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- Author or Editor: Marjorie Eskay Auerbach x
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Abstract
Although back pain is the most common and expensive cause of work disability in the United States, our understanding of low back pain (LBP) is limited despite the advantages of advanced imaging technologies. Diagnostic studies often are requested for fear of missing serious or occult pathology or to reassure patients but have a low likelihood of identifying a specific cause for the reported symptoms in patients who present with nonspecific LBP. From a clinical perspective, the information provided in lumbar imaging, whether plain X rays or magnetic resonance imaging (MRI), has not been found either to influence treatment recommendations or improve outcomes. Further, routine advanced imaging is not associated with improved outcomes and identifies many radiographic findings that correlate poorly with symptoms; imaging is recommended when severe or progressive neurologic deficit is present or if serious underlying disease is suspected. Surgery rates are highest where imaging rates are highest, and a significant proportion of the variation in rates of spine surgery can be explained by differences in the rates of advanced spinal imaging. Because imaging has no role in the impairment rating of nonspecific LBP, an individual's having a work injury that requires an impairment rating is not a reason to order spinal imaging. To answer the question in this article's title, the answer usually is not to order a spinal image.
Abstract
The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, caused controversy with respect to changes in rating percentages. Impairment ratings in this edition are more specific than in previous editions and are intended to reflect lesser impairment in cases when symptomatology has improved with appropriate treatment. Grids in the AMA Guides, Sixth Edition, include impairment ratings for multiple-level conditions, so an alternative rating system (such as the range-of-motion method in the fifth edition) are not needed. The Diagnosis-related estimate (DRE) categories described in the fifth edition have been modified and expanded by the creation of regional grids that are used in the sixth edition to rate spinal impairments. The grids provide clearer categorization of many conditions and are consistent with clinical outcomes; ratings in the sixth edition reflect the results of treatment rather than the method of treatment. A significant difference in impairment ratings occurs between the fifth and sixth editions of the AMA Guides with respect to the classification of diagnoses of Alteration of Motion Segment Integrity, which includes fusion and, in the sixth edition, motion preserving technologies. A table compares the fifth and sixth editions for single-level spinal disease with or without radiculopathy and with or without surgery, including fusion.
Abstract
The incidence of cervical and lumbar fusion surgery has increased in the past twenty years, and during follow-up some of these patients develop changes at the adjacent segment. Recognizing that adjacent segment degeneration and disease may occur in the future does not alter the rating for a cervical or lumbar fusion at the time the patient's condition is determined to be at maximum medical improvement (MMI). The term adjacent segment degeneration refers to the presence of radiographic findings of degenerative disc disease, including disc space narrowing, instability, and so on at the motion segment above or below a cervical or lumbar fusion. Adjacent segment disease refers to the development of new clinical symptoms that correspond to these changes on imaging. The biomechanics of adjacent segment degeneration have been studied, and, although the exact mechanism is uncertain, genetics may play a role. Findings associated with adjacent segment degeneration include degeneration of the facet joints with hypertrophy and thickening of the ligamentum flavum, disc space collapse, and translation—but the clinical significance of these radiographic degenerative changes remains unclear, particularly in light of the known presence of abnormal findings in asymptomatic patients. Evaluators should not rate an individual in anticipation of the development of changes at the level above a fusion, although such a development is a recognized possibility.
Abstract
Spinal stenosis refers to narrowing of the spinal canal that may result in compression of the spinal cord, or cauda equina. The most common type of spinal stenosis is degenerative stenosis associated with the natural process of aging. In the lumbar spine, the narrowing may result in compression of spinal nerve roots, causing a constellation of symptoms that may include lower pack pain, neurogenic claudication, and lower extremity pain. This case illustrates the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition process of assessing impairment for spinal stenosis. The case involves a 54-year-old male truck driver whose lumbar spine was injured when he unloaded and lifted a tire; he underwent lumbar decompression at L3-4 and L4-5, and fourteen months after surgery was evaluated as being at maximum medical improvement, was able to walk, and could void spontaneously. In a one-page final medical report, the patient's physician hand wrote a note assigning 29% whole person impairment without a medical rationale to support the rating. The author of this case example first notes that the medical reporting does not support placing this patient in class 4, and the examinee's condition is most consistent with a class 1 rating for spinal stenosis. Using Section 17.3, Adjustment Grids and Grade Modifiers: Non-Key Factors, an evaluator would conclude a grade B, 6% whole person impairment for the lumbar spine.
Abstract
Credibility of expert witnesses is essential. It is important that medical experts do not incorrectly assume that administrative law judges are their audience. Instead, it should be noted that most disputes will be resolved between the parties and their representatives. When providing opinions, experts are well-served by understanding the audience as much as practical. The best advice for experts rendering opinions is to remain true to the questions posed and follow the scientific method.
