I am at 20%, I asked for an increase. What do you think?

Tshujn22

Registered Member
Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire



Name of patient/Veteran: Jones, Tshura Deola



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
[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: L5-S1 small left paracentral disc herniation with
impingement of the left S1 nerve; left L5-S1 radiculopathy




ICD code: M51.26 / M54.16
Date of diagnosis: 2017

Diagnosis #2: lumbar spondylosis ICD code: M47.816
Date of diagnosis: 2017

Medical history
------------------
Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary):
Veteran is service connected for lumbar strain.

Since last C&P exam on NOV 2, 2016, continues with chronic low back pain, feeling of pins and needles to the left foot which began since several
years ago, numbness if sits or drives for too long. Denies new injuries.
She underwent private PT, chiropractor and acupuncture approx 2013-2014 in Brooklyn, NY and received pain injections and pain medications at the Brooklyn VA.


BRW VA PCP- 2017
CT SCAN, MRI and X-rays done; referred to Neurosurgery
MIA SUR NEUROSURG DR 1 Appt. on 03/02/18 @ 11:00 was a no-show.


Last BRW VA PCP note- 8/24/18

"....She also complains of neck pain, and low back pain, left hip pain, associated to numbness and tingling on her left leg;
she says is using her friend's TENS unit."




"...ASSESSMENT/PLAN:

3.Acute on chronic low back pain. Pt. was recommended to follow recommendations
provided by neurosurgery for LS spine XR and Lumbar spine CT scan.






Continue
Meloxicam and Cyclobenzaprine. She will provided with TENS unit. Refer to PM&RS. Refer to neurosurgery once imaging tests are completed. She declines
referral to ER today. She was strongly recommended to go to ER if she presents
with worsening of her pain, weakness on her extremities. She voiced understanding instructions.
She is provided with medical excuse for her work today..." PM&R consult pending


Currently takes meloxicam, flexeril, uses TENS Denies injections, surgeries.

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:
if I sit or lay too long; I have to adjust and stand up periodically or this leg goes numb. When I have a flare up, is difficult moving around, walking, standing, exercising
I can't wash dishes, drive


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.
when I have a flare up, is difficult moving around, walking, standing, exercising
I can't wash dishes, drive

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 55 degrees
Extension (0 to 30): 0 to 10 degrees
Right Lateral Flexion (0 to 30): 0 to 15 degrees
Left Lateral Flexion (0 to 30): 0 to 10 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? [X] Yes (please explain) [ ] No
If yes, please explain: pain on movement


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):
midline T4-S1, bilateral L4-S1 paraspinals and bilat SI joints






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

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?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Weakness

Able to describe in terms of range of motion: [X] Yes [ ] No Forward Flexion (0 to 90): 0 to 55 degrees
Extension (0 to 30): 0 to 10 degrees
Right Lateral Flexion (0 to 30): 0 to 15 degrees
Left Lateral Flexion (0 to 30): 0 to 10 degrees
Right Lateral Rotation (0 to 30): 0 to 15 degrees
Left Lateral Rotation (0 to 30): 0 to 15 degrees

d. Flare-ups







Is the exam being conducted during a flare-up? [X] Yes [ ] No

Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Weakness

Able to describe in terms of range of motion: [X] Yes [ ] No Forward Flexion (0 to 90): 0 to 55 degrees
Extension (0 to 30): 0 to 10 degrees
Right Lateral Flexion (0 to 30): 0 to 15 degrees
Left Lateral Flexion (0 to 30): 0 to 10 degrees
Right Lateral Rotation (0 to 30): 0 to 15 degrees
Left Lateral Rotation (0 to 30): 0 to 15 degrees

e. Guarding and muscle spasm

Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [X] Yes [ ] No

Muscle spasm: [ ] None
[ ] Resulting in abnormal gait or abnormal spinal contour
[X] 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

Muscle strength testing
--------------------------
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: [ ] 5/5 [X] 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: [ ] 5/5 [X] 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

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+

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: [ ] Normal [X] Decreased [ ] Absent

Foot/toes (L5):
Right: [X] Normal [ ] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent

Straight leg raising test
----------------------------
Provide straight leg raising test results:






Right: [ ] Negative [ ] Positive [X] Unable to perform Left: [ ] Negative [ ] Positive [X] Unable to perform

8. Radiculopathy
----------------
Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy?
[X] Yes [ ] No
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: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe

Paresthesias and/or dysesthesias
Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe

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

Does the Veteran have any other signs or symptoms of radiculopathy? No response provided.

