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Leon H. Ensalada
in AMA Guides® Newsletter
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Leon H. Ensalada

Abstract

The cauda equina is a collection of peripheral nerves in the common dural sheath within the lumbar spinal canal. Cauda equina syndrome, also known as bilateral acute radicular syndrome, usually is caused by a large, sequestered acute disc rupture at L3-4, L4-5, or L5-S1 that produces partial or complete lesions of the cauda equina–lower motor neuron lesions associated with flaccid paralysis, atrophy, and other conditions. Patients usually present with a history of back symptoms that have worsened precipitously. The syndrome includes back pain, bilateral leg pain, saddle anesthesia, bilateral lower extremity weakness, urinary bladder retention, and lax rectal tone. Cauda equina syndrome is rated using Diagnosis-related estimates (DRE) lumbosacral categories VI or VII. Category VI, Cauda Equina–like Syndrome Without Bowel or Bladder Signs, is used when there is permanent bilateral partial loss of lower extremity function but no bowel or bladder impairment. Category VII, Cauda Equina Syndrome with Bowel or Bladder Impairment, is similar to Category VI but also includes bowel or bladder impairment. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) uses the term cauda equina syndrome with reference to both the thoracolumbar and cervicothoracic spine regions; this usage is unique to the AMA Guides but maintains the internal consistency of the Injury Model, which is the best approach to date for assessing spine impairment.

in AMA Guides® Newsletter
Leon H. Ensalada
in AMA Guides® Newsletter
Leon H. Ensalada

Abstract

In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, the methods for rating impairment to causalgia, reflex sympathetic dystrophy (RSD), and complex regional pain syndromes (CRPS) differ from the approaches found in previous editions. Methods for evaluating impairment due to causalgia, RSD, and CRPS can be described as having anatomic or functional bases. The physical evaluation determines the anatomic impairment and is based on history and a detailed examination; the functional evaluation measures the individual's performance of the activities of daily living (ADL). Chapter 13 of the AMA Guides, Fifth Edition, considers causalgia and RSD in Section 13.8, Criteria for Rating Impairments Related to Chronic Pain, and defines chronic pain as the diagnoses of causalgia, posttraumatic neuralgia, and reflex sympathetic dystrophy. In contradistinction to Chapters 16 and 17 and the Glossary, the new term CRPS is not used here. Chapter 16 considers CRPS, RSD (now CRPS I), and causalgia (now CRPS II) and notes that, “contrary to previous suggestions, regional sympathetic blockade has no role in the diagnosis of CRPS.” Chapter 17 uses a functional approach for assessing impairment due to causalgia, RSD, and CRPS. Pending further guidance, evaluators should ensure that their methods for rating lower extremity impairments due to causalgia, RSE, and CRPS are internally consistent.

in AMA Guides® Newsletter
Leon H. Ensalada
in AMA Guides® Newsletter
Leon H. Ensalada

Abstract

Reflex sympathetic dystrophy (RSD) refers to subjective complaints of pain associated with soft-tissue changes that may not be caused by sympathetic nervous system dysfunction and for which no reflex has been demonstrated. One definition indicates that RSD, like causalgia, is manifested by pain, allodynia, hyperalgesia, and hyperesthesia and, frequently, by vasomotor and sudomotor disturbances and skeletal muscle hypotonia. The diagnosis of RSD depends on the patient's response to regional sympathetic blockade but does not take into account the questionable validity of the sympathetic mediation hypothesis, the placebo effect, or inadequately performed regional sympathetic blockade. These confounders have contributed to the misdiagnosis and overdiagnosis of RSD and causalgia. Since the publication of the AMA Guides to the Evaluation of Permanent Impairment, Fourth Edition, the International Association for the Study of Pain has proposed a new term, complex regional pain syndrome (CRPS) that replaces RDS and causalgia. Dissenting views suggest that the criteria for RDS are vague or that patients with RSD are not a homogeneous population. Evaluators should eliminate alternative diagnoses and then base a finding of RSD, causalgia, or CRPS on a preponderance of clinical evidence. [Part 2 of this article in the next issue of The Guides Newsletter will address impairment due to RSD/causalgia/CRPS.]

in AMA Guides® Newsletter
Leon H. Ensalada

Abstract

Part II of this two-part series continues the discussion of diagnostic and treatment issues related to reflex sympathetic dystrophy (RSD) and presents approaches to assessing pain and disability associated with complex regional pain syndrome (CRPS). CRPS encompasses CRPS Type I (RSD) and CRPS Type II (causalgia), but the approach of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition is problematic. The current approach may not account for the complete impairment, and RSD/CRPS I by definition does not involve a specific peripheral nerve disorder. Causalgia/CRPS II by definition involves a specific peripheral nerve disorder, and the physician can assess impairment due to pain and sensory deficit or loss of power and motor deficits by multiplying the graded percent deficit with the maximum allowable impairment for the specific peripheral nerve. RSD/CRPS I by definition does not involve disruption of a peripheral nerve, but the criteria recommended by the AMA Guides may be difficult to use. The fourth edition of the AMA Guides advises that, in general, only one evaluation method should be used to evaluate a specific impairment, and a table specifies which tests should not be used together, those that may be used in combination, if appropriate, and those for which combination is not specified.

in AMA Guides® Newsletter