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Tomahawk

Any SWAG as to how this will be rated?

Question

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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im gonna take a wild guess and assume your not already rated for lumbar. then im gonna JUST GUESS that yes it looks similar to mine and you will get Sc for lumbar at least 10% and at least 10% for radicilurapathy. But the Dr opine that less likely for a but likely for b.....

But please look at when the DR states this "

 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.

Edited by paulcolrain

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