17.31b Spine and Pelvis Impairment Evaluation Record Template
- DBI Table 17-19 Cervical Spine Impairment
- 17-19-00 Confirmed Diagnosis Corroborated by the Clinical History (Presentation) With No Residual Symptoms
- 17-19-01 Incongruent Clinical Presentation With Residual Symptoms
- 17-19-02 Incongruent Clinical Presentation With Residual Symptoms (Nonspecific Pain)
- 17-19-03 Cervical Radiculopathy Involving the C1 Nerve Root (Very Rare)
- 17-19-04 Cervical Radiculopathy Involving the C2 Nerve Root (Very Rare)
- 17-19-05 Cervical Radiculopathy Involving the C3 Nerve Root
- 17-19-06 Cervical Radiculopathy Involving the C4 Nerve Root
- 17-19-07 Cervical Radiculopathy Involving the C5 Nerve Root
- 17-19-08 Cervical Radiculopathy Involving the C6 Nerve Root
- 17-19-09 Cervical Radiculopathy Involving the C7 Nerve Root
- 17-19-10 Cervical Radiculopathy Involving the C8 Nerve Root
- 17-19-11 Cervical Spinal Fracture C1 or C2
- 17-19-12 Cervical Spinal Fracture C3 to C7
- 17-19-13 Cervical AOMSI Associated With Fusion
- 17-19-14 Cervical AOMSI Associated With Instability
- DBI Table 17-20 Thoracic Spine Impairment
- 17-20-00 Confirmed Diagnosis Corroborated by the Clinical History (Presentation) With No Residual Symptoms
- 17-20-01 Incongruent Clinical Presentation With Residual Symptoms
- 17-20-02 Incongruent Clinical Presentation With Residual Symptoms (Nonspecific Pain)
- 17-20-03 Thoracic Radiculopathy Involving the T1 Nerve Root
- 17-20-04 Thoracic Radiculopathy Involving the T2-T12 Nerve Roots
- 17-20-05 Thoracic Spinal Fracture
- 17-20-06 Thoracic AOMSI Associated With Fusion
- 17-20-07 Thoracic AOMSI Associated With Instability
- DBI Table 17-21 Lumbar Spine Impairment
- 17-21-00 Confirmed Diagnosis Corroborated by the Clinical History (Presentation) With No Residual Symptoms
- 17-21-01 Incongruent Clinical Presentation With Residual Symptoms
- 17-21-02 Incongruent Clinical Presentation With Residual Symptoms (Nonspecific Pain)
- 17-21-03 Lumbar Radiculopathy Involving the L1 Nerve Root
- 17-21-04 Lumbar Radiculopathy Involving the L2 Nerve Root
- 17-21-05 Lumbar Radiculopathy Involving the L3 Nerve Root
- 17-21-06 Lumbar Radiculopathy Involving the L4 Nerve Root
- 17-21-07 Lumbar Radiculopathy Involving the L5 Nerve Root
- 17-21-08 Lumbar Radiculopathy Involving the S1 Nerve Root
- 17-21-09 Lumbar Spinal Fracture
- 17-21-10 Lumbar Stenosis With Neurogenic Claudication
- 17-21-11 Lumbar AOMSI Associated With Fusion
- 17-21-12 Lumbar AOMSI Associated With Instability
- DBI Table 17-22 Pelvis Impairment
- 17-22-00 Confirmed Diagnosis Corroborated by the Clinical History (Presentation) With No Residual Symptoms
- 17-22-01 Incongruent Clinical Presentation with Residual Symptoms
- 17-22-02 Incongruent Clinical Presentation With Residual Symptoms (Nonspecific Pain)
- 17-22-03 Fractures of the Pubic Rami (symphysis)
- 17-22-04 Fractures of the Ilium, Ischium, Sacrum, or Coccyx
- 17-22-05 Sacroiliac Joint Injury, Transverse Sacral Fracture, or Spinopelvic Dislocation
- 17-22-06 Fracture of the Acetabulum
- 17-22-07 Pelvic Fracture With Leg Length Loss
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