Hello everyone, newbie here, so I apologize if I have WAY to much info or posted in wrong place. First, I would like to thank everyone for their service or their family members service to this great country. I also want to give props to this site, WOW, just by reading many threads I have learned SO MUCH, so THANK YOU ALL!
I just my results back from my C&P's for my Neck (Cervical Spine) and Back (Thoracolumbar Spine). If the rater goes off of the ROM alone and if it is deemed SC then I think I should get at least 10% SC for Neck/Spine and 10% SC for lower back. (I have evidence in my files confirming the fall and going to TMC because of Neck & Back Pains while in Iraq etc.) I read on here where someone mentioned to pay attention to things like "Arthritis", I noticed in both my reports that the Arthritis question is answered as YES. CERVICAL: a. Have imaging studies of the cervical spine been performed and are the
results available?
[X] Yes [ ] No
If yes, is arthritis (degenerative joint disease) documented?
[X] Yes [ ] No BACK: 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
Here's my questions:
1. Does having Arthritis with images possibly increase the percentage of disability, decrease the percentage or they simply just stick with ROM when determining SC disability percentage?
2. My forward Flexion in Spine and Back are 30 or less and 50 or less, should that put me @ 20%, if these are given SC status?
3. Do they normally just rate ALL of these conditions as 1 and basically just give either the 10%-20% SC?
Also, anyone with knowledge of general ratings care to let me know what they think about the report, SC, Possible percentages etc. would be greatly appreciated.
Thank you. Posting both full C&P's for reference below.
*** C&P GENERAL MEDICAL Has ADDENDA *** Neck (Cervical Spine) Conditions
Disability Benefits Questionnaire
Name of patient/Veteran: XXXXXXXXXXXXXX
Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination [X] Yes [ ] No
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with a cervical
spine (neck) condition?
[X] Yes [ ] No
[ ] Ankylosing spondylitis
[X] Cervical strain
[X] Degenerative arthritis of the spine
[ ] Intervertebral disc syndrome
[ ] Segmental instability
[ ] Spinal fusion
[ ] Spinal stenosis
[ ] Spondylolisthesis
[ ] Vertebral dislocation
[ ] Vertebral fracture
Diagnosis #1: Strain
ICD code: S13.8XXA
Date of diagnosis: 2004
Diagnosis #2: Multilevel uncovertebral arthritis
ICD code: M50.30
Date of diagnosis: 2017
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
cervical spine (neck) condition (brief summary):
Does the Veteran have a diagnosis of (a) Neck pain that is at least as
likely as not (50 percent or greater probability) incurred in or caused by
(the) injury during service?
There is a LOD dated 07/13/2004 where the veteran
was seen and treated for an injury to his neck and back while in service.
The veteran reports that since the time of his fall, he has experienced neck and back pain that
increases with activity.
---------------------------------------------------------------------------------------------------------------------------
===========================================================
Note Text
LOCAL TITLE: 1010M MEDICAL CERTIFICATE
STANDARD TITLE: ADMISSION EVALUATION NOTE
DATE OF NOTE: JUL 22, 2005@12:34
==========================================================
TRIAGE
HISTORY
---------------------------------------------------------
----CHIEF COMPLAINT:back pain that started over 1 yr ago while deployed
in Iraq, onset in assoc with wearing the gear required, body armor, weapon,
helmet, etc. back pain is across low back , does not radiate. Has stiffness in
am, pain worsens as day progresses and varies according to activity,
increased pain at night, interferes with sleep. Has records from visit while on active
duty 9/04, indicates rx was naprosyn and robaxin, patient says he was given
light duty consisting of no additional lifting, but had to continue usual
carrying of pack and vest. rx was ineffective.
---------------------------------------------------------
---------------------------------------------------------
----HX. OF PRESENT ILLNESS: as above, he initially also had neck pain
but this has improved and is minor. back pain however, is daily , constant,
with associated stiffness. saw family doctor who prescribed toradol, it did
not help. has taken vicodin that belonged to family member, it did help,
just took a couple. currently taking tylenol or alleve intermittently.
xray result unknown to patient. denies numbness or weakness in legs.
sometimes limps but this is due to his back pain and guarding.
Is not exercising regularly, occasional golf. does stretching at times
but not regularly. swims occasionally.
--------------------------------------------------------------------------------------------
b. Dominant hand:
No response provided
c. Does the Veteran report flare-ups of the cervical spine (neck)?
