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Routine: DVBCWSP2

DVBCWSP2.m

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DVBCWSP2 ;ALB/RLC - SPINE WKS TEXT - 2 ; 14 JUN 2005

 ;;2.7;AMIE;**144**;DEC 2, 2003;Build 5

 ;

TXT ;

 ;;       c.  Ankylosis

 ;;

 ;;           If ankylosis is present, is it unfavorable or favorable?

 ;;           Unfavorable ankylosis is a condition in which the entire cervical

 ;;           spine, the entire thoracolumbar spine, or the entire spine is

 ;;           fixed in flexion or extension, and the ankylosis results in one

 ;;           or more of the following:  difficulty walking because of a limited

 ;;           line of vision; restricted opening of the mouth and chewing;

 ;;           breathing limited to diaphragmatic respiration; gastrointestinal

 ;;           symptoms due to pressure of the coastal margin on the abdomen;

 ;;           dyspnea or dysphagia; alantoaxial or cervical subluxation or

 ;;           dislocation; or neurologic symptoms due to nerve root stretching.

 ;;           Favorable ankylosis is a fixation of a spinal segment in neutral

 ;;           position (zero degrees).  Indicate the accompanying sign(s) and/or

 ;;           symptom(s).

 ;;

 ;;   3.  Neurological examination

 ;;

 ;;        Please perform complete neurologic evaluation as indicated based

 ;;        upon disability for which the exam is being performed. Please provide

 ;;        brief statement if any of the following (a-e) is not included in exam.

 ;;        For additional neurologic effects of disability not captured by a - e, 

 ;;        (e.g. bladder problems) please refer to appropriate worksheet for the

 ;;        body system affected.

 ;;

 ;;        a. Sensory examination, to include sacral segments (0 absent, 

 ;;           1 impaired, 2 normal). 

 ;;        b. Motor examination (atrophy, circumferential measurements, tone, 

 ;;           and strength).

 ;;

 ;;           Standard muscle strength grading scale:

 ;;

 ;;              0 = Absent.  No muscle movement felt.

 ;;              1 = Trace.  Muscle can be felt to tighten, but no movement

 ;;                  produced.

 ;;              2 = Poor.  Muscle movement produced only with gravity

 ;;                  eliminated.

 ;;              3 = Fair.  Muscle movement produced against gravity, but

 ;;                  cannot overcome any resistance.

 ;;              4 = Good.  Muscle movement produced against some resistance,

 ;;                  but not against "normal" resistance.

 ;;              5 = Normal.  Muscle movement can overcome "normal" resistance.

 ;;

 ;;        c. Reflexes (deep tendon (0 absent, 1+ hypoactive, 2+ normal, 3+

 ;;           hyperactive without clonus, 4+ hyperactive with clonus),

 ;;           cutaneous, and pathologic). 

 ;;        d. Rectal examination (sensation, tone, volitional control, and 

 ;;           reflexes). 

 ;;        e. Lasegue's sign.

 ;;

 ;;    4.  Non-organic physical signs (e.g., Waddell tests, others).

 ;;

 ;;D.  Functional Loss With Use:

 ;;

 ;;    Impairment of spine function is determined by range of motion as reported

 ;;    in the physical examination and additional loss of range of motion after

 ;;    repetitive use caused by the following factors:

 ;;

 ;;    1.  Pain

 ;;    2.  Fatigue

 ;;    3.  Weakness

 ;;    4.  Lack of endurance

 ;;    5.  Incoordination

 ;;

 ;;    Have the veteran move the affected spinal segment through repetitive

 ;;    active range of motion, as tolerated (maximum of 3 repetitions).  After

 ;;    repetitive motion re-measure the range of motion of the affected spinal

 ;;    segment.  Do any of the above factors cause any additional loss of range

 ;;    of motion?  If so, record the re-measured range of motion and state the

 ;;    predominant factor causing the change in motion.

 ;;

 ;;    If repetitive active range of motion cannot be done, state so and give the

 ;;    reason.

 ;;

 ;;E.  For intervertebral disc syndrome

 ;;

 ;;    1. Conduct and report a separate history and physical examination for

 ;;       each segment of the spine (cervical, thoracic, lumbar) affected by

 ;;       disc disease. 

 ;;    2. Conduct a complete history and physical examination of each affected

 ;;       segment of the spine (cervical, thoracic, lumbar), whether or not

 ;;       there has been surgery, as described above under B. Present Medical

 ;;       History and C. Physical Examination. 

 ;;    3. Conduct a thorough neurologic history and examination, as described

 ;;       in C5, of all areas innervated by each affected spinal segment.

 ;;       Specify the peripheral nerve(s) affected.  Include an evaluation of

 ;;       effects, if any, on bowel or bladder functioning. 

 ;;    4. Describe as precisely as possible, in number of days, the duration of

 ;;       each incapacitating episode during the past 12-month period. An

 ;;       incapacitating episode, for disability evaluation purposes, is a

 ;;       period of acute signs and symptoms due to intervertebral disc

 ;;       syndrome that requires bed rest prescribed by a physician and

 ;;       treatment by a physician.

 ;;

 ;;F.  Diagnostic and Clinical Tests:

 ;;

 ;;    1.  Imaging studies, when indicated.

 ;;    2.  For vertebral fractures, report the percentage of loss of height,

 ;;        if any, of the vertebral body. 

 ;;    3.  Electrodiagnostic tests, when indicated. 

 ;;    4.  Clinical laboratory tests, when indicated. 

 ;;    5.  Isotope scans, when indicated. 

 ;;    6.  Include results of all diagnostic and clinical tests conducted in the

 ;;        examination report.

 ;; 

 ;;G.  Diagnosis:

 ;;

 ;;

 ;;

 ;;Signature:                                    Date:

 ;;END