C&P: Lower Back Exam Notes (Opinions Requested)

[Ocean]

I am impressed by the C&P doctor, she actually went through my paperwork (300 pages) and got my records from Simon Med (I still owe them a few bucks and they wouldnt release them to me). It took her about 14 days to post the DBQ, which was keeping me anxious. Her exam looks pretty solid, I think. There seems to be a few things that she states that seems to contradict herself in terms of my loss of function, but all-in all, I think this looks favorable. I am currently rated 40% for my lower back and this was a regular scheduled re-examination. If anything stands out, please let me know:

Name of patient/Veteran: Ocean
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
[X] Other Diagnosis
Diagnosis #1: Lumbar strain
ICD code: M54.8
Date of diagnosis: unknown
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
thoracolumbar spine (back) condition (brief summary):
Since the prior rating's exam, Veteran reports that he is
experiencing continuous low back pain. Usually the pain is sharp. When he lies down,
the pain is throbbing in nature. He experiences back spasms, particularly
in his right lower back. Intermittently, he reports that he feels that a
sharp pain and he loses his balance.

He tried cortisone injections given
to him by Dr. Jones, at Southwest Spine and Sports. However, the
injections only provided a few weeks of relief. He has not required
surgery on the low back. He has participated in multiple courses of
physical therapy. He indicates that he has PTSD. "I don't
respond to heavy meds." He takes naproxen and a uses a topical gel medication.
He reports that he is experiencing some incontinence, etiology is
unclear.

(I told her I can not take opiodes as it exacerbates my symptoms of PTSD)

He has numbness in his groin. Urodynamic testing is pending with East
Valley Urology. About 1.5 years ago, he had urinary incontinence. He is
wearing a urinary liner. He been told his prostate is normal. He denies
any problems with his genitalia. He has pins and needles sensation in the
bilateral thighs, bilateral since 2014. He has not undergone EMG testing
of the lower extremities.

(She asked if my genitalia as a whole was fine, I responded by telling her I have ED)

In 2015, Veteran indicates that he hurt his back at work, moving some
equipment. He bent over to unplug his monitor and reached with his right
hand and hurt his back. He went to Simon Med for an MRI.
He has been working in a sedentary position with USAA. He has a
sit/stand station. He has been on long term disability since February
2018.

Sept 24, 2015 Thoracic spine x-ray
1. No acute findings

2. Mild degenerative changes of the midthoracic spine similar to the 2012
exam
Sept 2015
MRI thoracic spine
Impression:
Stable 40% chronic anterior wedge deformity of the T7 vertebral body
20% chronic anterior wedge deformity of the T8 vertebral body as seen on
the current lateral plain film, unchanged compared to the prior lateral
plain film. No retropulsion or canal compromise is seen.
T7-T8 3mm focal disc protrusion with no canal stenosis.
MRI of the thoracic spine is otherwise within normal limits with normal
spinal cord signal.

b. Does the Veteran report flare-ups of the thoracolumbar spine (back)?
[ ] Yes [X] No

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.
Pain in the low back with reduced range of motion

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 30 degrees
Extension (0 to 30): 0 to 10 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 20 degrees
Left Lateral Rotation (0 to 30): 0 to 20 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 and causes functional loss

If noted on exam, which ROM exhibited pain (select all that apply)?
Forward Flexion, Extension, Left Lateral Flexion

Is there evidence of pain with weight bearing? [ ] Yes [X] No

Is there objective evidence of localized tenderness or pain on palpation
of the joints or associated soft tissue of the thoracolumbar spine
(back)?
[X] Yes [ ] No

If yes, describe including location, severity and relationship to
condition(s):
Right lower lumbar paravertebral muscle tenderness would be
attributed to the diagnosed condition

b. Observed repetitive use
Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] No
Is there additional loss of function or range of motion after three
repetitions? [ ] Yes [X] No

c. Repeated use over time
Is the Veteran being examined immediately after repetitive use over time?
[ ] Yes [X] No
If the examination is not being conducted immediately after
repetitive use over time:
[ ] The examination is medically consistent with the Veteran's
statements describing functional loss with repetitive use over
time.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss with repetitive use over
time. Please explain.
[X] The examination is neither medically consistent or inconsistent
with the Veteran's statements describing functional loss
with
repetitive use over time.

Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[ ] Yes [X] No [ ] Unable to say w/o mere speculation

d. Flare-ups
Not applicable

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: None

 

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 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [X] 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: [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?

[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)

b. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition:
Is using cane a few time a week for back condition, when he feels that
he will lose his balance

 

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?
[ ] Yes [X] No

 

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:
With prolonged sitting or standing would need to be able to stand
up to change positions; would need to limit bending forward at the
waist and heavy lifting

 

17. Remarks, if any:
--------------------
1. Pain with non-weight bearing (at rest)?
None noted on exam.
2. Pain with passive ROM?
Cannot be performed or is not medically appropriate
3. Pain with weight bearing?
None noted on exam

[acesup]

Based on the reported Range of Motion, it sounds as if you're probably going to continue at 40%.  I don't consider myself an expert, but I've had SC lower back ratings for 44 years now.  

Hopefully you'll find out the official results soon, so you don't have to wait and worry.  Best of luck.

[Ocean]

Did they ever make you P&T with the low back?

[Navy04]

Looks like they will continue as stated above. I have had 2 back surgeries in the last year, and actually going to see the surgeon again this week for possible fusion. It took multiple injuries and surgeries to get above 20% on back in my case. The VA really does not like to rate back conditions high, but you can use even the lower ratings to get IU or SSDI if you can not work. Good luck

[pwrslm]

"Stable 40% chronic anterior wedge deformity of the T7 vertebral body
20% chronic anterior wedge deformity of the T8 vertebral body"

Did the examiner give any opinions on the wedge deformity? These deformities can be caused by osteoporosis in older adults or they can be a birth defect.  The vertebra is crushed when its from osteo which is considered a fracture. 

 

Edited October 16, 2018 by pwrslm

[rk4435]

Just wondering about the DBQ you posted.  I had a C&P exam for my back a few weeks ago, I do not see a DBQ posted by the examiner, should I see it in eBenefits?

[pwrslm]

dbq will be in your blue button report on healthevet if it was done by the va