Indicate nerve roots involved: (check all that apply)

[X] Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve)

If checked, indicate: [ ] Right [X] Left [ ] Both

d. Indicate severity of radiculopathy and side affected: Right: [X] Not affected [ ] Mild [ ] Moderate [ ] Severe





Left: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe

Ankylosis
------------
Is there ankylosis of the spine? [ ] Yes [X] No

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

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
---------------------
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


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
------------------------------------------------------------------------
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

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

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

Does the Veteran have a thoracic vertebral fracture with loss of 50 percent or more of height?
[ ] Yes [X] No

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):
CT LUMBAR SPINE W/O CONT (CT Detailed) CPT:72131
Reason for Study: Chronic low back pain, L5-S1 disc hernia

Clinical History: RADIOLOGY USE ONLY:

( ) No change ( ) Contrast ( ) WO Contrast ( ) W/WO Contrast

Dr. Date: Time: Protocol:



Report Status: Verified Date Reported: DEC 11, 2017
Date Verified: DEC 11, 2017

Report:
Comparison: 10/10/2017 MR

Technique: CT of the lumbar spine was performed without contrast Manufacturer estimated dose, DLP, is 576 mGy*cm.

Findings: Lumbar spine is intact and aligned.
Mineralization
is normal. Paraspinous soft tissues are intact. There are bilateral degenerative/chronic reactive changes in the sacroiliac
joints. Spinal canal is patent at all levels. There is no foraminal or lateral recess stenosis.

Appearance is similar to recent MRI.




Impression:
1. Patent canal, no neural compression. 2. Sacroiliac joint






degenerative/chronic reactive changes bilaterally.






SPINE LUMBOSACRAL MIN 2 VIEWS (RAD Detailed) CPT:72100
Reason for Study: Chronic low back pain, L5-S1 disc hernia

Clinical History:
Chronic low back pain, L5-S1 disc hernia

Report Status: Verified Date Reported: DEC 01, 2017
Date Verified: DEC 01, 2017
Verifier E-Sig:/ES/INES B GOLDSZMIDT MD

Report:
A.P and lateral views of the lumbar spine were submitted for
interpretation. The vertebral bodies are in a good anatomic alignment. The vertebral body heights are preserved. The intervertebral disc spaces are intact. The visualized pedicles
and spinous processes are unremarkable.




Impression:
No radiographic evidence of any bony pathology in the lumbar spine.

Moderately sclerotic changes are present in the SI joints, additional oblique views are suggested for further diagnostic value.







(Case 619 COMPLETE) MRI LUMBAR SPINE WO CONTRAST (MRI
Detailed) CPT:72148
Reason for Study: Chronic low back pain Clinical History:



SI - Selected Images
No data available for MRI LUMBAR SPINE WITH AND WITHOUT
CONTRAST; MRI LUMBAR SPINE WITH CONTRAST; MRI LUMBAR SPINE WO CONTRAST






RADIOLOGY USE ONLY:

( ) No change ( ) Contrast ( ) WO Contrast ( ) W/WO Contrast

Dr. Date: Time: Protocol:



Report Status: Verified Date Reported: OCT 11, 2017
Date Verified: OCT 11, 2017


Report:
MRI OF THE LUMBAR SPINE WITHOUT CONTRAST

Technique: Sagittal T1-weighted, T2-weighted and STIR, and axial
T1-weighted and T2-weighted images.






Comparison: None.

