Rating Impairments of the Spine

DWC Statewide Training March 2006

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Rating Impairments of the Spine

March 2006

Presenters: Craig Barry, Annalisa Faina, Barry Knight, Blair Megowan, Tess Snaer


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Overview

• Principles of Combining

• Methods of Rating Spinal Impairment

• Sample Cases


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What is Combining?

• Estimate of cumulative effect of multiple impairments or disabilities

• Example:– Lumbar spine = 25% PD– Shoulder = 20% PD

25 C 20 = 40 Final PD


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Combining v. Adding

• Most impairments are combined• Two notable exceptions use addition

– Motion values of the same joint, e.g. the six motion values of the shoulder

– Finger impairments Example: 20 Hd for the thumb + 10 Hd for the index finger

30 Hd for the hand


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Calculating a Combined Value

• Formula– A + B(1-A) where A and B are expressed as

percentages or decimals

• Combined Values Chart– Use the table in the PDRS (AMA Guides

contain five errors)


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General Combining Principles

• For three or more values, combine from largest to smallest

• Round the result to the nearest whole number (percentage) after each combination


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Sequencing Matters

• Combine 48 PD, 20 PD and 27 PD


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Order of Combining

1. Combine by body part within extremities

2. Convert to whole person (WP) scale

3. Adjust for FEC, occupation and age

4. Combine by extremity

5. Combine all remaining values


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Combining Example

• Cervical DRE = 5 WP• Lumbar DRE = 25 WP• L Shoulder ROM = 6 UE• L Shoulder instability = 10 UE• L Wrist ROM = 4 UE


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1. Consolidate by Body Part

Cervical DRE = 5 WP 5 WP

Lumbar DRE = 25 WP 25 WP

L Shoulder ROM = 6 UE 17 UE

L Shoulder instability = 12 UE

L Wrist ROM = 4 UE 4 UE


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2. Convert to Whole Person

Cervical DRE = 5 WP

Lumbar DRE = 25 WP

L Shoulder = 17 UE x .6 = 10 WP

L Wrist = 4 UE x .6 = 2 WP


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3. Adjust for FEC, etc.

Cervical DRE:

15.01.01.00 – 5 – [5]6 – 320F – 6 – 6 PD

Lumbar DRE:

15.03.01.00 – 25 – [5]32 – 320F – 32 – 32 PD

L Shoulder:

16.02.02.00 – 10 – [7]14 – 320H – 18 – 18 PD

L Wrist:

16.04.01.00 – 2 – [4]2 – 320I – 4 – 4 PD


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4. Combine by Extremity

Cervical DRE:

6 PD 6 PD

Lumbar DRE:

32 PD 32 PD

L Shoulder:

18 PD 21 PD

L Wrist:

4 PD


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5. Combine Remaining Values

Cervical DRE: 6 PD

Lumbar DRE: 32 PD

L Extremity: 21 PD

32 PD C 21 PD = 46 PD

46 PD C 6 PD = 49 Final PD


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Spine

• Consists of 5 regions:– Cervical – Thoracic– Lumbar– Sacral– Coccygeal


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Spine

• Three Primary Regions– Cervical – Thoracic– Lumbar

These are rated similarly.


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Spine

• Two Methods for Rating the Spine

– Diagnostic Related Estimate (DRE)

– Range of Motion (ROM)


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When to Use DRE Method

• Injury (as opposed to illness)

• Single level within a spinal region, e.g. L4-5

• First injury or repeat injury to a different region

• Corticospinal damage


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When to Use ROM Method

• Impairment caused by illness, not specific injury

• Multilevel involvement (fractures, herniations or stenosis) with radiculopathy in same region

• Bilateral radiculopathy

• Recurrent radiculopathy in same region

See AMA Guides, pg. 380 for flowchart to determine which method to use


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Spine Example

Roofer fell off ladder, herniated disk at

L4-5, had laminectomy

Which method?


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Spine Example

Carpenter re-injured neck at C5-6 level with recurrent radiating pain in right arm

Which method?


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Spine Example

Farm laborer run over by tractor, fractured lumbar spine at L3, herniated disk at C3-4

Which method?


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Spine Example

Roofer fell off roof, fusion at T3-T5

Which method?


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Terms

Radiculopathy is the significant alteration of function of a nerve root.

