Diagnostic Codes

• **Code 5237: Lumbosacral or cervical strain—**a generic label for back pain
• **Code 5238: Spinal stenosis—**the spinal column narrows and presses on the spinal cord or nerves
• Code 5239: Spondylolisthesis or **segmental instability—**when a vertebra slips out of position
• **Code 5240: Ankylosing spondylitis—**an arthritic disease that causes the spinal joints to freeze in place
• **Code 5241: Spinal fusion—**the vertebrae are surgically fused together
• Code 5235: Vertebral fracture or **dislocation—**the bones of the spine break or slip out of alignment due to a traumatic event like a car accident. Any generic spinal bone injury would be coded here.

Rating Neck & Back Conditions

Principles that Apply

When rating a spine condition, the basic rule of thumb is to rate it under the code that would give the highest rating. Always start first with the General Rating Formula, which evaluates range of motion. This is always the main rating system for any spine condition, and any other rating system listed below should only be used if it gives a higher rating. There are a few more rating options under this general formula that only come into play if the ROM is not restricted enough to warrant a higher rating:

• If there is an abnormal spine contour (like scoliosis), or if you have muscle spasms, or if you guard your spine movements enough that you walk abnormally, then the condition is rated 20%.
  • Proof of the abnormal spine contour or abnormal walk must be noted by the physician in an exam, not just with radiological evidence.
• If there are muscles spasms and guarding present that do not interfere with the way you walk, it is rated 10%.
• A 10% rating is also given if there is a compressed (fractured) vertebra that has lost 50% or more of its height.
• Finally, if there is pain with motion, then the rating must be at least 10%.

There are some very rare circumstances where a physician can declare that a limited ROM is normal for an individual and thus not ratable. This is very rare and only happens if the physician can provide significant evidence that the ROM is normal for a particular individual.

General Rating Formula for Spine Conditions

• or - Entire thoracolumbar spine frozen in a FAVORABLE position | | 30% | Flexion measures 15' or less
• or - Entire cervical spine is frozen in a FAVORABLE position | | | 20% | Flexion measures more than 15' but not more than 30'
• or - Combined ROM is 170' or less | Flexion measures more than 30' but not more than 60'
• or - Combined ROM is 120' or less | | 10% | Flexion measures more than 30' but less than 45'
• or - Combined ROM is between 175' and 340' | Flexion measures more than 60' but less than 90'
• or - Combined ROM is between 125' and 240' | | 0% | Flexion measures 45' or more
• or - Combined ROM measures 340' or more | Flexion measures 90' or more
• or - Combined ROM measures 240' or more |

NOTE: It is important that your physician records correct and thorough measurements for any back condition. The measurements should be measured with a Goniometer. If possible, make sure your physician records the range of motion for EVERY direction. As shown in the above images, there should be 6 total measurements taken for both the cervical and thoracolumbar spines.

THIS IS VITAL TO A PROPER AND FAIR RATING!!!!! Too often physicians do not record these important measurements properly, and then the veteran’s condition is not appropriately rated.

Resources

Secondary Conditions

Rating Functional Loss

<aside> 😣 What About Pain?

• Functional loss due to pain is to be rated at the same level as where ROM is impeded. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991).
• “Lay statements or evidence may also be included within the umbrella of ‘objectively confirmed’ evidence of painful motion.” Petitti v. McDonald, 27 Vet. App. 415 (2015).
• Where there is painful, unstable, or malaligned joints, due a healed injury, the veteran is entitled to at least the minimum compensable rating for the joint available under the appropriate DC. The regulation is applicable to the evaluation of musculoskeletal disabilities involving joint or periarticular pathology that are painful, whether or not evaluated under a Diagnostic Code predicated on range of motion measurements. Southall-Norman v. McDonald, No. 15-1357, 2016 WL 7240720 (Dec. 15 2016); 38 C.F.R. 4.59.
• Saunders v. Wilkie, No. 17-1466 (Fed. Cir. 2018): Pain alone, without an accompanying diagnosis or identifiable condition, can constitute a “disability” under § 1110, because pain in the absence of a presently-diagnosed condition can cause functional impairment. </aside>

Effect on ADLs

38 C.F.R. § 4.10 provides that “in addition to [furnishing] etiological, anatomical, pathological, laboratory and prognostic data required for ordinary medical classification,” a VA medical examination must also include a “full description of the effects of disability upon the person’s ordinary activity.”

<aside> 💡 The cervical spine and the thoracolumbar spine are to be rated as two separate conditions except when both are frozen in an unfavorable position.

</aside>

<aside> 📌 Unfavorable: not at 0’ flexion or extension, stuck in that position; cannot move at all Favorable: frozen at 0’ flexion or extension

Measurements: All measurements are rounded to the nearest 5 (ie. 80 rounds up to 10', 7' rounds down to 50, etc.) ** Comp & Pen Tip - It is important that your physician records correct and thorough measurements for any back condition. The measurements should be measured with a goniometer. If possible, make sure your physician records the range of motion for EVERY direction. As shown in the above images, there should be 6 total measurements taken for both the cervical and thoracolumbar spines. THIS IS VITAL TO A PROPER AND FAIR RATING. Too often physicians do not record these important measurements properly, and then the service member's condition is not appropriately rated.

</aside>

<aside> 📌 Combined ROM: Add all the measurements together: left rotation, right rotation, flexion, extension, right lateral flexion, and left lateral flexion. The normal combined measurements for the cervical spine is 340' and the thoracolumbar spine is 240'

</aside>

The court has original federal-question jurisdiction over the statutory claim. But the negligence claim is based on state law, and there’s no diversity of citizenship.