Back (Thoracolumbar Spine) Conditions C&P Exam results What would think I get? (2022)

I know this is a long report. My current disability rating is 70% I have asked for an increase in my Back (Thoracolumbar Spine) and Radiculopathy, right lower extremity claimed as right leg numbness. Listed below is my present rating.

degenerative joint disease, right ankle 10%

degenerative joint disease, left shoulder claimed as residuals, left shoulder surgery and arm 20%

residual scar, left shoulder 0%

right foot pes planus also claimed as right foot arthritis 30%

bilateral hearing loss 0%

right foot hallux valgus claimed as right toe pain and right foot arthritis 0%

degenerative disc disease, lumbar spine claimed as low back condition 20%

radiculopathy, right lower extremity claimed as right leg numbness 20%

C&P Exams Results

Back (Thoracolumbar Spine) Conditions

Thoracolumbar Common Diagnoses:

[ ] Ankylosing spondylitis

[ ] Lumbosacral strain

[X] Degenerative arthritis of the spine

[X] Intervertebral disc syndrome

[ ] Sacroiliac injury

[ ] Sacroiliac weakness

[ ] Segmental instability

[ ] Spinal fusion

[ ] Spinal stenosis

[ ] Spondylolisthesis

[ ] Vertebral dislocation

[ ] Vertebral fracture

[X] Other Diagnosis

Diagnosis

1: Lumbar spine DDD/DJD L4-S1, DDD L1-2, per imaging, with moderately severe Right L4, L5, S1 radiculopathy ICD code: M51.27 / M54.1

Date of diagnosis: SC

2. Medical history

a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): per vet he injured his low back over the years running in service and this continues to this date with right radiculopathy pain meds:

b. Does the Veteran report flare-ups of the thoracolumbar spine (back)?

[X] Yes [ ] 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. the vet must avoid lifting more than a few pounds and avoid bending over to pick things up and cannot stand more than about 20 minutes all due to his back and can sometimes trip on his right foot due to his radiculopathy all limiting these activities; this does not preclude limited duty or sedentary employment.

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 15 degrees

Extension (0 to 30): 0 to 5 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 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: the vet must avoid lifting more than a few pounds and avoid

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Bending over to pick things up and cannot stand more than about 20 minutes all due to his back , and can sometimes trip on his right foot due to his radiculopathy all limiting these activities; this does not preclude limited duty or sedentary employment. 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, 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): bilateral lumbar paraspinous, muscle tenderness, spasm, and guarding all attributed to the lumbar spine 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?

[X] Yes [ ] No

Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time?

[X] Yes [ ] No [ ]

Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain

Able to describe in terms of range of motion:

[X] Yes [ ] No

Forward Flexion (0 to 90): 0 to 15 degrees

Extension (0 to 30): 0 to 5 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 30 degrees

Left Lateral Rotation (0 to 30): 0 to 30 degrees

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:

[ ] 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.

[X] 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 [ ] No [X]

Unable to say w/o mere speculation if unable to say w/o mere speculation, please explain: As the veteran is not having a flare today, it would be only with resort to mere speculation to report the additional ROM limitation due to pain during a flare at that time.

e. Guarding and muscle spasm

Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)?

[X] Yes [ ] No

Muscle spasm:

[ ] None

[X] Resulting in abnormal gait or abnormal spinal contour

[ ] Not resulting in abnormal gait or abnormal spinal contour

[ ] Unable to evaluate, describe below:

Provide description and/or etiology: bilateral lumbar paraspinous muscle tenderness, spasm, and guarding all attributed to the lumbar spine condition. Localized tenderness:

[ ] None

[X] Resulting in abnormal gait or abnormal spinal contour

[ ] Not resulting in abnormal gait or abnormal spinal contour

[ ] Unable to evaluate, describe below: Provide description and/or etiology: bilateral lumbar paraspinous muscle tenderness, spasm, and guarding all attributed to the lumbar spine condition.

Guarding:

[ ] None

[X] Resulting in abnormal gait or abnormal spinal contour

[ ] Not resulting in abnormal gait or abnormal spinal contour

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[ ] Unable to evaluate, describe below:

Provide description and/or etiology: bilateral lumbar paraspinous muscle tenderness, spasm, and guarding all attributed to the lumbar spine condition.

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: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Ankle dorsiflexion:

Right: [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: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

b. Does the Veteran have muscle atrophy?

