Rating Schedule

EVALUATION OF THE SPINE

For evaluation purposes, the spine is divided into three sections; cervical, thoracic, and lumbosacral. Each section must be evaluated individually and then combined, using the Combined Values Chart found in Section 15.

The Specific Disorders of the Spine Table serves as the basis upon which, after a diagnosis has been established, an impairment can be formulated. The table serves as a basis for numerous spinal disorders ranging from fractures to herniated intervertebral discs; soft tissue injuries to spondylolisthesis.

After determination of the impairment from a spinal disorder has been obtained that value must be combined with the appropriate value of residual objective signs for ankylosis, and spinal cord and/or spinal nerve injury.

SPECIFIC DISORDERS OF THE SPINE TABLE

FRACTURES

Disorder ... Impairment of the Whole Person

1. Compression of one vertebral body

• 1-25% ... C=4% T=2% L=5%
• 26-50% ... C=6% T=3% L=7%
• 51%+... C=10% T=5% L=12%

When two or more compression fractures are present, COMBINE.

Pre-existing compression fractures should be rated only when there has been aggravation by a new injury shown by objective radiological findings. These values should be addressed in the report as a preexisting factor.

2. Fracture of the Posterior Elements of the Vertebra (pedicles, laminae, or articular processes)

• Cervical ... 4%
• Thoracic ... 2%
• Lumbar... 5%

This may include nonunion or mal-union.

Values given are the same whether it is a single or multiple fracture in the SAME vertebra. Fractures of the body and the posterior elements in the same vertebra are to be COMBINED.

At MMI if the fracture is healed and causes no functional impairment, it is not ratable.

3. Healed vertebral odontoid, Jefferson, and slice fractures ... 5%

Malunion or non-union ... 10%

4. Dislocation

• Dislocation reduced without fusion... 5%
• Dislocation reduced with surgical fusion ... 10%
• Dislocation unreduced ... 5-15%

Additional segments: Combine with value from appropriate section of the spine where applicable.

INTERVERTEBRAL DISC OR OTHER SOFT TISSUE LESIONS

Disorder ... Impairment of the Whole Person

1. Unoperated with no objective residual signs of injury ... 0%

2. Pain associated with rigidity (loss of motion or postural abnormality) and chronic muscle spasm. The chronic muscle spasm and rigidity is substantiated by objective clinical findings but without associated demonstrable degenerative changes

• Cervical ... 3%
• Thoracic ... 3%
• Lumbar... 3%

3. Unoperated, with medically documented* injury and associated with minimal post traumatic changes on diagnostic tests (including disc lesions with the exception of HNP)

• Cervical... 4%
• Thoracic ... 3%
• Lumbar... 5%

4. Herniated intervertebral disc single vertebral level, not surgically treated.

Diagnostic imaging studies specifically positive for herniated disc; with or without resolution of objective neurological findings**

• Cervical... 5%
• Thoracic ... 4%
• Lumbar... 6%

5. Surgically treated disc lesion with or without objective finding** neurological

• Cervical... 6%
• Thoracic ... 5%
• Lumbar... 7%

* Medically documented: e.g., records which shall include history, physical exam findings, and appropriate diagnostic studies.

** If there are no residuals, there are no values to be combined with these numbers. With objective neurologic findings the neurologic impairment must be rated in accordance with Section 5 of this Guide.

Patient should not be evaluated for permanency until the patient has reached MMI. “Objective clinical findings” as used in these guides means examination results which are reproducible and consistent. Examples of objective clinical findings are involuntary muscle spasms, consistent postural abnormalities, and changes in deep tendon reflexes. “Postural abnormality” means a deviation from normal posture caused by injury as found on anterior/posterior or lateral x-rays that involves the spine and pelvis or segments of the spine or pelvis, such as kyphosis, lordosis, or scoliosis.

6. Multiple levels of disc involvement with or without operation and with or without objective residual signs of injury... Add 1% level

7. Multiple operations with or without residual signs of injury

A. Second operation ... Add 2%

B. Third or subsequent operation... Add 2%/operation

8. With surgically treated disc lesion including a surgical spinal fusion, increase the impairment by 1% per vertebral level fused.

SPONDYLOLYSIS AND SPONDYLOLISTHESIS, UNOPERATED

Disorder ... Impairment of the Whole Person

1. Spondylolysis or Grade 1 (1%—25% slippage), or Grade II (26%—50% slippage) Spondylolisthesis, accompanied by objective studies documenting injury

• Cervical... 7%
• Thoracic ... 4%
• Lumbar... 8%

2. Grade III (51%—75% slippage) or Grade IV (76%—100% slippage) Spondylolisthesis, accompanied by objective studies documenting injury

• Cervical... 9%
• Thoracic ... 5%
• Lumbar... 10%

SPINAL STENOSIS AND SEGMENTAL INSTABILITY

1. Unoperated with objective signs of injury

• Cervical... 5%
• Thoracic ... 5%
• Lumbar... 5%

2. Unoperated, multiple levels... Add 1%/level

SPINAL STENOSIS, SEGMENTAL INSTABILITY, OR SPONDYLOLISTHESIS, OPERATED

NOTE: List impairments separately for cervical, thoracic and lumbar regions.

