degenerative arthritis Lumbar Back With Radiculopathy/sciatica Increase (Input Needed)

[marinejay]

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.

[RUREADY]

you got a lot of problems with your back it they make a rating

for range of motion forward flexion 0-30 degrees is 40 % for back

your legs he really didn't give you much maybe 20%. If you don't like

the decision appeal get an nerve study done on legs an another opinion

from a private doctor if you can. And it maybe be enough to get the increase

Do you work? I had to retire from some of the problems you got. If you don't have

a doctor to write your opinion maybe I could help. RU

[RUREADY]

you need an opinion to counter this mess about the smoking

is the cause of some of your problems and to counter mere spectulation

because he cant decide right or wrong.

[marinejay]

you got a lot of problems with your back it they make a rating

for range of motion forward flexion 0-30 degrees is 40 % for back

your legs he really didn't give you much maybe 20%. If you don't like

the decision appeal get an nerve study done on legs an another opinion

from a private doctor if you can. And it maybe be enough to get the increase

Do you work? I had to retire from some of the problems you got. If you don't have

a doctor to write your opinion maybe I could help. RU

RUREADY,

I work, but my back affects my ability to work, i constantly have to sit down or stand up. I work in an office so it kills me when i sit all day. I had Dr. Bash do a IME for me back in May 13, and his measurements were the following.

Flexion/extension 20/10

L/R rotation 20/20

L/R lateral bending 10/10

I want to see how the rate this and I'll keep you guys updated.

[pwrslm]

Get a letter from your employer detailing what special accomodations are allowed to you for your back problem, if any.

Edited August 12, 2015 by pwrslm