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Patrick Luers

Abstract

The Diagnosis-related estimate (DRE) method is the principal methodology to evaluate spinal impairment, and alteration of motion segment integrity results at least in a DRE Category IV rating, based on a single-level fusion. Multilevel fusions are rated using the range-of-motion (ROM) method. Detailed examination of the medical literature identifies definitions of loss of motion segment integrity that differ from those in the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fourth and Fifth Editions. Evaluators should note that the descriptions of certain figures were revised in the Errata to the Fifth Edition of the AMA Guides. Evaluators should note three key points from the AMA Guides: permanent impairment is based on findings at maximal medical improvement (MMI); motion in the spite must be abnormal to qualify for permanent impairment; and imaging results, by themselves, cannot be used to establish a DRE impairment rating. Overall, evaluators should consider flexion/extension radiographs that are technically adequate and taken at MMI; read and understand the Errata for Figures 15-3a, 15-3b, and 15-3c; and apply only normal translation and angular motion thresholds that are consistent with the scientific literature.

in AMA Guides® Newsletter
Patrick R. Luers

Abstract

Spinal impairment evaluation includes determination of the presence or absence of alteration of motion segment integrity (AOMSI). The diagnosis-related estimate (DRE) method is the principal methodology used to evaluate spinal AOMSI impairment in the fourth and fifth editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). In the AMA Guides, Sixth Edition, impairment ratings are calculated using the diagnosis-based impairment (DBI) method that uses five impairment classes determined by diagnoses and specific criteria, adjusted by consideration of non-key factors and grade modifiers. This article includes a correction of numbers in the AMA Guides, Sixth Edition, Figure 17-6. The following factors must be considered to determine if AOMSI is present: 1) flexion/extension radiographs are performed when the individual is at maximum medical improvement and are technically adequate; 2) the proper methodology is used in obtaining measurements of translation and angular motion; 3) normal translation and angular-motion thresholds consistent with the literature are used in determining AOMSI. Imaging modalities such as videofluoroscopy, digital fluoroscopy, and upright/motion magnetic resonance imaging cannot be used to establish an AOMSI permanent impairment using the AMA Guides. A number of technical factors can affect the image quality associated with measurements of AOMSI, including film centering, artifacts, poor edge resolution, endplate normal variations and spurring, and use of analog rather than digital radiography.

in AMA Guides® Newsletter
Patrick R. Luers

Abstract

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, defines a motion segment as “two adjacent vertebrae, the intervertebral disk, the apophyseal or facet joints, and ligamentous structures between the vertebrae.” The range of motion from segment to segment varies, and loss of motion segment integrity is defined as “an anteroposterior motion of one vertebra over another that is greater than 3.5 mm in the cervical spine, greater than 2.5 mm in the thoracic spine, and greater than 4.5 mm in the lumbar spine.” Multiple etiologies are associated with increased motion in the cervical spine; some are physiologic or compensatory and others are pathologic. The standard radiographic evaluation of instability and ligamentous injury in the cervical spine consists of lateral flexion and extension x-ray views, but no single pattern of injury is identified in whiplash injuries. Fluoroscopy or cineradiographic techniques may be more sensitive than other methods for evaluating subtle abnormal motion in the cervical spine. The increased motion thus detected then must be evaluated to determine whether it represents normal physiologic motion, normal compensatory motion, motion related to underlying degenerative disk and/or facet disease, or increased motion related to ligamentous injury. Imaging studies should be performed and interpreted as instructed in the AMA Guides.

in AMA Guides® Newsletter