1. Single level operation without objective residual signs of injury

• Cervical... 8%
• Thoracic ... 4%
• Lumbar... 9%

2. Single level operation with residual objective signs of injury

• Cervical... 10%
• Thoracic ... 5%
• Lumbar... 12%

3. Multiple levels, operated, with or without residual objective signs of injury ... Add 1%/level

4. Multiple operations with residual, objective signs of injury

A. Second operation ... Add 2%

B. Third or subsequent operation... Add 2%/operation

NOTE: All impairments listed in Specific Disorders of the Spine should be combined with only the following appropriate values of residual signs:

a. Ankylosis secondary to surgery or injury in the spinal area (see Ankylosis table).

b. Spinal cord or spinal nerve root injuries, with neurologic impairment (see neurological section).

c. Any combination of the above using the Combined Values Chart.

ANKYLOSIS

The following techniques for determining impairment ratings for Ankylosis and the use of the goniometer is for the purpose of determining the degree of Ankylosis clinically rather than radiographically. In determining the impairment for this condition, loss of motion shall not be used. An alternate method for determining impairment can be based on radiographic methods as hereinafter provided. Diagrams for performing testing to determine impairment ratings are as follows:

1. Cervical Region—Flexion-Extension Technique of Measurement

a. Place goniometer base as if measuring the neutral position (Figure 1). Measure the deviation from neutral position with the goniometer arm and record the reading.

b. Consult the table below to determine the impairment of the whole person.

Example: Cervical region with ankylosed at 30 degrees flexion is equivalent to 23% impairment of the whole person.

OR

c. Determine number and position of ankylosed vertebrae by appropriate x-ray methods. (Consult Table 1)

2. Cervical Region—Lateral Flexion Technique of Measurement

a. Place goniometer base as if measuring the neutral position Figure 2). Measure the deviation from the neutral position with the goniometer arm and record the reading.

b. Consult the table below for the cervical region to determine the impairment of the whole person.

Example: A cervical region with ankylosis at 30° right lateral flexion is equivalent to 25% impairment of the whole person.

OR

c. Determine number and position of ankylosed vertebrae by appropriate x-ray methods. (Consult Table 1)

3. Cervical Region—Rotation Technique of Measurement

a. Place the patient in the neutral position (Figure 3) while supine; place the goniometer in the coronal plane at the crown of the head.

b. Estimate by the position of the chin the angle at which the cervical region is ankylosed.

c. Consult the table below to determine the impairment of the whole person.

Example: A cervical region ankylosed at 20° right rotation is equivalent to 17% impairment of the whole person.

OR

d. Determine number and position of ankylosed vertebrae by appropriate x-ray methods. (Consult Table 1)

4. Dorsolumbar Region—Flexion Extension Technique of Measurement

a. Place the patient in the neutral position (Figure 4).

b. Place the goniometer base as if measuring neutral position (Figure 4). Measure the deviation from the neutral position with the goniometer arm and record the reading.

c. Consult table below to determine the impairment of the whole person.

Example: A thoracolumbar region ankylosed at 20° flexion is equivalent to 24% impairment of the whole person.

OR

d. Determine number and position of ankylosed vertebrae by appropriate x-ray methods. (Consult Table 1.)

5. Dorsolumbar Region—Lateral Flexion (Lateral Bending) Technique of Measurement

a. Place the patient in the neutral position (Figure 5).

b. Place the goniometer base as if measuring the neutral position (Figure 5). Measure the deviation from the neutral position with the goniometer arm and record the reading.

c. Consult the table below to determine the impairment of the whole person.

Example: A thoracolumbar region with ankylosis at 10° right lateral flexion is equivalent to 27% impairment of the whole person.

OR

d. Determine number and position of ankylosed vertebrae by appropriate x-ray methods. (Consult Table 1)

Ankylosis in the lumbosacral spine has significance only if immobility occurs in both the hips and the lumbar spine region, so that the neutral position cannot be attained in the sagittal plane. This is a very rare event. Isolated fusions of either a hip or two to three spinal levels place additional stresses on adjacent segments, but do not lead to biomechanical failure of the functional unit. Thus, impairment related to fusion of part of the lumbar/hip motion complex are treated only by radiographic methods Table.

6. Dorsolumbar Region—Rotation Technique of Measurement

Determine number and position of ankylosed vertebrae by appropriate x-ray methods. (Consult Table 1)

7. Spinal Region—When Two or More Ranges of Motion Are Involved

a. Calculate separately and record impairment contributed by ankylosis in each position of the spinal region.

b. The largest ankylosis impairment value is the impairment of the whole person contributed by spinal region.

Example: Cervical Region ankylosed at: ... % Impairment of Whole Person

20 degrees FLEXION ... 33%

10 degrees RIGHT ROTATION ... 27%

The largest ankylosis impairment value is 33%; therefore, the whole person is 33% impaired by ankylosed cervical region.

PELVIS

The following shows impairment values associated with conditions of the pelvis.

Disorder ... Impairment of the Whole Person

1. Healed fracture without displacement or residuals 0%

2. Healed fracture with displacement, without residuals involving:

a. Single ramus... 0%

b. Rami, bilateral... 0%

c. Ilium... 0%

d. Innominate... 0%

e. Symphysis pubis, without separation... 5%

f. Sacrum ... 5%

g. Coccyx... 0%

3. Healed fracture with displacement, deformity and residuals:

a. Single ramus... 0%

b. Rami, bilateral... 5%

c. Ilium... 2%

d. Innominate, displaced 1 inch or more... 10%

e. Symphysis pubis, displaced or separated ... 15%

f. Sacrum, into sacroiliac joint ... 10%

g. Coccyx, non-union or excision... 5%

h. Fracture into acetabulum; evaluate on basis of restricted motion of hip joint.

The impairment value for hemipelvectomy is 50% of the whole person.