ptsd Radiculopathy L4-L5 vs Chronic Sciatica Claim

[Mo]

Hello all,

First off...BIG THANKS!!!!  I am a newbie (sorta) and have been following this site for close to 2 years. You all helped me go from 40% to 70% total last year! This is my first post so I hope I am asking it in the right place. (Haven't found an answer similar). 

I have initiated a claim for an increase of my PTSD. I am also claiming secondary disabilities to DDD (rated 40%)  such as Depression and Radiculopathy. But I noticed I don't have a diagnosis for it.  All my treatment records state DDD or chronic LBP until they recently starting stating "Radicular symptoms begining 6/18/15".  I have 21 pages of VA medical documentation for burning, altered gait, radical symptoms, inability to ambulate, in addition to over 50 days of work missed this year, 2 local ER visits, and 1 VA ER visit.

Do I file for Radiculopathy or Sciatica and if Awarded ask for retroactive pay from 2004?

I have my medical files and here is the following:

• 8/13/15 MRI:

Test Name: MRI L Spine without contrast  

Reason for study: 32m with low back pain radianting to right leg

Clinical History: hx of lumbar radiculopathy L$-L% in 2004. Now with worsening pain, muscle spasms, and nubness in RLE

Report:
MRI lumbar spine without contrast.
Clinical Indication: 32M with low back pain radiating to right
leg.
Contrast: None.
Comparison: None.
Findings:
Segmentation: Normal.
Vertebral column: Vertebral marrow signal without evidence of
fracture or metastasis. Alignment normal.
L1-L2: Disc without significant dessication. Negative for disc
herniation or spinal stenosis.
L2-L3: Disc without significant dessication. Negative for disc
herniation or spinal stenosis.
L3-L4: Disc without significant dessication. Negative for disc
 herniation or spinal stenosis.
L4-L5: Moderate disc desiccation and bulge with dorsal annular
fissure and small central disc extrusion with minimal cephalad
migration. Negative for resultant spinal stenosis.
L5-S1: Mild disc desiccation and bulge with dorsal annular
fissure. There is a 10 mm extradural cyst within the right
lateral recess at the upper S1 vertebral level, consistent with a
discal cyst and resulting in moderate right lateral recess
stenosis with displacement and impingement of the right S1 nerve
root. Negative for canal or foraminal stenosis.
Impression:
1. Negative for spinal canal stenosis. 2. Degenerative changes
at L4-5 and L5-S1 with right-sided discal cyst at L5-S1 resulting
in moderate right lateral recess stenosis and impingement of the
right S1 nerve root.
 

• 6/15/04 MRI 

L3-4: Mild, broad-based disk bulge. The spinal and neuroforamina are unremarkable.

L4-5: Focal, central disk extrusion with partial migration of the disks superiorly along the L4 level posteriorly. There is contact of the exiting L4 nerve root by the disk extrusion. The lateral recess is unremarkable. The spinal canal at the L4-5 level demonstrates flattening from the disks. There is high signal at the central part of the L4-5 disk, which may represent annular.

L5-S1: Mild , broad-basked disk bulge, but the spinal canal and neuroforamina are normal.

Impression: Findings consistent with disk extrusion at the L4-L5 level, with migration of the disk superiorly. Psossible annular tear at L4-L5 level.

• 8/11/04 In service ER visit

Physical Assessment: Posture and gait both abnormal/ antalgic, abnormal striaight leg raise, ROM (limited to pain), and tender to palpation

Comments: HNP @ L4-L5, annular tear L4-L5

Diagnosis: Chronic sciatica

 

Sorry to be so long on my first post, but I want to give as much info as possible. Thanks so much in advance!!!

Edited September 25, 2015 by Mo

[Mo]

I never put in any claims until 2014. The claims form 2004 were from my MEB and PEB. I had all exams while still in service as part of my MedBoard. VA did theirs and made decision before I separated. I was a clueless and confused 21 year old who had no clue what was going on other than I was being pushed put the Army because i was hurt.Until last year I thought I could continue to deal with the pain on my own as well as my claim until someone told me about this website in passing! 

[jbasser]

S1 nerve root impingement likely means Sciatica.