[ ] Yes [X] No

5. Reflex exam

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 [ ] 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

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Lower leg/ankle (L4/L5/S1):

Right: [ ] Normal [X] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

Foot/toes (L5):

Right: [ ] Normal [X] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

Other sensory findings, if any: sensation is decreased only in the right L4, L5 and S1 dermatomal distributions.

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: [ ] None [ ] Mild [X] Moderate [ ] Severe

Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Intermittent pain (usually dull)

Right lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe

Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Paresthesias and/or dysesthesias

Right lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe

Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Numbness

Right lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe

Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

b. Does the Veteran have any other signs or symptoms of radiculopathy?

[ ] Yes [X] No

c. Indicate nerve roots involved: (check all that apply)

[X] Other nerves (specify nerve and side(s) affected): right L4, L5, S1

d. Indicate severity of radiculopathy and side affected:

Right: [ ] Not affected [ ] Mild [ ] Moderate [X] 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?

[ ] Yes [X] No

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

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14. Other pertinent physical findings, complications, conditions, signs, symptoms and scars

a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above?

[X] Yes [ ] No

If yes, describe (brief summary): the above radiculopathy is moderately severe but there is no tab for this in the Back DBQ.

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 test in

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):

Procedure Name

MRI LUMBAR SPINE W/O CONTRAST

Reason for Study

58 y/o male with chronic back pain presenting with xray on 1/14

Clinical History

58 y/o male with chronic back pain presenting with xray on 1/14 showing severe ddd, now presenting with radicular sx to both legs

1) Does the patient have any implanted electronic device (AICD), Pacemaker, spinal cord stimulator, pump or similar device): No

2) Does the patient have surgical brain aneurysm clip(s) or other Metal in the brain: No

3) Does the patient have known metal fragments in the orbits/eyes: No

4) Does the patient have a history of allergy or adverse reaction to IV MRI contrast agents: No

5) Has the patient had any Surgery in the past 12 weeks? No

6) Is the patient pregnant: (consider pregnancy testing if there is any question): NA

7) Does the patient have severe renal insufficiency; eGFR < 45: No

Patient Wt: 212 lb [96.4 kg] (02/06/2015 12:52) Impression No significant findings.

Report

MRI of the lumbar spine is performed. T1-weighted, inversion recovery, and T2-weighted sequences are obtained. Images are obtained in sagittal and coronal planes. There are no old studies available for comparison. At L5-S1, there is mild DDD. There is a hemangioma in the L5 vertebral body measuring 1.5 x 1.6 cm. As noted on plain film radiography, there is sclerotic change at the facet joints. At L4-L5, there is mild DDD and facet hypertrophy. There is mild central stenotic change with mild disc bulging.

At L3-L4, there is no significant pathology.

At L2-L3, there is no significant pathology.

At L1-L2, there is moderate to severe DDD.

There are no paraspinous masses or cord tethering. There are Schmorl's nodes at T11-T12.

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 vet must avoid lifting more than a few pounds and avoid bending over to pick things up and cannot stand more than about 20 minutes all due to his back , and can sometimes trip on his right foot due to his radiculopathy all limiting these activities; this does not preclude limited duty or sedentary employment.

17. Remarks, if any:

Unless otherwise documented in the report: passive ROM was unchanged from active ROM and on repetitive testing, range of motion values were unchanged from baseline values reported and no pain, fatigue, weakness or incoordination was noted.

As the veteran is not having a flare today, it would be only with resort to mere speculation to report the additional ROM limitation due to pain during a flare at that time.

The above functional limitations are as stated per veteran.

CPRS reviewed.

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Claims folder reviewed via VBMS/VV

Diagnostic testing is not clinically indicated at this time a more precise diagnosis cannot be rendered as there is no objective data to support a more definitive diagnosis. It is at least as likely as not that the veteran's current lumbar DJD is the result of the natural progression of his SC lumbar spine condition. The DJD found on exam today is consistent with the expected natural progression of the veteran's SC lumbar spine disease. Note Title: COMPENSATION & P

FAQs

What are thoracolumbar spine conditions? ›

Definition. Thoracolumbar fractures are breakages in the vertebrae of the spinal column in the thoracic and lumbar regions. They may be associated with disruption of the ligamentous complexes, and can result in instability or compression of neural structures.

What is favorable ankylosis of the entire thoracolumbar spine? ›

Favorable ankylosis is fixation of a spinal segment in neutral position (zero degrees). Indicate the accompanying sign(s) and/or symptom(s). Please perform complete neurologic evaluation as indicated based upon disability for which the exam is being performed.