– pain, numbness or paresthesia in a dermatomal

pattern. – confirmed by positive nerve tension sign and

imaging study


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Terms

Motion Segment Integrity is the normal degree of motion at two adjacent vertebrae.

– loss of motion segment integrity can either be a decrease or increase of motion between two adjacent vertebrae

– easiest to detect with flexion and extension x-rays


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DRE Method (Page 384)

DRE Method - Lumbar Spine

• DRE Category

• Corticospinal damage, if applicable


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DRE Category I0 WP Impairment

• Subjective findings only

• No significant clinical findings

• An example is a back strain with no radiculopathy


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DRE Category II5-8 WP Impairment

• Significant muscle guarding or asymmetric ROM

• Non-verifiable radicular pain

• History of verifiable radiculopathy no longer present

• Fracture < 25% compression one vertebrae


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Category III10-13 WP Impairment

• Verifiable radiculopathy

• Surgery (diskectomy)

• Fracture 25-50% compression of one vertebrae /posterior element fracture with displacement and disruption of spinal canal


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Category IV20-23 WP Impairment

• Loss of motion segment integrity– Increased – spondylolisthesis– Decreased – fusion (most common)

• Fracture of > 50% compression of one vertebrae


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Category V25-28 WP Impairment

• Loss of motion segment integrity with radiculopathy

• Fracture > 50% compression with neurologic compromise


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Spine Problem #1

Roofer, 39 years old, fell off ladder, herniated disk at L3-4 with pain radiating into left leg. After diskectomy pain was no longer present. No difficulty with ADL.

DRE Category: Standard:

Formula:


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Spine Problem #2

Custodian, 24 years old, herniated disk at L4-5. Following fusion she still has pain radiating down thigh into foot. She has difficulty with standing, walking and sitting.


Formula:


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Spine Problem #3

Farm laborer, 46 years old, strained low back. Still has pain in low back, but no radicular symptoms.


Can there be an add-on for pain?


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DRE Method

Corticospinal Damage (pgs. 396-97)

• Arm impairment

• Gait impairment

• Bladder and bowel impairment

• Sexual impairment

• Respiratory impairment


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Spine Example

Painter fell from scaffold resulting in 50% compression fracture of L2. L2 nerve root damaged with weakness in both legs. Walks with crutches and has intermittent incontinence of bladder.


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Spine Example

• Fracture is DRE Category III - 13 WP (Page 384)

• Crutches are class III gait impairment - 39 WP (Pg 396)

• Intermittent incontinence is a class I bladder impairment - 9 WP (Page 397)


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Spine Example

Formulas:

15.03.01.00 – 13 – [5]17 – 380H – 21 – 17 PD (A)

15.04.03.00 – 39 – [5]50 – 380I – 59 – 52 PD (A)

15.04.04.00 – 9 – [2]10 – 380H – 13 – 10 PD (A)

(A) 52 C 17 C 10 = 64 Final PD


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ROM Method

ROM Method – Lumbar Spine

• Diagnosis (pg. 404)

• ROM (pgs. 407 and 409)

• Neurologic Deficit ( pg. 424)


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Spine Problem #4

Farm laborer, 25 years old, sustained a re-injury of his low back while lifting. He sustained herniated disk at L3-4 which was operated on, however he continues to have pain radiating into left leg. Testing revealed a class 4 (25%) sensory and motor deficit in the L3 nerve root. ROM of lumbar spine shows forward flexion of 45 degrees (sacral flexion 50 degrees), extension of 10 degrees, right and left lateral bending of 15 degrees each.


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Spine Problem #4

Diagnosis (pg. 404)

What is the value of a surgically treated disk with residual?

Look under disk or soft tissue lesion Category E


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ROM (pg. 407 and 409)

Forward flexion 45 =

Extension 10 =

Lt lateral bending 15 =

Rt lateral bending 15 =

Total ROM =

Spine Problem #4


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Spine Problem #4

Combine the Diagnosis and ROM impairments


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Spine Problem #4

Nerve Root Deficit (pg. 424)

Maximum sensory deficit L3 nerve

5% x 25% (class 4) = 1%

1% x .4 = 0 WP

Maximum motor deficit L3 nerve

20% x 25% (class 4) = 5%

5% x .4 = 2 WP


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Spine Problem #4

Final formula looks like this:

15.03.02.02 – 20 – [5]25 – 491H – 30 – 25 PD (A)

15.03.02.06 – 2 – [5]3 - 491H – 5 – 4 PD (A)

(A) 25 C 4 = ?


