDS does not cause any bowel dysfunction, bladder dysfunction and erectile dysfunction.

DIAGNOSIS TESTS:

The attached lumbar spine X-ray report shows degenerative arthritis.

DIAGNOSIS:

For the claimant's claimed condition of LUMBAR SPINE CONDITION, the diagnosis is Intervertebral Disc Syndrome with degenerative arthritis changes and the most likely involved nerve is the Sciatic nerve. nerve which affects the right side of the body. The subjective factors are History. The objective factors are Exam and X-ray findings. There are no complications. The diagnosis is SLIGHT SCOLIOSIS LOWER THORACIC SPINE. The subjective factors are None. The objective factors are X-ray findings.

It also stated that my ROM was "WNL" which is totally wrong. I barely moved my back during the exam.

Keep in mind, my MRI results listed much more damage to my back than the x-ray results that the C&P doctor gave. The MRI showed sacralization of the L5, multi-level disc protrusions involving L1-L2, L2-L3, L3-L4 and L4-transitional levels. Stnosis of the spine at L2-L3 and L3-L4 levels, multi level spondylosis, right lateral spurs of the endplates adjacent to the L3-L4 disc space and the inferior endplates of L4, bilaterally. Anterior spurrings of the L3,L4 and the trasnitional vertebrae.

ALSO, I was just reading through my file and when I was in Physcial Therapy (Apr - Jun 09), they did a ROM test on me and the results were:

This is EXACTLY how it reads, so please forgive me if you don't understand it because I don't: :-)

ROM: LUMBAR FLEX: 50 EXT: 5 RSB: 25 LSB: 25 RROT: 40 LROT: 40 (PAIN WITH EXT)

And YES, this is in my C-file! So, who are they going to believe?

Again, the C&P doctor didn't even do a ROM test. She just told me to bend forward, now bend backward. Test was over!

So, from everyone's experience, what is your opinion on my results? Do I have a chance? As of Jan 25th, my claim was at the Rating Board. Thanks, all!

Edited February 8, 2010 by pilgrim01

[jbasser]

You need to get an outside IMO regardless if you can afford it or not. It appears you are faceing an uphill battle with t his C and P doc.

Hang in there and get it done.

J

[*Bergie*]

After retirement I was denied for a condition of numbness/tingling down my right leg to my right foot. They said it was not diagnosed, etc. I filed a RECONSIDERATION for Lumbar Condition with Radiculopathy. I received another C&P exam on Jan 4th, 2010. Well I got the results of my latest C&P exam today. The QTC doctor stated:

DIAGNOSIS TESTS:

The attached lumbar spine X-ray report shows degenerative arthritis.

DIAGNOSIS:

For the claimant's claimed condition of LUMBAR SPINE CONDITION, the diagnosis is Intervertebral Disc Syndrome with degenerative arthritis changes and the most likely involved nerve is the Sciatic nerve. nerve which affects the right side of the body. The subjective factors are History. The objective factors are Exam and X-ray findings. There are no complications. The diagnosis is SLIGHT SCOLIOSIS LOWER THORACIC SPINE. The subjective factors are None. The objective factors are X-ray findings.

It also stated that my ROM was "WNL" which is totally wrong. I barely moved my back during the exam.

So, from everyone's experience, what is your opinion on my results? Do I have a chance? As of Jan 25th, my claim was at the Rating Board. Thanks, all!

I totally agree with John, an IMO is your best bet. I think without it you can expect a lower rating than you might deserve.

Bergie

[pilgrim01]

"I totally agree with John, an IMO is your best bet. I think without it you can expect a lower rating than you might deserve.

Bergie "

I did. With my current RESONSIDERATION, I submitted a letter from my current doctor that stated:

"Mr. XXXXXX had an MRI of his lumbar spine on Mrach 10, 2009 which showed multi level lumbar disc protrusions causing bilateral foraminal stenosis at many levels and spinal stenosis at two levels. These findings were consistent with his complaints of lower back pain and right radicular leg pain that radiated to his right foot which he has had since July 2006. He had no previous MRI of his back. Please feel free to call me at XXXXXX with any questions/concerns."

Edited February 3, 2010 by pilgrim01

[pilgrim01]

So, since my doctor said that I had multi level lumbar disc protrusions causing bilateral foraminal stenosis at many levels and spinal stenosis at two levels from the MRI and X-ray results and the QTC doctor said that the diagnosis is Intervertebral Disc Syndrome with degenerative arthritis changes and the most likely involved nerve is the Sciatic nerve. The nerve which affects the right side of the body. The subjective factors are History. The objective factors are Exam and X-ray findings. There are no complications. The diagnosis is SLIGHT SCOLIOSIS LOWER THORACIC SPINE. The subjective factors are None. The objective factors are X-ray findings.

With all that, should I be rated on BILATERAL FORAMINAL STENOSIS, SPINAL STENOSIS, IVDS, SCOLIOSIS and RADICULOPATHY?

I'm just trying to get a handle on all this. Thanks, everyone!

[Vync]

Everyone's recommendation to get an IMO from your own doc would help greatly.

"Slight scoliosis lower thoracic spine" means your spine is not following the normal expected vertical curvature. It is probably unnaturally curving to the left or right. Within the back ratings, this can justify a rating by itself, even if the ROM requirements are not met. The ratings say that stenosis, IVDS, and scoliosis would be lumped together for the thoracolumbar spine section. You'll probably get a single rating for it. I'm not sure how the arthritis would factor in. Nerve issues *might* be factored in separately, if they are serious enough.

[pilgrim01]

Everyone's recommendation to get an IMO from your own doc would help greatly.

"Slight scoliosis lower thoracic spine" means your spine is not following the normal expected vertical curvature. It is probably unnaturally curving to the left or right. Within the back ratings, this can justify a rating by itself, even if the ROM requirements are not met. The ratings say that stenosis, IVDS, and scoliosis would be lumped together for the thoracolumbar spine section. You'll probably get a single rating for it. I'm not sure how the arthritis would factor in. Nerve issues *might* be factored in separately, if they are serious enough.

So, for example, if Stenosis, IVDS and Scoliosis are all 10% each, it would be 30%?

I thought that my doctor writing a letter that I stated below was an IMO? The statements that my doctor stated below, she wrote in a letter to the VA that I submitted with my claim.

Edited February 3, 2010 by pilgrim01