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Robert H. Haralson III
in AMA Guides® Newsletter
Robert H. Haralson
in AMA Guides® Newsletter
Robert H. Haralson III

Abstract

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, presents an impairment paradox: Single-level fusions rating using the Diagnosis-related estimates (DRE) method often result in higher impairment values than do multilevel cervical spine fusions. In the AMA Guides, Chapter 15, The Spine, the definition of Cervical Category IV (alteration of motion segment integrity or bilateral or multilevel radiculopathy) changed from the definition in the fourth edition for Cervicothoracic Category IV (loss of motion segment integrity or multilevel neurological compromise) because of changes in the definition of “alteration of motion segment integrity,” which now also includes surgical arthrodesis. This applies only for single-level fusions because the AMA Guides, states the range-of-motion (ROM) method is used in situations when “there is alteration of motion segment integrity (eg, fusions).” The AMA Guides, Fourth Edition, rated impairment on the basis of the injury, not the surgical procedure, and the maximum whole person permanent impairment for a patient with a single-level, single-sided cervical radiculopathy who had a discectomy and fusion would be 15%, but the minimum award for a similar patient rated using the DRE method is 25%. The author reports that, for the reasons outlined, evaluators should rate all cervical fusions, including single-level fusions, using the ROM method.

in AMA Guides® Newsletter
Robert H. Haralson III
in AMA Guides® Newsletter
Robert H. Haralson III

Abstract

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, was published in November 2000 and contains major changes from its predecessor. In the Fourth Edition, all musculoskeletal evaluation and rating was described in a single chapter. In the Fifth Edition, this information has been divided into three separate chapters: Upper Extremity (13), Lower Extremity (14), and Spine (15). This article discusses changes in the spine chapter. The Models for rating spinal impairment now are called Methods. The AMA Guides, Fifth Edition, has reverted to standard terminology for spinal regions in the Diagnosis-related estimates (DRE) Method, and both it and the Range of Motion (ROM) Method now reference cervical, thoracic, and lumbar. Also, the language requiring the use of the DRE, rather than the ROM Method has been strengthened. The biggest change in the DRE Method is that evaluation should include the treatment results. Unfortunately, the Fourth Edition's philosophy regarding when and how to rate impairment using the DRE Model led to a number of problems, including the same rating of all patients with radiculopathy despite some true differences in outcomes. The term differentiator was abandoned and replaced with clinical findings. Significant changes were made in evaluation of patients with spinal cord injuries, and evaluators should become familiar with these and other changes in the Fifth Edition.

in AMA Guides® Newsletter
Restricted access
Christopher R. Brigham
and
Robert H. Haralson III
in AMA Guides® Newsletter
Christopher R. Brigham
and
Robert H. Haralson

Abstract

Spondylolisthesis generally is defined as an anterior or posterior slipping or displacement of one vertebra on another. A unilateral or bilateral defect of the pars interarticularis without displacement of the vertebra is known as spondylolysis or, less frequently, spondyloschisis. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) notes that the two common types of spondylolisthesis are isthmic (related to the presence of spondylolysis and occurring in the immature spine) and degenerative spondylolisthesis (usually found in older individuals with degenerative changes, usually at the fourth or fifth lumbar vertebra). The AMA Guides classifies spondylolisthesis based on the etiology of the slip: congenital, isthmic, degenerative, traumatic, pathologic, and iatrogenic/postsurgical. In addition, grades ranging from I to V are assessed based on the severity of the displacement of the vertebra above on the vertebra below. Some of the confusion concerning terminology used in the AMA Guides regarding alteration of motion segment integrity arises because multiple different but similar terms exist, eg, those from the American Academy of Orthopaedic Surgeons vs the AMA Guides. The AMA Guides specifies that an x-ray finding of spondylolisthesis alone does not equal alteration of motion segment integrity, and a Diagnosis-related estimate (DRE) is the appropriate method for assessing spondylolisthesis (except in rare occurrences of multilevel spinal involvement, when the range-of-motion method is recommended).

in AMA Guides® Newsletter
Robert H. Haralson III
and
Christopher R. Brigham

Abstract

A careful and thorough physical examination is a critical component of the spinal impairment evaluation. Two methods have been used for this evaluation, the Diagnosis-related estimates (DRE) method and the Range of Motion (ROM) method, but the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, states that “the DRE method is the principal methodology used to evaluate an individual who has had a distinct injury.” The DRE rating is based on objective findings at the time of evaluation and includes the following clinical findings: muscle spasm; muscle guarding; asymmetric spinal motion (previously called dysmetria); nonverifiable radicular pain; reflexes, neurological changes such as weakness or loss of sensation, atrophy, radiculopathy, and electrodiagnostic changes; alteration of motion segment integrity; cauda equina–like syndrome; and urodynamic tests. This article examines the definitions of the findings and discusses their use in the DRE method. For example, the AMA Guides, Fifth Edition, defines muscle spasm as a sudden, involuntary contraction of a muscle or group of muscles, and muscle spasm must be present at the time of a DRE-based evaluation; in the Fourth Edition, examiners used only a history of spasm. The AMA Guides, Fifth Edition also has different parameters, compared with the Fourth Edition, for determining atrophy.

in AMA Guides® Newsletter
James B. Talmage
and
Robert H. Haralson III

Abstract

Intra-discal electrothermal annuloplasty (IDET) is a relatively recently described surgical procedure for chronic low back pain that is caused by degenerative discs is unresponsive to nonoperative treatment. IDET involves percutaneously inserting a catheter into a disc(s) and then heating the catheter to 90 °C for 17 minutes. Randomized controlled trials are in progress but not yet reported, so the proper role of IDET in the care of chronic back pain is not yet known. Neither the Fourth nor the Fifth Edition of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) specifically addresses IDET. Evaluators who use the AMA Guides, Fifth Edition, apply the Diagnosis-related estimates (DRE) method to assess impairment when the patient is at maximum medical improvement (MMI). Because the long-term effects of IDET are not known and the patient's disc probably has been permanently changed by the procedure, evaluators should consult the AMA Guides, Fifth Edition, regarding categorization. This is because the injury and surgery have not resulted in a normal disc but rather one that may be prone to future problem episodes. If the evaluator chooses to use the range-of-motion method from the AMA Guides, Fourth Edition, in some scenarios the authors recommend considering IDET as if it were “surgical treatment” of the disc.

in AMA Guides® Newsletter