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

[carlie]

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

pilgrim,

No.

carlie

[pilgrim01]

pilgrim,

No.

carlie

10% for all? Please explain.

[Vync]

Pilgrim,

Here are the ratings for the spine. Look under Note 6 (about halfway through) for a description of how they lump multiple conditions together.

Source: http://www.warms.vba.va.gov/regs/38CFR/BOO...ART4/S4_71a.DOC

The Spine

Rating

General Rating Formula for Diseases and Injuries of the Spine

(For diagnostic codes 5235 to 5243 unless 5243 is evaluated under the Formula for Rating

Intervertebral Disc Syndrome Based on Incapacitating Episodes):

With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease

Unfavorable ankylosis of the entire spine............................................................... 100

Unfavorable ankylosis of the entire thoracolumbar spine......................................... 50

Unfavorable ankylosis of the entire cervical spine; or, forward flexion

of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of

the entire thoracolumbar spine...........................................................................

.. 40

Forward flexion of the cervical spine 15 degrees or less; or, favorable

ankylosis of the entire cervical spine.................................................................... 30

Forward flexion of the thoracolumbar spine greater than 30 degrees but not

greater than 60 degrees; or, forward flexion of the cervical spine greater

than 15 degrees but not greater than 30 degrees; or, the combined range of

motion of the thoracolumbar spine not greater than 120 degrees; or, the

combined range of motion of the cervical spine not greater than 170 degrees;

or, muscle spasm or guarding severe enough to result in an abnormal gait

or abnormal spinal contour such as scoliosis, reversed lordosis, or

abnormal kyphosis........................................................................

........................ 20

Forward flexion of the thoracolumbar spine greater than 60 degrees but not

greater than 85 degrees; or, forward flexion of the cervical spine greater than

30 degrees but not greater than 40 degrees; or, combined range of motion of

the thoracolumbar spine greater than 120 degrees but not greater than 235

degrees; or, combined range of motion of the cervical spine greater than

170 degrees but not greater than 335 degrees; or, muscle spasm, guarding,

or localized tenderness not resulting in abnormal gait or abnormal spinal

contour; or, vertebral body fracture with loss of 50 percent or more of the

height..........................................................................

.......................................... 10

Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code.

Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion.

Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner’s assessment that the range of motion is normal for that individual will be accepted.

Note (4): Round each range of motion measurement to the nearest five degrees.

Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis.

Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability.

5235 Vertebral fracture or dislocation

5236 Sacroiliac injury and weakness

5237 Lumbosacral or cervical strain

5238 Spinal stenosis

5239 Spondylolisthesis or segmental instability

5240 Ankylosing spondylitis

5241 Spinal fusion

5242 Degenerative arthritis of the spine (see also diagnostic code 5003)

5243 Intervertebral disc syndrome

Evaluate intervertebral disc syndrome (preoperatively or postoperatively) either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under §4.25.

Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes

With incapacitating episodes having a total duration of at least 6 weeks during the

past 12 months..........................................................................

...................................... 60

With incapacitating episodes having a total duration of at least 4 weeks but less than

6 weeks during the past 12 months..........................................................................

...... 40

With incapacitating episodes having a total duration of at least 2 weeks but less than

4 weeks during the past 12 months..........................................................................

...... 20

With incapacitating episodes having a total duration of at least one week but less than

2 weeks during the past 12 months..........................................................................

...... 10

Note (1): For purposes of evaluations under diagnostic code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.

Note (2): If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment.

[pilgrim01]

Thanks, Vync, but how do they "lump together" if I have three of those listed in Note 6?

[pilgrim01]

^bump^... Please. I just want some info and knowledge about the possibilities of my claim.

Edited February 4, 2010 by pilgrim01

[Vync]

I could be wrong here. I'm also trying to get SC for lower back problems due to injuries I had while in the service. Maybe someone who is actually SC can clear this up for us.