What is the disability percentage for back pain? ›

What is the average VA disability rating for back pain? VA disability ratings for back pain can range from 10% to 100%, depending on the severity of the pain, the range of motion the veteran is left with, and the frequency of the pain.

What is the VA disability rating for lumbosacral strain? ›

Lumbosacral or Cervical Strain

Pain is a very common symptom of lumbosacral and cervical strain, as well as trouble bending or having limited range of motion. VA rates lumbosacral and cervical strain under Diagnostic Code 5237, with ratings ranging from 10 to 100 percent.

Where is the thoracolumbar area? ›

The thoracolumbar fascia is the gray area at bottom center. The thoracolumbar fascia (TLF) is a girdling structure consisting of several aponeurotic and fascial layers that separates the paraspinal muscles from the muscles of the posterior abdominal wall.

Is thoracolumbar scoliosis a disability? ›

This sideways curvature of the spine can have many side effects and health problems. So, the Social Security Administration (SSA) offers benefits for scoliosis disorder. If you are wondering whether scoliosis is a disability, the answer is YES! It is a disability, and you can get disability benefits for it.

What is the VA rating for degenerative arthritis of the spine? ›

Arthritis of the back will be rated at 10 or 20 percent based upon the number of joints/joint groups affected and the level of incapacitation. VA requires that limitations of motion be confirmed by observations such as swelling, muscle spasms, or evidence of painful motion.

What is the average VA rating for degenerative disc disease? ›

So, individuals with a low range of motion and other severe symptoms will receive a higher VA disability rating for DDD. The VA generally rates degenerative disc disease between 10 and 20%, depending on the number of joints affected.

What percentage disability is degenerative disc disease? ›

Despite how much pain the condition causes, the maximum VA disability rating for degenerative disc disease, as mentioned above, is typically 20 percent.

Can I get disability for chronic back pain? ›

If your chronic back pain is preventing you from performing the essential duties of your job, you may qualify for long-term disability (LTD). Chronic back pain is a common symptom. Spine injuries and other medical conditions can cause severe back pain.

Can you get disability for arthritis in the spine? ›

You may automatically qualify for benefits if your arthritis is affecting your spine and compromising any nerve roots within the spinal cord. Arthritis should cause your spinal cord to experience widespread pain, limited flexibility, and inflammation that necessitates a change in positioning every few hours.

What conditions are secondary to degenerative disc disease? ›

It's important to look into worsening symptoms and secondary conditions that may have surfaced as a result of the degenerative disc disease. DDD can trigger other conditions including radiculopathy, herniated discs, neurological impairments, spinal stenosis, and more.

Is a lumbosacral strain permanent? ›

Back muscle strains typically heal with time, many within a few days, and most within 3 to 4 weeks. Most patients with mild or moderate lumbar strains make a full recovery and are free of symptoms within days, weeks, or possibly months.

Can lumbar strain cause degenerative disc disease? ›

Risk factors for degenerative disc disease include: Family history of back pain or musculoskeletal disorders. Excessive strain on the low back caused by sports, frequent heavy lifting, or labor-intensive jobs. Strain on the lumbar spinal discs due to prolonged sitting and/or poor posture.

How is thoracolumbar scoliosis treated? ›

The majority of cases of adult scoliosis can be managed non-operatively through regular observation by a doctor, over-the-counter pain medications, and core-strengthening exercises to strengthen your abdomen and back and to improve flexibility. If you smoke, it's important that you quit.

What spine disorders qualify for disability? ›

3 Back Conditions That May Qualify for Social Security Disability
  • Scoliosis;
  • Herniated or bulging discs;
  • One or more fractured vertebrae;
  • Degenerative joint disease; or.
  • Facet arthritis.
5 Mar 2021

What is thoracolumbar spondylosis? ›

Spondylosis refers to the natural wear and tear that can happen in the spine. Also called spinal osteoarthritis, it can affect any region of the spine, including the cervical (neck) or lower back.

What is thoracolumbar scoliosis? ›

Thoracolumbar scoliosis is a curvature of the spine at the junction of the mid back (lower thoracic) and low back (upper lumbar). Thoracolumbar scoliosis can be caused by a variety of reasons but as with all types of scoliosis it is usually idiopathic, about 80 – 90% of the time.

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