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Spine Problem #5

Truck driver, 56 years old, injured in a motor vehicle accident, sustained a 65% compression fracture at T-1. No previous injury. He is able to drive again and do usual ADL.

Which method?


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Spine Problem #5

Truck driver, 56 years old, injured in a motor vehicle accident, sustained a 65% compression fracture at T-1. No previous injury. He is able to drive again and do usual ADL.

Which method?


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Spine Method

Each region of the spine is evaluated as a separate body part


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Spine Problem #6

Farm laborer, 28 years old, was run over by a tractor sustaining a fracture at L3 with a 25 percent compression of the vertebrae. He also sustained a herniated disk at C5-6, resulting in a fusion surgery. He still has radiculopathy into the right arm causing some difficulty with activities of daily living.


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Spine Problem #6

Cervical spine (pg. 392)

What method?

Whole Person Impairment?

Which DRE Category?


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Spine Problem #6

Lumbar spine (pg. 384)

What method?

Which DRE Category?

Whole Person Impairment?


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Spine Problem #6

Combine formulas

15.01.01.00 – 28 – [5]36 – 491H – 42 – 39 PD (A)

15.03.01.00 – 10 – [5]13 – 491H – 17 – 15 PD (A)

(A) 39 C 15 = 48 Final PD


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Exercise #1

Janitor, 49 years old

Low back injury while lifting a trash bag. Worker felt a pop in his back and experienced immediate pain which radiated into his right leg. He reported the injury to his employer who referred him to an industrial doctor. When his symptoms did not resolve, he was sent to a neurosurgeon, Dr. Cutter, who ordered an MRI. The MRI showed a herniated disk at L3-4.


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Exercise #1

Dr. Cutter performed a laminectomy surgery. At MMI the injured worker continued to have pain radiating into his right leg. The worker had difficulty with almost all activities of daily living such as sleeping, standing, sitting, walking and sexual activity. He routinely used a cane for walking. In his final evaluation Dr. Cutter opined that a 3% whole person impairment should be added for pain.


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Which rating method for the spine should be used?

Exercise #1

Which category would you place the injured in?


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Given the ability to perform activities of daily living, what impairment within the DRE category would you utilize?

Exercise #1


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Rate the impairment, considering the effect on the pain add-on and adjust for FEC, occupation and age (remember that pain is added to the whole person impairment).

Exercise #1


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Defense Dave argues that there should be no pain add-on given since it is already accounted for in the category ranges given on page 384. What is your reply to Defense Dave?

Exercise #1


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Applicant Artie argues that a 20% impairment for gait should be combined with the spine disability since the injured uses a cane (see page 529). How would you answer Applicant Artie?

Exercise #1


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Dr. Cutter performs a two level fusion L3-5 on a 27 year old range hand. At MMI Dr. Cutter provided the following factors of disability:

ROM (pages 407 and 409)Flexion (sacral 45) 15 degreesExtension 10 degreesL lateral bending 10 degreesR lateral bending 10 degrees

Exercise #2


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Sensory Evaluation (page 424):Grade 4 (25%) sensory and motor deficit of

L4 nerve root

Injured worker continued to have pain and weakness radiating into his left leg. He has difficulty with some activities of daily living. Doctor Cutter placed the injured in DRE Category V (page 384) and gave a 26% impairment of the whole person.

Exercise #2


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Do you agree with Dr. Cutter’s assessment of impairment? Was the correct method of impairment used and the correct category and impairment percentage applied?

Exercise #2


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How would you rate the injured worker’s disability?

Exercise #2


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Evaluating the Diagnosis

Diagnosis (page 404, Table 15-7)


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ROM (pages 407 and 409)

Flexion (sacral 45) 15 =

Extension 10 =

L lateral bending 10 =

R lateral bending 10 =

Evaluating ROM


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Nerve deficit (page 424)Sensory:

Motor:

Total:

Evaluating Nerve Deficits


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Run Formulas and Combine

Diagnosis and ROM:

Nerve deficit:

Documents

Rating Impairments of the Spine