Impairment Tip of the Week

This week we want to discuss the problems we are seeing with rating spinal degenerative disk disease. A frequent problem we are seeing is using the Range of Motion Method for rating spinal degenerative disk disease. This was addressed in the November-December 2006 issue of the Guides Newsletter

Question:
In rating spinal impairment, should I use the range of motion method if there are findings of multilevel degenerative disc disease?

Answer:
Not necessarily. As explained in Section 15.2, Determining the Appropriate Method for Assessment (5th ed, 379-381), the Range of Motion (ROM) method is used in certain situations. On page 380, at the top left, indication 2 states when there is multilevel involvement in the same spinal region (eg, fractures at multiple levels, disk herniations, or stenosis with radiculopathy at multiple levels or bilaterally). On the same page at the bottom right, item 4 provides further clarity stating to use the ROM method if there is radiculopathy bilaterally or at multiple levels in the same spinal region. However, the ROM method is not used merely for degenerative disk disease and effects thereof, including disk bulges and herniations that show on imaging, but without radiculopathy by history, physical exam, or EMG. In the May-June 2001 Guides Newsletter, Robert Haralson, III, MD, the Spine Chapter Chair, and Dr. Brigham clarified this point stating, This refers to disk herniations with radiculopathy at multiple levels or bilaterally or spinal stenosis with radiculopathy at multiple levels or bilaterally. . . disk herniations are commonly seen among asymptomatic individuals, and these findings alone may not be significant. (Guides Newsletter, May – June 2001, 10) Thus the key feature is the presence or absence of radiculopathy. Radiculopathy means symptoms, physical findings, and electrodiagnostic abnormalities (if such testing is performed) consistent with nerve root impingement or dysfunction. The symptoms may be pain, numbness, and/or tingling in distribution of the nerve root, with weakness of the limb. Physical findings are weakness of the involved myotome, diminution in or loss of the corresponding deep tendon reflex, numbness of the appropriate dermatome and, in the case of the lumbar spine, positive root tension signs. Unequivocal electrodiagnostic evidence of acute nerve root pathology (radiculopathy) includes
. . . multiple positive sharp waves or fibrillation potentials in muscles innervated by one nerve root. (5th ed, 382) Without radiculopathy, imaging changes other than fracture are insufficient to produce an impairment. The common increasing prevalence of degenerative changes with age, including disk herniations, is discussed on page 378 in Section 15.1b, Description of Clinical Studies.