[X] Yes [ ] No
If yes, document the Veteran's description of the flare-ups in his or
her own words:
The veteran reports neck pain with prolonged sitting erect or when
turning his head from side to side.
d. Does the Veteran report having any functional loss or functional
impairment of the cervical spine (neck) (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:
The veteran reports neck pain with prolonged sitting erect or when
turning his head from side to side.
3. Range of motion (ROM) and functional limitations
---------------------------------------------------
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 (0-45): 0 to 30 degrees
Extension (0-45): 0 to 40 degrees
Right Lateral Flexion (0-45): 0 to 35 degrees
Left Lateral Flexion (0-45): 0 to 35 degrees
Right Lateral Rotation (0-80): 0 to 60 degrees
Left Lateral Rotation (0-80): 0 to 60 degrees
If abnormal, does the range of motion itself contribute to a
functional loss? [X] Yes, (please explain) [ ] No
If yes, please explain:
Decreased ROM interferes with the veteran turning his head from
side to side, interferes with driving when needing to look side too
side when changing lanes.
Description of pain (select best response):
Pain noted on examination and causes functional loss
If noted on examination, 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? [ ] Yes [X] No
Is there objective evidence of localized tenderness or pain on palpation
of the joint or associated soft tissue of the cervical spine (neck)?
[X] Yes [ ] No
If yes, describe including location, severity and relationship to
condition(s):
Pain at posterior neck on palpation.
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:
[X] 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.
[ ] The examination is neither medically consistent nor 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 [X] No [ ] Unable to say w/o mere speculation
d. Flare-ups
Is the examination 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 nor 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 [X] No [ ] Unable to say w/o mere speculation
e. Guarding and muscle spasm
Does the Veteran have guarding, or muscle spasm of the cervical spine?
[ ] Yes [X] No
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:
Less movement than normal due to ankylosis, adhesions, etc.,
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
Elbow 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
Elbow 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
Wrist 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
Wrist 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
Finger 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
Finger Abduction
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
Biceps:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Triceps:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Brachioradialis:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
6. Sensory exam
---------------
Provide results for sensation to light touch (dermatomes) testing:
Shoulder area (C5):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Inner/outer forearm (C6/T1):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Hand/fingers (C6-8):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
7. Radiculopathy
-----------------
Does the Veteran have radicular pain or any other signs or symptoms due to
radiculopathy?
[ ] Yes [X] No
8. Ankylosis
------------
Is there ankylosis of the spine? [ ] Yes [X] No
9. Other neurologic abnormalities
---------------------------------
Does the Veteran have any other neurologic abnormalities related to a
cervical spine (neck) condition (such as bowel or bladder problems due to
cervical myelopathy)?
[ ] Yes [X] No
10. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest
-----------------------------------------------------------------------
a. Does the Veteran have IVDS of the cervical spine?
[ ] Yes [X] No
11. 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
b. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition:
No response provided.
12. Remaining effective function of the extremities
----------------------------------------------------
Due to a cervical spine (neck) 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.)
[ ] Yes, functioning is so diminished that amputation with prosthesis would
equally serve the Veteran.
[X] No
13. 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?
[ ] Yes [X] No
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.
14. Diagnostic testing
----------------------
a. Have imaging studies of the cervical spine been performed and are the
results available?
[X] Yes [ ] No
If yes, is arthritis (degenerative joint disease) documented?
[X] Yes [ ] No
b. Does the Veteran have a 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):
SPINE CERVICAL MIN 4 VIEWS
Exm Date: OCT 02, 2017@11:55
Reason for Study: C&P Exam
Clinical History:
Pain fall from truck
Report:
Findings: There is straightening of the cervical spine
compatible
muscle spasm. No fracture or dislocation. No focal lytic or
sclerotic osseous lesion. No degenerative disc disease. There
is C5-6 uncovertebral arthritis with bilateral neuroforaminal
narrowing. There is also left-sided foraminal stenosis at
C3-4 and C4-5.
Impression:
1. Straightening of the cervical spine due to muscle spasm.
2. Multilevel uncovertebral arthritis with bilateral
neuroforaminal --------------------------------------------------------------------------------------------------------------------------------------------------------------
Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire
Name of patient/Veteran:
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination Request?
[X] Yes [ ] No
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
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:
No response provided.
Diagnosis #1: Multilevel annular bulging
ICD code: M51.36
Date of diagnosis: 2005
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
thoracolumbar spine (back) condition (brief summary):
Does the Veteran have a diagnosis of (a) Back pain that is at least as
likely as not (50 percent or greater probability) incurred in or caused by
(the) injury during service?