J

[Mo]

***Update***

Sorry I been gone so long. I fell into a deep depression for a while after losing my job due to physica lproblems.

I had a C&P exam for my PTSD 10/2315 and a C&P for my lower back 10/31/15.

I was diagnosed with:

MDD

Radiculapathy of both lower extremities (right>left)

I also applied for TDIU. I submitted my claim 11/19/15 via FDC with copies of treatment records and DBQs.

What do you all think as far as time and rating?

 

 

[Mo]

This is what I got from my C&P Exam...I'm hoping for 60% for my right side and maybe 30% for my left side. Currently my status is "Gathering Evidence" needing VA Form 21-4192 from my two previous employers. It seems I should be getting approved for TDIU as well since I lost my job due to my injuries. Thoughts anyone?

 

1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with a
thoracolumbar spine (back) condition?
[X] Yes [ ] No
[X] Other Diagnosis
Diagnosis #1: IVDS/DEGENERATIVE DISC DISEASE (DDD), LUMBOSACRAL SPINE,
L4-
L5, L5-S1
ICD code: M51
Date of diagnosis: SC
Diagnosis #2: Bilateral lower extremity radiculopathy due to IVDS/DDD
of
lumbar spine
ICD code: M54
Date of diagnosis: 2004 by hx

2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
thoracolumbar spine (back) condition (brief summary):
Veteran is being seen at his request in the DBQ referral clinic for the
SC
condition of DEGENERATIVE DISC DISEASE, LUMBOSACRAL SPINE, L5-S1.
Veteran relates his condition is worse, and he is awaiting a pain clinic
evaluation, however it is currently scheduled in December. Veteran
relates that he had similar presenting symptoms when the condition
occurred in 2004. Has had pain and radiation os symptoms since 2004 for
short periods of time-a few days or weeks.
He indicates that around May of this year had a worsening of low back
pain
with radiation into the legs (currently right > left), at time has
body
shaking as a response, numbness and tingling that begins in the lumbar
spine, radiates to bilateral buttocks and continues along lateral
hip/thigh area then to anterior calf down to great toe when sitting or
standing, and pain and burning sensation of posterior thigh and calf when
lying down. He indicates that it is just not getting better despite
taking
pain medications, having had steroid taper doses, and muscle relaxers. No
loss of bowel control, urinary retention, or saddle anesthesia.
Due to worsening symptoms, he underwent an MRI in Aug 2015 that revealed
Degenerative changes at L4-5 and L5-S1 with right-sided discal cyst at
L5-S1 resulting in moderate right lateral recess stenosis and impingement
of the right S1 nerve root.
Veteran is very tearful, has difficulty sitting still in the exam room,
has "jerking" almost bouncing movements associated with his
reported
severe pain symptoms, or with various movements of legs or back.

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:
Veteran reports an inability to walk or stand during flares
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.
cannot stand, walk, run, climb stairs, etc
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)
Right Lateral Flexion (0 to 30): 0 to 5 degrees
Left Lateral Flexion (0 to 30): 0 to 20 degrees
Right Lateral Rotation (0 to 30): 0 to 15 degrees
Left Lateral Rotation (0 to 30): 0 to 10 degrees

Unable to test forward flexion and extension formally due to veteran
not being able to stand without risk of fall, due to his repeated
jerking movements
If abnormal, does the range of motion itself contribute to a
functional loss? [X] Yes (please explain) [ ] No
If yes, please explain:
unable to twist or bend adequately; although veteran cannot
undergo
formal testing of forward flexion, it is clear he cannot apply his
own shoes, etc. due to low back pain and readicular pain
Description of pain (select best response):
Pain noted on exam on rest/non-movement
If noted on exam, which ROM exhibited pain (select all that apply)?
Forward Flexion, Extension, Right Lateral Flexion, Left Lateral
Flexion, Right Lateral Rotation, Left Lateral Rotation
Is there evidence of pain with weight bearing? [X] Yes [ ] 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):
caused by SC DDD causing muscle spasms due to resisting movement

b. Observed repetitive use
Is the Veteran able to perfor
m repetitive use testing with at least three
repetitions? [ ] Yes [X] No
If no, please provide reason:
severe pain reported
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:
[X] The examination is medically consistent 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?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain
Able to describe in terms of range of motion: [ ] Yes [X] No
If no, please describe:
veteran is unable to complete movements after repeated movement
over time due to severe pain, limitation cannot be described in
degrees of motion, but would be severe in all planes of motion
based on todays limited exam,
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:
[X] 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.
[ ] 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?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain
Able to describe in terms of range of motion: [ ] Yes [X] No

