Test and build upon your knowledge of the Guides by receiving weekly case exercises via email. Purchase of a one year subscription will deliver a series of 52 emails to your Inbox on a weekly basis. The content of the email will be a fact pattern on a specific case and will require you to determine the final impairment rating. The following week you will receive a new case with the answer(s) from the case the week prior. This excellent, unique resource is available for a nominal fee of $97 - less than $2 a week! This is a very effective and fun way to increase your understanding of the Guides. Your satisfaction is assured – thus subscribe today and start receiving the exercises today. This is an easy decision - high value and minimal cost.

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Example:

Question
This week’s case involves the spine. The examinee sustained injury and immediately experienced the onset of acute low back and right leg pain. The examinee described burning pain, diminished sensation and "tingling" of his right lateral calf and the dorsum of his right foot, but he denied weakness or loss of bowel or bladder control. Relevant history included two lumbar injuries resulting in lumbar radiculopathy due to herniated nucleus pulposus at L4 5, for which he underwent two lumbar microdiscectomies. Both of these resolved without sequlae.

With this current injury exam findings revealed diminished sensation of his right lateral calf, diminished strength of his right extensor digitorum longus and extensor hallucis longus muscles, and pain on right straight-leg raising at 20 degrees. Waddell's signs were absent. Diagnostic evaluation included lumbar spine MRI with contrast enhancement revealing recurrent herniated nucleus pulposus at L4 5, impinging the right L5 nerve root. The diagnosis of recurrent lumbar radiculopathy was confirmed with electromyography, which revealed multiple positive sharp waves and fibrillation potentials, indicative of acute nerve root compromise. Lumbar plain films with flexion and extension views revealed grade I spondylolisthesis of L4 on L5, but no loss of motion segment integrity.

The examinee underwent surgical treatment, which included decompressive laminectomy at L4 5, excision of herniated disc at L4 5 on the right, implantation of BAK interbody metal cage at L4 5 on the right, posterior lumbar interbody fusion at L4 5, and intertransverse arthrodesis at L4 5.

At the time of the MMI examination revealed diminished sensation over the dorsum of his right foot, but the remainder of his neurologic examination was normal, straight leg raising was negative bilaterally and Waddell's signs were absent. His lumbar motion, measured with inclinometers, was reproducible and thus valid. His measurements were: true lumbar flexion 20 degrees, true lumbar extension 10 degrees, and left and right lateral bending 25 degrees each. His sacral flexion was 35 degrees and sacral extension was 5 degrees. Straight leg raising resulted in right leg pain at 40 degrees.

Which method is used?

What is the final impairment rating?

We will be in contact in a week – have a wonderful one!

Best regards,
Leslie Dilbeck, CIR and the team at Brigham and Associates, Inc.

© 2007 Brigham and Associates, Inc. All rights reserved.


Answer (you will receive this one week later with the next question)
Last week’s case exercise involved an examinee with recurrent radiculopathy who underwent spinal fusion at L4-5. At MMI he had diminished sensation over the dorsum of his right foot, but the remainder of his neurologic examination was normal, straight leg raising was negative bilaterally and Waddell's signs were absent. His lumbar motion, measured with inclinometers, was reproducible and thus valid. His measurements were: true lumbar flexion 20 degrees, true lumbar extension 10 degrees, and left and right lateral bending 25 degrees each. His sacral flexion was 35 degrees and sacral extension was 5 degrees. Straight leg raising resulted in right leg pain at 40 degrees.

The method to be used in this case is the Range of Method as there is recurrent herniation with radiculopathy.

The rating process is as follows:

Combine the values 12% and 14% to result in final impairment of 24%. 

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