There is a LOD dated 07/13/2004 where the veteran was seen and treated for
an injury to his neck and back while in service. The veteran reports that
since the time of his fall, he has experienced neck and back pain that
increases with activity.
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:
The veteran reports constant lower back pain that increases with
prolonged sitting, standing, walking, bending, lifting, pushing and
pulling motions. He reports increased pain when exposed to cold damp
weather.
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.
The veteran reports constant lower back pain that increases with
prolonged sitting, standing, walking, bending, lifting, pushing and
pulling motions. He reports increased pain when exposed to cold damp
weather.
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 50 degrees
Extension (0 to 30): 0 to 25 degrees
Right Lateral Flexion (0 to 30): 0 to 25 degrees
Left Lateral Flexion (0 to 30): 0 to 25 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:
Decreased ROM interferes with stair climbing, lifting and bending.
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? [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):
Pain at mid lumbar region on palpation.
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:
[X] 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.
[ ] 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 [X] No [ ] Unable to say w/o mere speculation
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?
[ ] Yes [X] No [ ] Unable to say w/o mere speculation
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:
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:
Less movement than normal due to ankylosis, adhesions, etc.,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
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: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Foot/toes (L5):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] 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?
[ ] Yes [X] No
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?
[ ] 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
b. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition:
No response provided.
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?
[ ] Yes [X] No
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):
SPINE LUMBOSACRAL 2 OR 3 VIEWS
Exm Date: OCT 02, 2017@11:55
Reason for Study: C&P Exam
Clinical History:
Multiple bulging disc, Fall from truck
Report:
Findings: 5 lumbar-type vertebral bodies are seen. No
fracture or
dislocation. No compression fracture. No focal lytic or
stenotic
osseous lesion is seen. There is no significant facet
arthritis.
Mild L5-S1 degenerative disc disease is noted. The sacroiliac
joints are normal.
Impression:
1. Mild L5-S1 degenerative disc disease.
===================================================================
===========
Exam Date/Time 09/29/2005 13:00
Procedure Name MRI LUMBAR W/O CONTRAST
Clinical History pain in the back
Report
T1 and fast spine echo t2 weighted sagittal imaging was performed
through the
lumbar spine. this was augmented by thin section axial imaging
through the
lower three lumbar levels.
The vertebral bodies are normal in heighth and signal intensity.
the
intervrebral disk spaces are maintained. minimal desiccative
changes are
present at the level of l5-s1. thin section axial imaging reveals
a normal
l3-l4 disk. minimal annular bulging is seen at the level of l4-l5
without
encroachment upon the thecal sac or exiting nerve roots. similar
change is
seen at the level of l5-s1, again without encroachment upon the
thecal sac or
exiting nerve roots. the conus medullaris is well seen and is of
normal
contour and signal intensity.
Impression
Multilevel annular bulging without significant canal stenosis.
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:
The veteran reports constant lower back pain that increases with
prolonged sitting, standing, walking, bending, lifting, pushing and
pulling motions. He reports increased pain when exposed to cold
damp weather.
17. Remarks, if any:
--------------------
No remarks provided.
****************************************************************************
Medical Opinion
Disability Benefits Questionnaire
Name of patient/Veteran: XXXXXXXXXXXXXXXXXXXXX
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
MEDICAL OPINION SUMMARY
-----------------------
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Does the Veteran have a diagnosis of (a)
Back pain that is at least as likely as not (50 percent or greater
probability) incurred in or caused by (the) injury during service?
b. Indicate type of exam for which opinion has been requested: Back
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]
a. The condition claimed was at least as likely as not (50% or greater
probability) incurred in or caused by the claimed in-service injury, event or
illness.
c. Rationale: Conclusion/Raationale: The claim file has been reviewed. Does
the Veteran have a diagnosis of (a) Back pain that is at least as likely as
not (50 percent or greater probability) incurred in or caused by (the) injury
during service?
Based on the claim file review, there is evidence that the veteran suffered
injuries to his neck and back as the result of a fall from a truck. MRI
findings revealed multilevel annular bulging without significant canal
stenosis.
Based on the claim file review as well as the veteran's current diagnosis and
symptoms, it is my opinion that the veteran's multilevel annular bulging
without significant canal stenosis is at as least as likely as not (50
percent or greater probability) incurred in or caused by (the) injury during
service.
