Understanding and Interpreting Spinal Injuries in Compliance with the AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition, 2001

(Recommendation: This is an overview. Please obtain and read a copy of the AMA Guides, Fifth Edition for a complete understanding of thisinformation and its use.)

 

Injuries to the spine cause (1) functional loss and (2) structural damage. Functional loss is the resultant effect of the injury on normal body systems. These include but are not limited to: muscular strength, joint mobility, coordination, and sensory perception. Structural damage includes the fracture of bones, dislocation or subluxation of spinal joints/segmental somatic dysfunction, and the tearing of joint capsules, discs, and other connective tissue. Other connective tissue includes supporting ligaments, tendons, muscles, nerves, and blood vessels.

Demonstrating the effect of spinal injuries is dependant upon the examination performed on the patient, the documentation of these findings and finally the appropriate interpretation and reporting of the information gathered.

EXAMINATION:

The examination should confirm or deny the presence of functional loss and structural damage.

Functional Losses can be evaluated by measuring spinal ranges of motion, extremity strength, muscle spasm or guarding, muscular atrophy, reflexes, and dermatomal sensory loss. Other functional losses such as bowl and bladder dysfunction, corticospinal tract impairments, or spinal cord injuries must be added using the combined values chart (AMA Guides pp 604-606).

To adequately demonstrate structural damage, imaging studies should be performed. Plain film radiography, including flexion / extension views, provide evidence of fracture, instability, arthrosis, and loss of motion segment integrity (MSI). MRI / CT exams are more useful to demonstrate disc bulges and disc herniations which in turn strongly suggests the presence of nerve root or cord compression.

DOCUMENTATION:

Loss of Motion Segment Integrity must be demonstrated on flexion/extension radiographs. The AMA Guide, pages 378-379, describes a motion segment as two adjacent vertebrae and their related joints and ligamentous structures. Specific, normal motions are expected at different levels of the spine. Aberrancies in this normal motion can be evaluated by measuring losses in ranges of motion (subluxation / fixation, arthrosis and/or degeneration) or by demonstrating hypermobility and instability with Loss of Motion Segment Integrity.

Two types of MSI are explained: Translation and Angular Motion (saggital rotation).

INTERPRETATION:

(DRE) Diagnosis Related Estimates Method of Assigning Impairment Rating Based on the AMA Guide to Permanent Impairment, 2001 pp. 373-431.

“The DRE method is the principal methodology used to evaluate an individual who has a distinct injury” (pp. 379)

Cervical Spine (pp. 392-394)

Category I (0%)

Category II (5-8%)

May include:

Or:

Or one of the following Fractures:

Category III (15-18%)

Significant signs of radiculopathy:

Or:

Or one of the following Fractures:

Category IV (25-28%)

Or:

Category V (35-38%)

Thoracic Spine (pp. 388-391)

Category I (0%)

Category II (5-8%)

May include:

Or:

Or one of the following Fractures:

Category III (15-18%)

Lower extremity neurologic impairment related to thoracolumbar injury documented by examination findings of:

Or:

Or one of the following Fractures:

Category IV (20-23%)

Or:

Category V (25-28%)

Or:

Lumbar Spine (pp. 384-388)

Category I (0%)

Category II (5-8%)

May include:

Or:

Or one of the following Fractures:

Category III (10-13%)

Lower extremity neurologic impairment related to thoracolumbar injury document by examination findings of:

Or:

Or one of the following Fractures:

Category IV (20-23%)

Or:

Category V (25-28%)

Or:

REPORTING:

Documentation is best presented in a narrative report.

Writing narrative reports can seem tedious, daunting, or downright scary. This doesn’t have to be. Complete examinations and complete record keeping makes report writing much simpler to do. The fact is that reports are necessary communication tools. Procrastination of or missing this important step in patient care will cause delays in reimbursement, require multiple explanations to patients about their diagnosis and treatment plans, and provide you with hours of dread.

Like any other form of communication, a report must have a purpose. Often times, one report may serve many purposes. Examples may include:

Types of reports often presented are:

A final few thoughts:
When presenting your findings in a report format, impairment ratings are very useful and at times even required. This is easily accomplished by using the DRE method.

Remember Loss of Motion Segment Integrity findings on flexion extension radiographs are by definition a category IV impairment (20% to 28% whole body impairment).

The rest of the health care community understands Segmental Somatic Dysfunction. We have called it Subluxation.