If no, please describe:
Veteran is not being examined during a flare, limitation cannot be
described in degrees of motion, but would be severe in all planes
of motion based on todays limited exam
e. Guarding and muscle spasm
Does the Veteran have guarding or muscle spasm of the thoracolumbar spine
(back)? [X] Yes [ ] No
Muscle spasm:
[ ] None
[X] Resulting in abnormal gait or abnormal spinal contour

Provide description and/or etiology:
tenderness with light touch in anticipation of pain due to DDD of
lumbar spine
Localized tenderness:
[ ] None
[X] Resulting in abnormal gait or abnormal spinal contour

Provide description and/or etiology:
veteran is resistent to allow examination and if the wheelchair he is
sitting in is going to hit a bump preparing for anticipated pain due
to
DDD of lumbar spine
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:
Instability of station, Disturbance of locomotion, Interference with
sitting, Interference with standing

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
Ankle plantar flexion:
Right: [ ] 5/5 [X] 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: [ ] 5/5 [X] 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: [ ] 5/5 [X] 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
--------------
No response provided
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: [ ] Negative [ ] Positive [X] Unable to perform
Left: [ ] Negative [ ] Positive [X] 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: [ ] None [ ] Mild [X] Moderate [ ] Severe
Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
Intermittent pain (usually dull)
Right lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe
Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe
Paresthesias and/or dysesthesias
Right lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe
Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
Numbness
Right lower extremity: [ ] None [ ] Mild [ ] Moderate [X] 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 [ ] Mild [ ] Moderate [X] Severe
Left: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe
9. Ankylosis
------------
Is there ankylosis of the spine? [ ] 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?
[X] Yes [ ] No
If yes, identify assistive device(s) used (check all that apply and
indicate frequency):
Assistive Device: Frequency of use:
----------------- -----------------
[X] Cane(s) [ ] Occasional [ ] Regular [X] Constant
b. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition:
single cane used for DDD of lumbar spine
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):
Reflexes and strength of hips and knees were NOT tested due to
veteran's guarding on exam and jerking motions with any sort
of
spikes in pain. Minimal movements of veteran's lower
extremities
casued significant pain;

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?
[ ] Yes [X] 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 Lumbar spine 08/13/2015
Impression:
1. Negative for spinal canal stenosis. 2. Degenerative changes at
L4-5 and L5-S1 with right-sided discal cyst at L5-S1 resulting in
moderate right lateral recess stenosis and impingement of the
right
S1 nerve root.
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:
Veteran has difficulty walking at this time, cannot stand for more
than a few moments, needs to use a cane when ambulating, cannot
walk more than a few feet, cannot sit for more than 10 minutes
without needing to move.

17. Remarks, if any:
--------------------
Veteran's condition is currently in the process of additional treatment
with
pain clinic evaluation scheduled in December 2015, possibly sooner; it is
possible that this treatment could improve his overall physical functioning
and symptoms related to the lumbar spine condition;
Veteran's upadted diagnosis of IVDS/DDD of lumbar spine now inlcudes
bilateral lower extrmeity radiculopathy, Right worse than left, as evidenced
by physical examination and history; the updated diagnosis includes the
findings due to progression of the condition over time.

 

Edited December 16, 2015 by Mo
personal info

[Mo]

**Update**

Moved to Prep for notification stage....praying 

[pwrslm]

You really should think about getting that cyst removed.  Minimally invasive techniques might be available.  Have you gotten to see a surgeon yet?

 

Your C&P is good, they aught to give you 40% on your back and then possible extra scheduler consideration for higher rating.  Legs need a DBQ as well to get them to do a rating on radiculopathy.  You just might get another appointment for that.  I know they got me an EMG and said I had chronic Radiculopathy, then ignored half of my symptoms after that and gave me 10% for both legs in a low ball that I am fighting now.