*************************************************************************
Question
rhdawgs
Hello everyone, newbie here, so I apologize if I have WAY to much info or posted in wrong place. First, I would like to thank everyone for their service or their family members service to this great country. I also want to give props to this site, WOW, just by reading many threads I have learned SO MUCH, so THANK YOU ALL!
I just my results back from my C&P's for my Neck (Cervical Spine) and Back (Thoracolumbar Spine). If the rater goes off of the ROM alone and if it is deemed SC then I think I should get at least 10% SC for Neck/Spine and 10% SC for lower back. (I have evidence in my files confirming the fall and going to TMC because of Neck & Back Pains while in Iraq etc.) I read on here where someone mentioned to pay attention to things like "Arthritis", I noticed in both my reports that the Arthritis question is answered as YES.
CERVICAL:
a. Have imaging studies of the cervical spine been performed and are the
results available?
[X] Yes [ ] No
If yes, is arthritis (degenerative joint disease) documented?
[X] Yes [ ] No
BACK:
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
Here's my questions:
1. Does having Arthritis with images possibly increase the percentage of disability, decrease the percentage or they simply just stick with ROM when determining SC disability percentage?
2. My forward Flexion in Spine and Back are 30 or less and 50 or less, should that put me @ 20%, if these are given SC status?
3. Do they normally just rate ALL of these conditions as 1 and basically just give either the 10%-20% SC?
Also, anyone with knowledge of general ratings care to let me know what they think about the report, SC, Possible percentages etc. would be greatly appreciated.
Thank you.
Posting both full C&P's for reference below.
*** C&P GENERAL MEDICAL Has ADDENDA ***
Neck (Cervical Spine) Conditions
Disability Benefits Questionnaire
Name of patient/Veteran: XXXXXXXXXXXXXX
Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination [X] Yes [ ] No
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with a cervical
spine (neck) condition?
[X] Yes [ ] No
[ ] Ankylosing spondylitis
[X] Cervical strain
[X] Degenerative arthritis of the spine
[ ] Intervertebral disc syndrome
[ ] Segmental instability
[ ] Spinal fusion
[ ] Spinal stenosis
[ ] Spondylolisthesis
[ ] Vertebral dislocation
[ ] Vertebral fracture
Diagnosis #1: Strain
ICD code: S13.8XXA
Date of diagnosis: 2004
Diagnosis #2: Multilevel uncovertebral arthritis
ICD code: M50.30
Date of diagnosis: 2017
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
cervical spine (neck) condition (brief summary):
Does the Veteran have a diagnosis of (a) Neck pain that is at least as
likely as not (50 percent or greater probability) incurred in or caused by
(the) injury during service?
There is a LOD dated 07/13/2004 where the veteran
was seen and treated for an injury to his neck and back while in service.
The veteran reports that since the time of his fall, he has experienced neck and back pain that
increases with activity.
---------------------------------------------------------------------------------------------------------------------------
===========================================================
Note Text
LOCAL TITLE: 1010M MEDICAL CERTIFICATE
STANDARD TITLE: ADMISSION EVALUATION NOTE
DATE OF NOTE: JUL 22, 2005@12:34
==========================================================
TRIAGE
HISTORY
---------------------------------------------------------
----CHIEF COMPLAINT:back pain that started over 1 yr ago while deployed
in Iraq, onset in assoc with wearing the gear required, body armor, weapon,
helmet, etc. back pain is across low back , does not radiate. Has stiffness in
am, pain worsens as day progresses and varies according to activity,
increased pain at night, interferes with sleep. Has records from visit while on active
duty 9/04, indicates rx was naprosyn and robaxin, patient says he was given
light duty consisting of no additional lifting, but had to continue usual
carrying of pack and vest. rx was ineffective.
---------------------------------------------------------
---------------------------------------------------------
----HX. OF PRESENT ILLNESS: as above, he initially also had neck pain
but this has improved and is minor. back pain however, is daily , constant,
with associated stiffness. saw family doctor who prescribed toradol, it did
not help. has taken vicodin that belonged to family member, it did help,
just took a couple. currently taking tylenol or alleve intermittently.
xray result unknown to patient. denies numbness or weakness in legs.
sometimes limps but this is due to his back pain and guarding.
Is not exercising regularly, occasional golf. does stretching at times
but not regularly. swims occasionally.
--------------------------------------------------------------------------------------------
b. Dominant hand:
No response provided
c. Does the Veteran report flare-ups of the cervical spine (neck)?