Findings: There is mild exaggeration of lumbar lordosis. Vertebral alignment and vertebral body heights are normal.
There
is no spondylolysis. Marrow signal in the lumbar spine is normal.
There is mild posterior disc height loss at L5-S1. Remaining disc
heights are preserved.

Limited images through the upper sacrum demonstrate marked abnormal periarticular T1-hypointense marrow signal along the bilateral sacroiliac (SI) joints. This is incompletely imaged
and
cannot be further characterized.

The conus medullaris terminates at L1-L2, a normal level. The distal spinal cord, conus medullaris and cauda equina are normal.

T12-L1, L1-L2, L2-L3, L3-L4: Mild bilateral facet arthropathy. No
thecal sac or neural foraminal stenosis.

L4-L5: Bilateral facet arthropathy and mild right-sided disc bulge resulting in mild right neural foraminal stenosis with mild
touching of the exiting right L4 nerve root. No thecal sac stenosis.

L5-S1: Small left paracentral disc protrusion causing left lateral recess stenosis with impingement of the traversing left
S1 nerve root. Mild bilateral facet arthropathy without neural
foraminal stenosis. No central zone thecal sac stenosis.

The paraspinal soft tissues and caliber of the infrarenal






abdominal aorta are normal.




Impression:


L5-S1 small left paracentral disc herniation with impingement
of the left S1 nerve in the left lateral recess.

L4-L5 mild spondylosis with mild right neural foraminal stenosis and mild touching of the right L4 nerve root.

No thecal sac stenosis.

Marked T1-hypointense marrow signal along the bilateral SI joints, likely periarticular sclerosis. However, this is incompletely imaged and cannot be further characterized. Recommend dedicated x-rays of the bilateral "sacroiliac joints"
for further evaluation (do not order "sacrum/coccyx").


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: currently wokrs for Dept of Homeland Security (office- desk job); difficulty sitting prolonged (has to get up and stretch); driving ( has to call out from work)
States can't work as a deportation officer ( couldn't enroll in the academy) due to her limited physical activity







17. Remarks, if any:
--------------------
ADL effects: flare ups- difficulty moving around, walking, standing, exercising
can't wash dishes, drive


**** Diagnosis of L5-S1 small left paracentral disc herniation with impingement of the left S1 nerve; left L5-S1 radiculopathy and lumbar spondylosis are a progression of the
service connected for lumbar strain.





Correia Requirements:
Is there evidence of pain on passive range of motion testing? Cannot be performed or is not medically appropriate
Unable to test in the thoracolumbar spine passive ROM due to risk of injury to Veteran.

Is there evidence of pain when the joint is used in non-weight bearing? Cannot be performed or is not medically appropriate
Unable to test in the thoracolumbar spine, because weight is applied even while at rest in all positions.

If yes, is the opposing joint undamaged (i.e. no abnormalities)? N/A There is no contralateral joint to test in the thoracolumbar spine
 

Warrior644

Staff Member
PEB Forum Lifetime Supporter
PEB Forum Veteran
Registered Member
Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire

Name of patient/Veteran: Jones, Tshura Deola

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
[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: L5-S1 small left paracentral disc herniation with
impingement of the left S1 nerve; left L5-S1 radiculopathy

ICD code: M51.26 / M54.16
Date of diagnosis: 2017

Diagnosis #2: lumbar spondylosis ICD code: M47.816
Date of diagnosis: 2017

Medical history
------------------
Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary):
Veteran is service connected for lumbar strain.

Since last C&P exam on NOV 2, 2016, continues with chronic low back pain, feeling of pins and needles to the left foot which began since several
years ago, numbness if sits or drives for too long. Denies new injuries.
She underwent private PT, chiropractor and acupuncture approx 2013-2014 in Brooklyn, NY and received pain injections and pain medications at the Brooklyn VA.

BRW VA PCP- 2017
CT SCAN, MRI and X-rays done; referred to Neurosurgery
MIA SUR NEUROSURG DR 1 Appt. on 03/02/18 @ 11:00 was a no-show.

