The Guides Newsletter- Important
Clinical Concepts from Past Issuesby Craig M. Uejo
MD, MPH, QME, CIME, CIR
This is the next article in a
series written to assist evaluators in their use and
interpretation of the AMA
Guides to the Evaluation of
Permanent Impairment, Fifth Edition (Cocchiarella L,
Anderson G,
AMA Guides to the Evaluation of Permanent
Impairment, Fifth Edition, AMA Press, 2001). It will be
used to help summarize key points of clarification documented
in past issues of the
Guides Newsletter. References to
specific issues will be provided to allow anyone the
opportunity to review the entire issue/article for assistance
in understanding and accuracy of reporting.
This
particular article will discuss the issues of rating a spinal
injury in which there is residual findings which may or may
not include Alteration of Motion Segment Integrity (AMSI).
This issue was discussed in the January/February 2003 edition
of the
Guides Newsletter - Question and Answers page
8-9; Christopher Brigham, MD was the author.
Question:
Should I take flexion extension x-rays prior to impairment
rating to determine if there is loss of motion segment
integrity?There is confusion among evaluators
frequently about whether a permanent impairment evaluation
must include flexion extension radiographs of all spinal
injuries. The answer is NO. Flexion extension radiographs are
important for specific situations, but routinely testing all
individuals with spinal injuries for AMSI is not required or
recommended.
The
Guides Newsletter article answers
this question with the following:
- The Fifth Edition provides a different definition for
loss of motion segment integrity compared to the Fourth
Edition. The most common cause of loss of motion segment
integrity is now a single-level fusion. Loss of motion
segment integrity as previously defined in the Fourth
Edition is most commonly seen in elderly females as a
degenerative condition. Therefore, most individuals do not
need flexion extension x-rays prior to impairment rating.
Spinal pain that was induced by severe trauma and
significantly worsens with flexion extension, but improves
in a rigid brace, suggests the possibility of instability
and perhaps the indication for flexion extension x-rays.
Spinal fusion for back pain without demonstrated loss of
motion segment integrity is controversial. Since treatment
is now considered in the Fifth Edition, evaluators needed
some method to take into account those patients who undergo
arthrodesis of a motion segment. The Fifth Edition authors
have elected to include in the definition of alteration of
motion segment integrity those patients who have had
successful or even unsuccessful attempts at surgical
arthrodesis of the spine and those patients who developed
loss of all or near all motion in a motion segment due to
developmental arthrodesis secondary to trauma or infection.
These are the only definitions of loss of motion segment
integrity. The authors specifically did not use the term
instability because the definition of that term is variable.
Some physicians even use that term to describe narrowing of
a disc space. Narrowing of a disc space does not meet the
definition of loss of motion segment integrity. The question
arises as to whether flexion and extension x- rays must be
taken in every patient to rule out alteration of motion
segment integrity. The answer, according to the Guides, is
"no." Alteration of motion segment integrity is nearly
always suggested on routine x-rays. It is extremely rare in
the face of normal lateral x-rays. As a matter of fact,
alteration of motion segment integrity, other than for
arthrodesis, is extraordinarily rare in the workers'
compensation arena. It is nearly always developmental and,
though it may be aggravated by injury, it is rarely caused
by an injury. The exceptions are certain fractures of the
pedicles that result from severe trauma and the result of
aggressive posterior decompressions. If a patient
demonstrates spondylolisthesis and there is a question as to
whether it is developmental or secondary to a recent injury,
review of previous x-rays or bone scentillography may be
helpful.
~Christopher R. Brigham, MD
In summary:
The
Guides 5th ed.
recommends considering flexion extension views when you
suspect AMSI for spinal injuries. In cases that involve spinal
fusion surgery, flexion extension views are not required for
rating purposes since the inherent fact that fusion surgery
was attempted satisfies the definition of AMSI. On the
opposite end of the spectrum, it would be rare for cases
involving normal imaging studies to find AMSI, therefore such
radiographs are not necessary in these cases either. Lastly,
although not included in this question/answer topic, MRI
testing is not a recommended substitution for flexion
extension radiographs when evaluating a case for possible
AMSI. As per the
Guides, any concerns about AMSI found
solely on MRI testing must be documented on flexion extension
plain radiographs for rating purposes.
- Look for additional articles in this series, The
Guides Newsletter - Important Clinical Concepts from
Past Issues, coming in upcoming issues of this Brigham
and Associates Ezine.
_______________________
Impairment Rating Integrated Solution -
IRIS
The best practices and most cost-effective claims
management approach to impairment ratings is our Impairment
Rating Integrated Solution (IRIS), which includes low cost
screen of all ratings (Impairment
Screen), detailed critique of erroneous ratings (Impairment
Review), Impairment
Profiling System data analysis (your cases and overall
data, including impairments for specific diagnoses and
physician profiling), and access to GuidesIQ.
The fee for this solution is nominal; for most impairment
screens the cost is only $95 if the rating is correct or $195
if incorrect - a fraction of the cost of even a single
percentage error. The fee for detailed critiques is based on
the time involved for that case. We will develop with you a
process that is most effective for your organization. Ratings
are reviewed typically within five days and invoices are sent
for each case. The fee for the professional service is
typically billed to the file. *If we review all of your
ratings, we provide you on a complimentary basis our
data analysis (otherwise quarterly licensing fee of $9500) and
also access to GuidesIQ for your staff (otherwise annual
membership fee of $897 per person). You also receive priority
status. Most importantly you have a cost-effective mechanism
to assure accurate impairment ratings.
We recommend a three month trial with this intervention. At
the end of that time you assess the impact of this strategy
and determine whether to continue and if any modifications are
needed. Every client implementing this has continued with the
screens and the return on investment has been several-fold.
Contact Mindy Brigham
today and solve the challenge of erroneous impairment ratings.
_______________________
We'd love to see you in Chicago!
We are pleased to offer you a discounted registration fee
for attending the exhibit hall at the National Workers'
Compensation Conference & Disability Expo in Chicago, IL
on November 6-8, 2007.
We will be exhibiting in the
exhibit hall and would love for you to stop
by.
Register for the Expo at www.WCConference.com
now, the $25 on-site registration fee is waived.