[X] Yes [ ] No
If yes, document the Veteran's description of the flare-ups in his or
her own words:
The veteran reports neck pain with prolonged sitting erect or when
turning his head from side to side.
d. Does the Veteran report having any functional loss or functional
impairment of the cervical spine (neck) (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:
The veteran reports neck pain with prolonged sitting erect or when
turning his head from side to side.
3. Range of motion (ROM) and functional limitations
---------------------------------------------------
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 (0-45): 0 to 30 degrees
Extension (0-45): 0 to 40 degrees
Right Lateral Flexion (0-45): 0 to 35 degrees
Left Lateral Flexion (0-45): 0 to 35 degrees
Right Lateral Rotation (0-80): 0 to 60 degrees
Left Lateral Rotation (0-80): 0 to 60 degrees
If abnormal, does the range of motion itself contribute to a
functional loss? [X] Yes, (please explain) [ ] No
If yes, please explain:
Decreased ROM interferes with the veteran turning his head from
side to side, interferes with driving when needing to look side too
side when changing lanes.
Description of pain (select best response):
Pain noted on examination and causes functional loss
If noted on examination, 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? [ ] Yes [X] No
Is there objective evidence of localized tenderness or pain on palpation
of the joint or associated soft tissue of the cervical spine (neck)?
[X] Yes [ ] No
If yes, describe including location, severity and relationship to
condition(s):
Pain at posterior neck on palpation.
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:
[X] 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.
[ ] The examination is neither medically consistent nor 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 [X] No [ ] Unable to say w/o mere speculation
d. Flare-ups
Is the examination 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 nor 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 [X] No [ ] Unable to say w/o mere speculation
e. Guarding and muscle spasm
Does the Veteran have guarding, or muscle spasm of the cervical spine?
[ ] Yes [X] No
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:
Less movement than normal due to ankylosis, adhesions, etc.,
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
Elbow 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
Elbow 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
Wrist 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
Wrist 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
Finger 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
Finger Abduction
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
Biceps:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Triceps:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Brachioradialis:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
6. Sensory exam
---------------
Provide results for sensation to light touch (dermatomes) testing:
Shoulder area (C5):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Inner/outer forearm (C6/T1):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Hand/fingers (C6-8):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
7. Radiculopathy
-----------------
Does the Veteran have radicular pain or any other signs or symptoms due to
radiculopathy?
[ ] Yes [X] No
8. Ankylosis
------------
Is there ankylosis of the spine? [ ] Yes [X] No
9. Other neurologic abnormalities
---------------------------------
Does the Veteran have any other neurologic abnormalities related to a
cervical spine (neck) condition (such as bowel or bladder problems due to
cervical myelopathy)?
[ ] Yes [X] No
10. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest
-----------------------------------------------------------------------
a. Does the Veteran have IVDS of the cervical spine?
[ ] Yes [X] No
11. 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
b. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition:
No response provided.
12. Remaining effective function of the extremities
----------------------------------------------------
Due to a cervical spine (neck) 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.)
[ ] Yes, functioning is so diminished that amputation with prosthesis would
equally serve the Veteran.
[X] No
13. 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?
[ ] Yes [X] No
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.
14. Diagnostic testing
----------------------
a. Have imaging studies of the cervical spine been performed and are the
results available?
[X] Yes [ ] No
If yes, is arthritis (degenerative joint disease) documented?
[X] Yes [ ] No
b. Does the Veteran have a 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):
SPINE CERVICAL MIN 4 VIEWS
Exm Date: OCT 02, 2017@11:55
Reason for Study: C&P Exam
Clinical History:
Pain fall from truck
Report:
Findings: There is straightening of the cervical spine
compatible
muscle spasm. No fracture or dislocation. No focal lytic or
sclerotic osseous lesion. No degenerative disc disease. There
is C5-6 uncovertebral arthritis with bilateral neuroforaminal
narrowing. There is also left-sided foraminal stenosis at
C3-4 and C4-5.
Impression:
1. Straightening of the cervical spine due to muscle spasm.
2. Multilevel uncovertebral arthritis with bilateral
neuroforaminal
--------------------------------------------------------------------------------------------------------------------------------------------------------------
Back (Thoracolumbar Spine) Conditions
Disability Benefits Questionnaire
Name of patient/Veteran:
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination Request?
[X] Yes [ ] No
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
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:
No response provided.
Diagnosis #1: Multilevel annular bulging
ICD code: M51.36
Date of diagnosis: 2005
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
thoracolumbar spine (back) condition (brief summary):
Does the Veteran have a diagnosis of (a) Back pain that is at least as
likely as not (50 percent or greater probability) incurred in or caused by
(the) injury during service?