Last BRW VA PCP note- 8/24/18

"....She also complains of neck pain, and low back pain, left hip pain, associated to numbness and tingling on her left leg;
she says is using her friend's TENS unit."

"...ASSESSMENT/PLAN:

3.Acute on chronic low back pain. Pt. was recommended to follow recommendations
provided by neurosurgery for LS spine XR and Lumbar spine CT scan.

Continue
Meloxicam and Cyclobenzaprine. She will provided with TENS unit. Refer to PM&RS. Refer to neurosurgery once imaging tests are completed. She declines
referral to ER today. She was strongly recommended to go to ER if she presents
with worsening of her pain, weakness on her extremities. She voiced understanding instructions.
She is provided with medical excuse for her work today..." PM&R consult pending

Currently takes meloxicam, flexeril, uses TENS Denies injections, surgeries.

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:
if I sit or lay too long; I have to adjust and stand up periodically or this leg goes numb. When I have a flare up, is difficult moving around, walking, standing, exercising
I can't wash dishes, drive

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.
when I have a flare up, is difficult moving around, walking, standing, exercising
I can't wash dishes, drive

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 55 degrees
Extension (0 to 30): 0 to 10 degrees
Right Lateral Flexion (0 to 30): 0 to 15 degrees
Left Lateral Flexion (0 to 30): 0 to 10 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? [X] Yes (please explain) [ ] No
If yes, please explain: pain on movement

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):
midline T4-S1, bilateral L4-S1 paraspinals and bilat SI joints

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

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?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Weakness

Able to describe in terms of range of motion: [X] Yes [ ] No

Forward Flexion (0 to 90): 0 to 55 degrees
Extension (0 to 30): 0 to 10 degrees
Right Lateral Flexion (0 to 30): 0 to 15 degrees
Left Lateral Flexion (0 to 30): 0 to 10 degrees
Right Lateral Rotation (0 to 30): 0 to 15 degrees
Left Lateral Rotation (0 to 30): 0 to 15 degrees

d. Flare-ups

Is the exam being conducted during a flare-up? [X] Yes [ ] No

Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Weakness

Able to describe in terms of range of motion: [X] Yes [ ] No

Forward Flexion (0 to 90): 0 to 55 degrees
Extension (0 to 30): 0 to 10 degrees
Right Lateral Flexion (0 to 30): 0 to 15 degrees
Left Lateral Flexion (0 to 30): 0 to 10 degrees
Right Lateral Rotation (0 to 30): 0 to 15 degrees
Left Lateral Rotation (0 to 30): 0 to 15 degrees

e. Guarding and muscle spasm

Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [X] Yes [ ] No

Muscle spasm: [ ] None
[ ] Resulting in abnormal gait or abnormal spinal contour
[X] 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

Muscle strength testing
--------------------------
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: [ ] 5/5 [X] 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: [ ] 5/5 [X] 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

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+

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: [ ] Normal [X] Decreased [ ] Absent

Foot/toes (L5):
Right: [X] Normal [ ] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent

Straight leg raising test
----------------------------
Provide straight leg raising test results:

Right: [ ] Negative [ ] Positive [X] Unable to perform Left: [ ] Negative [ ] Positive [X] Unable to perform

8. Radiculopathy
----------------
Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy?
[X] Yes [ ] No
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: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe

Paresthesias and/or dysesthesias
Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe

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

Does the Veteran have any other signs or symptoms of radiculopathy? No response provided.

