Spine

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Review of Medical Records:

B. Present Medical History (Subjective Complaints):

Please comment whether etiology for any of these subjective complaints is unrelated to claimed disability.

1. Report complaints of pain (including any radiation), stiffness, weakness, etc.
   1. Onset
   2. Location and distribution
   3. Duration
   4. Characteristics, quality, description
   5. Intensity
2. Describe treatment - type, dose, frequency, response, side effects.
3. Provide the following (per veteran) if individual reports periods of flare-up:
   1. Severity, frequency, and duration.
   2. Precipitating and alleviating factors.
   3. Additional limitation of motion or functional impairment during the flare-up.
4. Describe associated features or symptoms (e.g., weight loss, fevers, malaise, dizziness, visual disturbances, numbness, weakness, bladder complaints, bowel complaints, erectile dysfunction).
5. Describe walking and assistive devices.
   1. Does the veteran walk unaided? Does the veteran use a cane, crutches, or a walker?
   2. Does the veteran use a brace (orthosis)?
   3. How far and how long can the veteran walk?
   4. Is the veteran unsteady? Does the veteran have a history of falls?
6. Describe details of any trauma or injury, including dates, and direction and magnitude of forces.
7. Describe details of any surgery, including dates.
8. Functional Assessment - Describe effects of the condition(s) on the veteran's mobility (e.g., walking, transfers), activities of daily living (i.e., eating, grooming, bathing, toileting, dressing), usual occupation, recreational activities, driving.

C. Physical Examination (Objective Findings): Address each of the following as appropriate to the condition being examined and fully describe current findings:

1. Inspection: spine, limbs, posture and gait, position of the head, curvatures of the spine, symmetry in appearance, symmetry and rhythm of spinal motion.
   
2. Range of motion

1. Cervical Spine
   
   The reproducibility of an individual's range of motion is one indicator of optimum effort. Pain, fear of injury, disuse or neuromuscular inhibition may limit mobility by decreasing the individual's effort. If range of motion measurements fail to match known pathology, please repeat the measurements. (Reference: Guides to the Evaluation of Permanent Impairment, Fifth Edition, 2001, page 399).

i. Using a goniometer, measure and report the range of motion in degrees of forward flexion, extension, left lateral flexion, right lateral flexion, left lateral rotation and right lateral rotation. Generally, the normal ranges of motion for the cervical spine are as follows:

• Forward flexion: 0 to 45 degrees
• Extension: 0 to 45 degrees
• Left Lateral Flexion: 0 to 45 degrees
• Right Lateral Flexion: 0 to 45 degrees
• Left Lateral Rotation: 0 to 80 degrees
• Right Lateral Rotation: 0 to 80 degrees

There may be a situation where an individual's range of motion is reduced, but "normal" (in the examiner's opinion) based on the individual's age, body habitus, neurologic disease, or other factors unrelated to the disability for which the exam is being performed. In this situation, please explain why the individual's measured range of motion should be considered as "normal".

ii. If the spine is painful on motion, state at what point in the range of motion pain begins and ends.

iii. Describe presence or absence of: pain (including pain on repeated use); fatigue; weakness; lack of endurance; and incoordination.

iv. Describe objective evidence of painful motion, spasm, weakness, tenderness, etc.

v. Describe any postural abnormalities, fixed deformity (ankylosis), or abnormality of musculature of cervical spine musculature. In the situation where there is unfavorable ankylosis of the cervical spine, indicate whether there is: difficulty walking because of a limited line of vision; restricted opening of the mouth (with limited ability to chew); breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea; dysphagia; atlantoaxial or cervical subluxation or dislocation

b. Thoracolumbar spine

The reproducibility of an individual's range of motion is one indicator of optimum effort. Pain, fear of injury, disuse or neuromuscular inhibition may limit mobility by decreasing the individual's effort. If range of motion measurements fail to match known pathology, please repeat the measurements. (Reference: Guides to the Evaluation of Permanent Impairment, Fifth Edition, 2001, page 399).