There is a LOD dated 07/13/2004 where the veteran was seen and treated for
an injury to his neck and back while in service. The veteran reports that
since the time of his fall, he has experienced neck and back pain that
increases with activity.
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:
The veteran reports constant lower back pain that increases with
prolonged sitting, standing, walking, bending, lifting, pushing and
pulling motions. He reports increased pain when exposed to cold damp
weather.
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.
The veteran reports constant lower back pain that increases with
prolonged sitting, standing, walking, bending, lifting, pushing and
pulling motions. He reports increased pain when exposed to cold damp
weather.
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 50 degrees
Extension (0 to 30): 0 to 25 degrees
Right Lateral Flexion (0 to 30): 0 to 25 degrees
Left Lateral Flexion (0 to 30): 0 to 25 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:
Decreased ROM interferes with stair climbing, lifting and bending.
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? [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):
Pain at mid lumbar region on palpation.
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:
[X] 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.
[ ] 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 [X] No [ ] Unable to say w/o mere speculation
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?
[ ] Yes [X] No [ ] Unable to say w/o mere speculation
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:
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:
Less movement than normal due to ankylosis, adhesions, etc.,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
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: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Foot/toes (L5):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] 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?
[ ] Yes [X] No
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?
[ ] 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
b. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition:
No response provided.
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?
[ ] Yes [X] No
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):
SPINE LUMBOSACRAL 2 OR 3 VIEWS
Exm Date: OCT 02, 2017@11:55
Reason for Study: C&P Exam
Clinical History:
Multiple bulging disc, Fall from truck
Report:
Findings: 5 lumbar-type vertebral bodies are seen. No
fracture or
dislocation. No compression fracture. No focal lytic or
stenotic
osseous lesion is seen. There is no significant facet
arthritis.
Mild L5-S1 degenerative disc disease is noted. The sacroiliac
joints are normal.
Impression:
1. Mild L5-S1 degenerative disc disease.
===================================================================
===========
Exam Date/Time 09/29/2005 13:00
Procedure Name MRI LUMBAR W/O CONTRAST
Clinical History pain in the back
Report
T1 and fast spine echo t2 weighted sagittal imaging was performed
through the
lumbar spine. this was augmented by thin section axial imaging
through the
lower three lumbar levels.
The vertebral bodies are normal in heighth and signal intensity.
the
intervrebral disk spaces are maintained. minimal desiccative
changes are
present at the level of l5-s1. thin section axial imaging reveals
a normal
l3-l4 disk. minimal annular bulging is seen at the level of l4-l5
without
encroachment upon the thecal sac or exiting nerve roots. similar
change is
seen at the level of l5-s1, again without encroachment upon the
thecal sac or
exiting nerve roots. the conus medullaris is well seen and is of
normal
contour and signal intensity.
Impression
Multilevel annular bulging without significant canal stenosis.
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:
The veteran reports constant lower back pain that increases with
prolonged sitting, standing, walking, bending, lifting, pushing and
pulling motions. He reports increased pain when exposed to cold
damp weather.
17. Remarks, if any:
--------------------
No remarks provided.
****************************************************************************
Medical Opinion
Disability Benefits Questionnaire
Name of patient/Veteran: XXXXXXXXXXXXXXXXXXXXX
ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this document:
[X] In-person examination
Evidence Review
---------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
MEDICAL OPINION SUMMARY
-----------------------
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Does the Veteran have a diagnosis of (a)
Back pain that is at least as likely as not (50 percent or greater
probability) incurred in or caused by (the) injury during service?
b. Indicate type of exam for which opinion has been requested: Back
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]
a. The condition claimed was at least as likely as not (50% or greater
probability) incurred in or caused by the claimed in-service injury, event or
illness.
c. Rationale: Conclusion/Raationale: The claim file has been reviewed. Does
the Veteran have a diagnosis of (a) Back pain that is at least as likely as
not (50 percent or greater probability) incurred in or caused by (the) injury
during service?
Based on the claim file review, there is evidence that the veteran suffered
injuries to his neck and back as the result of a fall from a truck. MRI
findings revealed multilevel annular bulging without significant canal
stenosis.
Based on the claim file review as well as the veteran's current diagnosis and
symptoms, it is my opinion that the veteran's multilevel annular bulging
without significant canal stenosis is at as least as likely as not (50
percent or greater probability) incurred in or caused by (the) injury during
service.
*************************************************************************
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