Indicate nerve roots involved: (check all that apply)

[X] Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve)

If checked, indicate: [ ] Right [X] Left [ ] Both

d. Indicate severity of radiculopathy and side affected: Right: [X] Not affected [ ] Mild [ ] Moderate [ ] Severe

Left: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe

Ankylosis
------------
Is there ankylosis of the spine? [ ] Yes [X] No

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

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
---------------------
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

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
------------------------------------------------------------------------
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

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

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

Does the Veteran have a thoracic vertebral fracture with loss of 50 percent or more of height?
[ ] Yes [X] No

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):
CT LUMBAR SPINE W/O CONT (CT Detailed) CPT:72131
Reason for Study: Chronic low back pain, L5-S1 disc hernia

Clinical History: RADIOLOGY USE ONLY:

( ) No change ( ) Contrast ( ) WO Contrast ( ) W/WO Contrast

Dr. Date: Time: Protocol:

Report Status: Verified Date Reported: DEC 11, 2017
Date Verified: DEC 11, 2017

Report:
Comparison: 10/10/2017 MR

Technique: CT of the lumbar spine was performed without contrast Manufacturer estimated dose, DLP, is 576 mGy*cm.

Findings: Lumbar spine is intact and aligned.
Mineralization
is normal. Paraspinous soft tissues are intact. There are bilateral degenerative/chronic reactive changes in the sacroiliac
joints. Spinal canal is patent at all levels. There is no foraminal or lateral recess stenosis.

Appearance is similar to recent MRI.

Impression:
1. Patent canal, no neural compression. 2. Sacroiliac joint

degenerative/chronic reactive changes bilaterally.

SPINE LUMBOSACRAL MIN 2 VIEWS (RAD Detailed) CPT:72100
Reason for Study: Chronic low back pain, L5-S1 disc hernia

Clinical History:
Chronic low back pain, L5-S1 disc hernia

Report Status: Verified Date Reported: DEC 01, 2017
Date Verified: DEC 01, 2017
Verifier E-Sig:/ES/INES B GOLDSZMIDT MD

Report:
A.P and lateral views of the lumbar spine were submitted for
interpretation. The vertebral bodies are in a good anatomic alignment. The vertebral body heights are preserved. The intervertebral disc spaces are intact. The visualized pedicles
and spinous processes are unremarkable.

Impression:
No radiographic evidence of any bony pathology in the lumbar spine.

Moderately sclerotic changes are present in the SI joints, additional oblique views are suggested for further diagnostic value.

(Case 619 COMPLETE) MRI LUMBAR SPINE WO CONTRAST (MRI
Detailed) CPT:72148
Reason for Study: Chronic low back pain Clinical History:

SI - Selected Images
No data available for MRI LUMBAR SPINE WITH AND WITHOUT
CONTRAST; MRI LUMBAR SPINE WITH CONTRAST; MRI LUMBAR SPINE WO CONTRAST

RADIOLOGY USE ONLY:

( ) No change ( ) Contrast ( ) WO Contrast ( ) W/WO Contrast

Dr. Date: Time: Protocol:


Report Status: Verified Date Reported: OCT 11, 2017
Date Verified: OCT 11, 2017

Report:
MRI OF THE LUMBAR SPINE WITHOUT CONTRAST

Technique: Sagittal T1-weighted, T2-weighted and STIR, and axial
T1-weighted and T2-weighted images.

Comparison: None.

Findings: There is mild exaggeration of lumbar lordosis. Vertebral alignment and vertebral body heights are normal.
There
is no spondylolysis. Marrow signal in the lumbar spine is normal.
There is mild posterior disc height loss at L5-S1. Remaining disc
heights are preserved.

Limited images through the upper sacrum demonstrate marked abnormal periarticular T1-hypointense marrow signal along the bilateral sacroiliac (SI) joints. This is incompletely imaged
and
cannot be further characterized.

The conus medullaris terminates at L1-L2, a normal level. The distal spinal cord, conus medullaris and cauda equina are normal.

T12-L1, L1-L2, L2-L3, L3-L4: Mild bilateral facet arthropathy. No
thecal sac or neural foraminal stenosis.

L4-L5: Bilateral facet arthropathy and mild right-sided disc bulge resulting in mild right neural foraminal stenosis with mild
touching of the exiting right L4 nerve root. No thecal sac stenosis.

