Questions and Answers
2001; Volume: 6; Issue: 3 Linguagem: Inglês
10.1001/amaguidesnewsletters.2001.mayjun03
ISSN2642-0880
AutoresChristopher R. Brigham, Robert H. Haralson,
ResumoChapter 15, The Spine, reflects significant refinement of the process of spinal impairment assessment. As with any change there will be questions on how these ratings are performed compared to the Fourth Edition. The purpose of these questions and answers are to provide further clarity and to correct some minor errors that appeared in the first printing of the Fifth Edition.QuestionIs Loss of Motion Segment Integrity: Translation now measured on single film as illustrated in Figure 15-3a (5th ed, 378), or is it now necessary to measure lumbar motion segment integrity with dynamic (flexion and extension) views as discussed in the text?AnswerFigures 15-3a, b, and c contain erroneous illustrations. Figures 15-3a and Figure 15-3c should demonstrate both flexion and extension views. Figure 15-33b should indicate the flexion angle of +8°. Both flexion and extension views are required for lumber loss evaluation of motion segment integrity; however this is only needed when instability is expected (e.g., in a rare case).QuestionIn the discussion of when to use the Range of Motion Model for assessing spinal impairment, one of the indications isDoes this refer to disk herniations alone or only if associated with a documented radiculopathy?AnswerThis refers to disk herniations with radiculopathy at multiple levels or bilaterally or spinal stenosis with radiculopathy at multiple levels or bilaterally. Findings of disk herniations are commonly seen among asymptomatic individuals, and these findings alone may not be significant.QuestionIs the 3% range for Diagnoses-Related Estimate (DRE) categories duplicative or mutually exclusive for the further 3% impairment that may be derived from the Chapter 18 (the Pain chapter)? For example, if a patient has a DRE Category II impairment (a 5% to 8% whole person permanent impairment) and has significant interference with ADLs (activities of daily living) and significant pain-related impairment, is the final impairment 8%, or is it 11% (e.g., 8% and a further 3%)?AnswerThe Spine and Pain chapters were written by different committees and each independently developed the 3% range that encompasses the variablity that may exist in impairment related to pain. If there is significant interference with ADLs, the upper range is chosen. The further up to 3% whole person permanent impairment referenced in the Pain chapter would be measuring the same factor. Therefore, including incremental up to 3% whole person permanent impairment from the Spine chapter and also incremental up to 3% whole person permanent impairment from the Pain chapter is duplicative. The evaluator may also choose to provide a pain-related impairment score, as directed in Chapter 18. This score, however, is not an impairment rating.QuestionIf an individual has a repeat injury, do you then always use the Range of Motion Model to rate the subsequent injury? For example, if you rate a patient as a DRE Category II and that individual then has a subsequent injury, do I rate this using the Range of Motion Model?AnswerNo. The Range of Motion Model is used in five situations as listed on pages 379 and 380. When there is a recurrent radiculopathy the Range of Motion Model is used for subsequent rating. If the individual has and injury with findings consistent with DRE Lumbar Category II, such as "significant muscle guarding or spasm observed at the time of the examination, asymmetric loss of range of motion, or nonverifiable radicular complaints" and has a subsequent injury still with these same findings, the DRE Lumbar Category II is still used, although, depending on the case, the person may be rated higher in the range.Question:On page 381, under Section 15.3 states "the DRE method has eight diagnosis-related categories," shouldn't this read five diagnosis-related categories? Eight diagnosis-related categories are also mentioned on page 383, first column, fifth line.AnswerThis is a typographical error, reflective of the Fourth Edition of the Guides. In the Fifth Edition there are five categories. Corticospinal tract damage in the Fifth Edition is now rated by combining the appropriate DRE category with functional tables for spinal cord involvement, as described in Section 15.7, Rating Corticospinal Tract Damage (5th ed, 395–398).QuestionExample 15-14 (5th ed, 394) appears confusing. The distribution identified as C6 is not typical into the ulnar hand with numbness of the ring and little fingers, isn't this more of a C8 distribution? The disk herniation is reported at C7-8, shouldn't that be C7-T1?AnswerYes, you are correct. The disk herniation is at C7-T1 and has resulted in a left C8 cervical radiculopathy.QuestionExample 15-22 (5th ed, 425) rates an individual with aherniated disk and radiculopathy using the range of motion model. Should the impairment for the neurological involvement from Table 15-18 (5th ed, 424), which is expressed in lower extremity impairment, be converted to whole-person permanent impairment prior to combining with the Table 15-7, Specific Spine Disorders (5th ed, 404), whole person impairment, and the motion deficit whole person impairments?AnswerYes. This conversion should have been done prior to combining impairments. There is a 6% lower extremity impairment due to neurologic cause. This converts via Table 17-3, Whole Person Impairment Values Calculated from Lower Extremity Impairment (5th ed, 527), to 2% whole person permanent impairment (e.g., the lower extremity is equivalent to 40% whole person permanent impairment). Using the Combined Values Chart (5th ed, 604), the combined impairment from Table 15-7 (12% whole person), motion deficits (7%) and neurologic deficit (2%) is 20% whole person permanent impairment.
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