It is best to measure range of motion for the thoracolumbar spine from a standing position. Measuring the range of motion from a standing position (as opposed to from a sitting position) will include the effects of forces generated by the distance from the center of gravity from the axis of motion of the spine and will include the effect of contraction of the spinal muscles. Contraction of the spinal muscles imposes a significant compressive force during spine movements upon the lumbar discs.

i. Provide forward flexion of the thoracolumbar spine as a unit. Do not include hip flexion. (See Magee, Orthopedic Physical Assessment, Third Edition, 1997, W.B. Saunders Company, pages 374-75). Using a goniometer, measure and report the range of motion in degrees for forward flexion, extension, left lateral flexion, right lateral flexion, left lateral rotation and right lateral rotation. Generally, the normal ranges of motion for the thoracolumbar spine as a unit are as follows:

• Forward flexion: 0 to 90 degrees
• Extension: 0 to 30 degrees
• Left Lateral Flexion: 0 to 30 degrees
• Right Lateral Flexion: 0 to 30 degrees
• Left Lateral Rotation: 0 to 30 degrees
• Right Lateral Rotation: 0 to 30 degrees

There may be a situation where an individual's range of motion is reduced, but "normal" (in the examiner's opinion) based on the individual's age, body habitus, neurologic disease, or other factors unrelated to the disability for which the exam is being performed. In this situation, please explain why the individual's measured range of motion should be considered as "normal".

ii. If the spine is painful on motion, state at what point in the range of motion pain begins and ends.

iii. Describe presence or absence of: pain (including pain on repeated use); fatigue; weakness; lack of endurance; and incoordination.

iv. Describe objective evidence of painful motion, spasm, weakness, tenderness, etc.

a. Indicate whether there is muscle spasm, guarding or localized tenderness with preserved spinal contour, and normal gait.

b. Indicate whether there is muscle spasm, or guarding severe enough to result in an abnormal gait, abnormal spinal contour such as scoliosis, reversed lordosis or abnormal kyphosis.

v. Describe any postural abnormalities, fixed deformity (ankylosis), or abnormality of musculature of back. In the situation where there is unfavorable ankylosis of the thoracolumbar spine, indicate whether there is: difficulty walking because of a limited line of vision; restricted opening of the mouth (with limited ability to chew); breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea; dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root involvement.

3. Neurological examination

Please perform complete neurologic evaluation as indicated based upon disability for which the exam is being performed. Please provide brief statement if any of the following (a-e) is not included in exam. For additional neurologic effects of disability not captured by a - e, (e.g. bladder problems) please refer to appropriate worksheet for the body system affected.

1. Sensory examination, to include sacral segments.
2. Motor examination (atrophy, circumferential measurements, tone, and strength).
3. Reflexes (deep tendon, cutaneous, and pathologic).
4. Rectal examination (sensation, tone, volitional control, and reflexes).
5. Lasegue's sign.

4. For vertebral fractures, report the percentage of loss of height, if any, of the vertebral body
5. Non-organic physical signs (e.g., Waddell tests, others).

D. For intervertebral disc syndrome

1. Conduct and report a separate history and physical examination for each segment of the spine (cervical, thoracic, lumbar) affected by disc disease.
2. Conduct a complete history and physical examination of each affected segment of the spine (cervical, thoracic, lumbar), whether or not there has been surgery, as described above under B. Present Medical History and C. Physical Examination.
3. Conduct a thorough neurologic history and examination, as described in C5, of all areas innervated by each affected spinal segment. Specify the peripheral nerve(s) affected. Include an evaluation of effects, if any, on bowel or bladder functioning.
4. Describe as precisely as possible, in number of days, the duration of each incapacitating episode during the past 12-month period. An incapacitating episode, for disability evaluation purposes, is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.

E. Diagnostic and Clinical Tests:

1. Imaging studies, when indicated.
2. Electrodiagnostic tests, when indicated.
3. Clinical laboratory tests, when indicated.
4. Isotope scans, when indicated.
5. Include results of all diagnostic and clinical tests conducted in the examination report.

F. Diagnosis:

G. Additional Limitation of Joint Function:

Impairment of joint function is determined by actual range of joint motion as reported in the physical examination and additional limitation of joint function caused by the following factors:

1. Pain, including pain on repeated use
2. Fatigue
3. Weakness
4. Lack of endurance
5. Incoordination

Do any of the above factors additionally limit joint function? If so, express the additional limitation in degrees.

Indicate if you cannot determine, without resort to mere speculation, whether any of these factors cause additional functional loss. For example, indicate if you would need to resort to mere speculation in order to express additional limitation due to repetitive use.