L5-S1: Small left paracentral disc protrusion causing left lateral recess stenosis with impingement of the traversing left
S1 nerve root. Mild bilateral facet arthropathy without neural
foraminal stenosis. No central zone thecal sac stenosis.

The paraspinal soft tissues and caliber of the infrarenal

abdominal aorta are normal.

Impression:

L5-S1 small left paracentral disc herniation with impingement
of the left S1 nerve in the left lateral recess.

L4-L5 mild spondylosis with mild right neural foraminal stenosis and mild touching of the right L4 nerve root.

No thecal sac stenosis.

Marked T1-hypointense marrow signal along the bilateral SI joints, likely periarticular sclerosis. However, this is incompletely imaged and cannot be further characterized. Recommend dedicated x-rays of the bilateral "sacroiliac joints"
for further evaluation (do not order "sacrum/coccyx").

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: currently wokrs for Dept of Homeland Security (office- desk job); difficulty sitting prolonged (has to get up and stretch); driving ( has to call out from work)
States can't work as a deportation officer ( couldn't enroll in the academy) due to her limited physical activity


17. Remarks, if any:
--------------------
ADL effects: flare ups- difficulty moving around, walking, standing, exercising
can't wash dishes, drive

**** Diagnosis of L5-S1 small left paracentral disc herniation with impingement of the left S1 nerve; left L5-S1 radiculopathy and lumbar spondylosis are a progression of the
service connected for lumbar strain.

Correia Requirements:
Is there evidence of pain on passive range of motion testing? Cannot be performed or is not medically appropriate
Unable to test in the thoracolumbar spine passive ROM due to risk of injury to Veteran.

Is there evidence of pain when the joint is used in non-weight bearing? Cannot be performed or is not medically appropriate
Unable to test in the thoracolumbar spine, because weight is applied even while at rest in all positions.

If yes, is the opposing joint undamaged (i.e. no abnormalities)? N/A There is no contralateral joint to test in the thoracolumbar spine
Welcome to the PEB Forum! :)

In accordance with 38 CFR VASRD §4.71a Schedule of ratings—musculoskeletal system "The Spine" General Rating Formula for Diseases and Injuries of the Spine, the results of the aforementioned DoVA Back (Thoracolumbar Spine) Conditions DBQ under section 3 suggests a rating of 20% due to a "Forward Flexion (0 to 90): 0 to 55 degrees" or a combined range of motion of the thoracolumbar spine not greater than 120 degrees; your combined ROM is exactly 120 degrees. The criteria for a 20% rating is as follows:

"Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis."

Alternatively, the 38 CFR VASRD §4.71a Schedule of ratings—musculoskeletal system "The Spine" General Rating Formula for Diseases and Injuries of the Spine states that a 40% rating is based upon the following criteria:

"Unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine."

With that all said, it would seem your DoVA disability claim requesting a rating increase via the results from the Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire will probably be denied unfortunately albeit your current rating of 20% should remain unchanged at this particular point in time. Take care!

Thus, I quite often comment that "possessing well-informed knowledge is truly a powerful equalizer!"

Best Wishes!
 

chaplaincharlie

Staff Member
PEB Forum Lifetime Supporter
PEB Forum Veteran
Registered Member
You can request a VARR if you feel your numbers were not appropriately reflected in the DBQ.
 

Tshujn22

Registered Member
I am currently a Veteran, can I ask for a VARR? It is funny this pinch nerve and numbness has gotten worse, to the point of constant day off from work and always having to get up from sitting to relieve my legs
 

chaplaincharlie

Staff Member
PEB Forum Lifetime Supporter
PEB Forum Veteran
Registered Member
As a veteran you can appeal the rating, if you are in the appeal period. Otherwise you can file a new claim. The fastest way to get a new claim adjudicated if to file a Fully Developed CLaim. Download the appropriate DBQ and take it to your doc. He/she can fill out the form and you upload the DBQ with your new claim. If you are in the appeal process complete the same form, in the same manner and upload it to your appeal.
 
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