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Any SWAG as to how this will be rated?
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Tomahawk
Pretty sure I redacted any personal info. Can anyone hazard a guess as to how this will be rated, and whether or not I will need to file a secondary claim after for radiculopathy or if they will grant it automatically?
Back (Thoracolumbar Spine) Conditions
Disability Benefits Questionnaire
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:
[ ] Ankylosing spondylitis
[ ] Lumbosacral strain
[ ] Degenerative arthritis of the spine
[X] Intervertebral disc syndrome
[ ] Sacroiliac injury
[ ] Sacroiliac weakness
[ ] Segmental instability
[ ] Spinal fusion
[ ] Spinal stenosis
[ ] Spondylolisthesis
[ ] Vertebral dislocation
[ ] Vertebral fracture
Diagnosis #1: Lumbosacral Degenerative Disc Disease
ICD code: M51.36
Date of diagnosis: 2010
2. Medical history
------------------
a. Describe the history (including onset and course) of the
Veteran's
thoracolumbar spine (back) condition (brief summary):
Veteran presents today claiming service connection for his
lumbosacral
degenerative disc disease secondary to his military service
or secondary
to his service connected left foot post surgery and complex
regional pain
syndrome. Veteran reports chronic daily low back pain that
radiates down
the right lower extremity. The pain will increase with
prolonged periods
of weight bearing, ambulation and repetitive bending. His
pain is managed
with pain clinic. He has had epidural injections. Veteran
reports that his
back began to cause chronic problems approximately 2004-2005.
He reports
altered antalgic gait since 1998 after his military discharge
that became
worse after being diagnosed with complex regional pain
syndrome in 2006.
He also reports that he has fallen on multiple occasions
secondary to his
left lower extremity giving way secondary to his CRPS
resulting in
frequent low back injuries.
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 flare ups usually one time per month
lasting 1-2 days.
Sometimes if more than one day will go to emergency room
and is
treated with Toradol. During the flare ups he is in bed
all day.
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.
as above
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 0 degrees
Right Lateral Flexion (0 to 30): 0 to 15 degrees
Left Lateral Flexion (0 to 30): 0 to 15 degrees
Right Lateral Rotation (0 to 30): 0 to 15 degrees
Left Lateral Rotation (0 to 30): 0 to 15 degrees
If abnormal, does the range of motion itself contribute
to a
functional loss? [ ] Yes (please explain) [X] No
Description of pain (select best response):
Pain noted on exam but does not result in/cause functional
loss
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):
pain to palpation of the LS spine L4/L5
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?
[X] Yes [ ] No
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)? [ ] 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., Weakened
movement due to muscle or peripheral
nerve injury, etc.,
Atrophy of
disuse, Disturbance of locomotion, 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: [ ] 5/5 [X] 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: [ ] 5/5 [X] 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: [ ] 5/5 [X] 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: [X] 0 [ ] 1+ [ ] 2+ [ ] 3+ [ ] 4+
Left: [X] 0 [ ] 1+ [ ] 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: [ ] Negative [X] 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 [ ] Mild [X] Moderate
[ ] Severe
Left lower extremity: [X] None [ ] Mild [ ] Moderate
[ ] Severe
Paresthesias and/or dysesthesias
Right lower extremity: [ ] None [X] Mild [ ] Moderate
[ ] Severe
Left lower extremity: [X] None [ ] Mild [ ] Moderate
[ ] Severe
Numbness
Right lower extremity: [ ] None [X] Mild [ ] Moderate
[ ] Severe
Left lower extremity: [X] None [ ] Mild [ ] Moderate
[ ] Severe
b. Does the Veteran have any other signs or symptoms of
radiculopathy?
No response provided.
c. Indicate nerve roots involved: (check all that apply)
[X] Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve)
If checked, indicate: [X] Right [ ] Left [ ] Both
d. Indicate severity of radiculopathy and side affected:
Right: [ ] Not affected [X] Mild [ ] Moderate [ ]
Severe
Left: [X] Not affected [ ] 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?
[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:
for his service connected left foot condtion with CRPS
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?
[ ] 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):
Report:
Clinical Information: Back pain with
radiculopathy.
Procedure: Images of the lumbar spine were obtained in
multiple
planes using multiple pulse sequences and compared to
10/23/13.
Findings:
At T11-T12, there is disc dehydration with loss of disc
height.
There is a central disc protrusion again noted
compressing
the
ventral dural sac. The midline dural sac
diameter is mildly
diminished. There is no cord compromise or
foraminal
impingement. An incidental perineural cyst is
seen within the
foramen on the right at this level without
change.
At T12-L1, there is disc dehydration with loss of disc
height.
The disc is normal in configuration.
At L1-L2, there is normal disc signal with preservation
of
disc
height. There is mild disc bulging compressing the
ventral
dural
sac. The midline dural sac diameter is adequate.
There is
no
foraminal impingement.
At L2-L3 and L3-L4, there is normal disc signal
and disc
configuration with preservation of disc height.
At L4-L5, there is disc dehydration with
preservation of disc
height. There is moderate disc bulging compressing the
ventral
dural sac. The midline dural sac diameter is adequate.
There is
mild bilateral foraminal narrowing. There is facet
hypertrophy.
At L5-S1, there is disc dehydration with
preservation of disc
height. There is moderate disc bulging eccentric
towards the
right and compressing the ventral dural sac. The
midline
dural
sac diameter is adequate. There is moderate to
severe
right-sided foraminal narrowing. There is mild
foraminal
narrowing on the left. There is facet
hypertrophy.
The lumbar vertebra and conus medullaris are
normal. No
paraspinal abnormality is seen.
There has been no substantial change from prior
study.
Impression:
1. Disc protrusion at T11-T12.
2. Disc bulging at L1-L2, L4-L5 and L5-S1.
3. Multilevel foraminal narrowing that is most
prominent on
the
right at L5-S1. Right L5 nerve root impingement may be
present.
4. No change from prior study.
Primary Diagnostic Code:
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's above noted low back condtions would
impair his
ability for physical work requiring any prolonged
periods of
standing, walking, climbing , repetitive bending or
lifting.
17. Remarks, if any:
--------------------
Provide a medical opinion regarding the etiology of the
Veterans current
low back disability, to include whether it is secondary to his
service-
connected left foot disability with complex regional pain
syndrome. Any
additional examination or testing of the Veteran may be
conducted, if deemed
necessary by the examiner. The examiner is asked to provide the
following
opinions:
a. Is it at least as likely as not (a 50 percent probability or
greater)
that the Veterans low back disability was caused by his period
of active
service? Specifically discuss the Veterans complaints of back
pain in July
1996, August 1996, and on his Report of Medical History prior
to
separation.
b. Is it at least as likely as not (a 50 percent probability or
greater)
that the Veterans low back disability was caused by or
aggravated by his
service-connected left foot disability, to include complex
regional pain
syndrome? Specifically discuss the report of the 2009 VA
examiner that the
Veteran had an abnormal gait due to a limping left foot.
2507 requested opinions:
a. After a review of the veteran's STR's his complaints of back
pain during
his military service consisted of an upper thoracic strain and
no complaints
of low back pain. Therefore it would be less likely than not
that this
veteran's chronic LS condition of degenerative disc disease with
right lower
extremity radiculopathy is directly related to his complaints of
back pain
during his military service.
b. The veteran's service connected left foot condition with CRPS
has resulted
in a chronically altered gait as well as multiple falls that
have affected
his back. Therefore it would be at least as likely as not that
this veteran's
current lumbosacral spine condition of degenerative disc disease
with right
lower extremity radiculopathy is secondary to his service
connected left foot
condition with CRPS.
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