Abstract
Pennsylvania adopted the impairment rating provisions described in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) in 1996 as an exposure cap for employers seeking predictability and cost control in workers’ compensation claims. In 2017, the Supreme Court of Pennsylvania handed down the Protz decision, which held that requiring physicians to apply the methodology set forth in the most recent edition of the AMA Guides reflected an unconstitutional delegation of legislative power to the American Medical Association. The decision eliminates the impairment-rating evaluation (IRE) mechanism under which claimants were assigned an impairment rating under the most recent edition of the AMA Guides. The AMA Guides periodically are revised to include the most recent scientific evidence regarding impairment ratings, and the AMA Guides, Sixth Edition, acknowledges that impairment is a complex concept that is not yet defined in a way that readily permits an evidence-based definition of assessment. The AMA Guides should not be considered standards frozen in time simply to withstand future scrutiny by the courts; instead, workers’ compensation acts could state that when a new edition of the AMA Guides is published, the legislature shall review and consider adopting the new edition. It appears unlikely that the Protz decision will be followed in other jurisdictions: Challenges to using the AMA Guides in assessing workers’ compensation claims have been attempted in three states, and all attempts failed.
Abstract
Myelopathy literally indicates any pathology of the spinal cord, but the term most commonly is used when the cord pathology results from degenerative disease. Specific names usually are used if the disorder is traumatic (spinal cord injury), infectious (myelitis), or neoplastic (the name of the tumor is used). Cervical myelopathy (CM) may result in symptoms such as clumsiness, loss of dexterity, imbalance or poor coordination; muscle weakness; pain; and, in severe cases, bowel, bladder, or sexual dysfunction. When impairment is rated, if the evaluator finds objective evidence of myelopathy when the individual is at maximum medical improvement, neurological impairment is combined with that for the spine. A detailed and thorough neurologic examination is the current standard for the diagnosis of CM, but diagnosis is challenging in the early stages. Correlation of patient symptoms and imaging studies, both plain radiographs and magnetic resonance imaging scans, is essential for correct diagnosis. When imaging studies are equivocal or insensitive, other studies such as electrodiagnostic testing and cerebrospinal fluid analysis may be considered. When CM is defined as the presence of more than one long-tract sign, spinal cord compression in isolation did not cause myelopathy, and up to 20% of those with cord compression did not exhibit CM.
Abstract
The sacroiliac joint (SIJ) is an accepted source of pain in patients with ankylosing spondylitis and other spondyloarthropathies, osteoarthritis, infections, and tumors, but the occurrence of isolated SIJ pain in the absence of such diseases is controversial. The term, sacroiliac joint dysfunction, which is used widely, describes pain from an SIJ that has no identifiable lesion but is presumed to have some mechanical etiology. Practitioners currently have no universally accepted gold standard for identifying a disc, facet joint, of SIJ as the pain generator. Treatment options for SIJ pain include medications, physical therapy, bracing, manual therapy, injections, radiofrequency neurotomy, and arthrodesis. Optimal management of patients with SIJ pain remains controversial. In the AMA Guides, Sixth Edition, a clinically established and causally related diagnosis of SIJ dysfunction is rated using the first row in Table 17-4. Surgery does not change the diagnosis or rating: The SIJ is not a motion segment of the lumbar spine, and SIJ fusion is not an alteration of motion segment integrity. Clinically, pain presumed to be from SIJ dysfunction is low back pain, so if this is the clinical diagnosis, the spine chapter in the AMA Guides, Fifth Edition, should be used. In such cases, the first step is to determine whether to use the diagnosis-related estimate or the range-of-motion method, and the article provides guidance about situations in which the use of each is appropriate.
Abstract
Physicians frequently are asked to assess work ability in individuals with low back pain (LBP) who also require an impairment rating. Physicians may be tempted to base their decisions about the individual's work ability on spinal anatomy/diagnosis as established by imaging, because that may seem objective. However, a review of the current medical literature consistently demonstrates that anatomical abnormalities identified on imaging do not predict functional ability. Rather, recent studies have demonstrated a strong association between the number of symptoms and functional status, on the one hand, and the lack of correlation between findings on imaging and symptoms, on the other hand. For example, a systematic review by Mayo Clinic physicians of 33 published studies in which 3110 asymptomatic adults were imaged using magnetic resonance imaging (MRI) showed that, in middle age when most problematic back pain problems present, roughly half of asymptomatic adults had disc bulges, roughly one-third had disc protrusions, and roughly one-quarter had annular fissures. The authors of the present study also review related studies regarding low back pain and conclude that current scientific knowledge suggests that imaging alone is not useful in predicting function or in assessing future risk. Degenerative changes on imaging are not a sound basis for work restrictions because they do not correlate with risk or capacity.
Abstract
Impairment evaluation of the spine has evolved notably since the 1958 publication by the American Medical Association of an article titled A Guide to the Evaluation of Permanent Impairment of the Extremities and Back. Significant differences exist among the editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) currently in use, including the third edition, revised (1988), fourth (1993), fifth (2000), and sixth (2008) editions. This article reviews exemplary cases according to the instructions and methods of each edition, beginning with a table that summarizes spinal impairment criteria by edition of the AMA Guides. Another extensive table presents seven exemplar cases that demonstrate the differences in impairment ratings between the fourth, fifth, and sixth editions; each example is discussed in terms of different approaches taken in each of these editions. In the AMA Guides, Sixth Edition, the process of rating impairment was simplified by the elimination of the range of motion method. In the examples presented, the impairment values calculated using the sixth edition fall between those obtained using the fourth and fifth editions. Evaluating physicians must know the appropriate edition of the AMA Guides to use in each case and must understand the differences between them, particularly the changes included in the sixth edition.
