August 7, 2025 • 60 mins
Bethanie Spangenberg from Valor 4 Vet explains the thoracolumbar spine DBQ process and what veterans need to know about back disability evaluations with the VA.
• Understanding the difference between clinical vs. VA perspectives on spine anatomy
• The DBQ examination covers both thoracic and lumbar spine despite their distinct functions
• Most degenerative spine issues begin at the L5-S1 junction due to biomechanical stress
• Range of motion testing requires documentation of pain onset and limitations during flare-ups
• Radiculopathy testing includes strength, reflexes, sensation, and straight leg raising
• Veterans with spinal fusion may qualify for higher ratings based on favorable/unfavorable positioning
• Heavy lifting occupations can lead to spondylolisthesis where vertebrae shift forward
• Severe radiculopathy causing foot drop may qualify for additional compensation for loss of use
• Unlike knee conditions, multiple spine diagnoses typically receive one combined rating
• Second opinions are strongly recommended before proceeding with any spine surgery
For assistance with Independent Medical Opinions or evaluations, contact Valor 4 Vet at 888-448-1011 or visit www.Valor4Vet.com.
Tune in live every Thursday at 7 PM EST and join the conversation! Click here to listen and chat with us.
Visit J Basser's Exposed Vet Productions (Formerly Exposed Vet Radioshow) YouTube page by clicking here.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:01):
Okay, welcome, folks, to another episode of J
Bassett's Exposed VetProductions on this beautiful
balmy.
Hot, I mean hot August 7, 2025.
The year's going by like arocket.
It can't slow down.
I don't know why.
I've tried to slow it down butyou get stuck in the jet wash, I
(00:22):
guess, on it and it messes youup.
So today we're going to continueour series on disability at the
DBQs and we're going to do theVA calls it the thoracolumbar
spine, which basically is acombination of the thoracic
spine and the lumbar spine.
That's how they reach you.
They reach up to the neck, thenyou've got the other two spinal
(00:43):
are put into one, because it'sbasically the same joints, I
guess.
And we have no other personthat knows this and they can do
this besides one lady that knowshow to do it, and it's Miss
Bethany Spangenberg.
Bethany is the principal ofValor Prevet.
It's a company that doesmedical independent opinions and
(01:07):
independent medicalexaminations in some cases, and
she writes a very strong IMO andshe backs it up with years of
knowledge and experience.
And I hate to say it, folks,she's also a non-practicing
accredited VA appeals agent andshe knows the law.
So she's going to explain thistoday in a way that everybody
can understand it.
Bethany, how are you doing?
Speaker 2 (01:28):
I'm doing great In a great place right now, Love the
season we're in of life and thekids and we're doing great.
Speaker 1 (01:38):
That's great.
School started back, yet.
Speaker 2 (01:43):
No, we've got one that starts back next week and
then two that starts back in acouple weeks.
Speaker 1 (01:50):
Okay.
Speaker 2 (01:54):
I've got my oldest, my son.
He's a soccer guy, he's ajunior.
This year he was asked to kickfor football, so we've got
soccer games and football gamesevery week.
And then my middle daughter.
She's starting middle schooland has volleyball.
(02:15):
And then my youngest auditionedfor a play and she's in play
practice and she's going to bein Charlotte Webb.
Speaker 1 (02:27):
So, we're running the kids around like crazy, you've
got to make the costumes.
Speaker 3 (02:35):
Bethany.
Take time to enjoy it, becausethose years go by too quick.
So take and cherish everyminute of it.
Speaker 1 (02:44):
Videotape that play Videotape it.
Speaker 2 (02:51):
You know what's terrible is.
I mean, it's not terrible, butNova falls the weekend that they
do the play and they do theplay five different times, so I
have to miss the first two days.
Speaker 1 (03:08):
Of the play, or Nova.
Speaker 2 (03:10):
Of the play In Nova.
My feet are going to be runningin and running out at the same
pace.
I'm just going to focus ongetting home.
Speaker 1 (03:21):
Where's the conference at this year?
Speaker 2 (03:24):
Washington DC.
Okay, home, Where's theconference at this year?
Washington DC?
I'm going to actually try,because my feedback in my
headphone is pretty bad, so I'mgoing to take this off If I
could kind of talk into the micand have you guys still hear me.
Speaker 1 (03:41):
We can hear you, you can hear me, okay.
Yeah, just pick up just alittle bit and go back.
Let me see if I can get this towhere I can hear you now.
Okay, all right, go ahead.
Speaker 2 (04:10):
Can you hear me?
Okay, you're okay, you're good,okay, so are we ready to get
started?
Speaker 1 (04:17):
yes, go right ahead.
Speaker 2 (04:24):
Go back to the headset, because what I'm doing
is the last time.
I couldn't share mypresentation, so I want to be
able to share it like apresentation Okay.
Okay, so while I get this turnedover, so we're going to talk
(04:51):
about the thoracolumbar and thisis for the lower back.
The DBQ is 14 pages, is 14pages.
It's about an hour to an hourand a half exam and it is a
face-to-face exam.
The one thing that I like topoint out about this is that the
(05:17):
thoracolumbar spine is not howwe think of it clinically.
This DBQ is purely designed forVA disability, so when veterans
talk about their echolumbarspine, it's not how we talk
(05:38):
about it in the clinic.
So I want to talk a little bitabout the anatomy so that you
can have an understanding ofwhat the examiners are looking
at and what we think clinically.
Okay, so here is a picture ofthe entire spine the cervical
spine, the thoracic spine andthe lumbar spine, then the
(06:00):
sacrum and the coccyx.
Speaker 3 (06:01):
So that's also your tailbone.
Speaker 2 (06:03):
Now the VA likes to separate it out from the
thoracic spine and the lumbarspine, but clinically we
typically focus on the lumbarspine and the sacrum.
Okay, that's because the nerveroot involvement is more, uh,
involved in the lumbar spine andthe sacrum.
(06:24):
There is very little movementin the thoracic spine so there's
not a lot of diseases thatoccur in the thoracic spine.
When you get older, the thethoracic spine can be crushed
through osteoporosis and throughaging.
(06:45):
So whenever we look at thethoracic spine, the biggest
issues that we see there is thevertebral bodies being crushed
from osteoporosis or we seeexaggerated curvature in the
thoracic spine.
Otherwise, the thoracic spineis stable, it is fixed and we
(07:05):
don't really focus on thethoracic spine when we're in the
clinic and we're active in life.
So this is just a picturepulling out the thoracic spine
and the lumbar spine which theVA wants us to consider.
This is actually what weconsider in the clinic and what
causes most symptoms in ourpatients.
This is actually what weconsider in the clinic and what
(07:26):
causes most symptoms in ourpatients and the thoracic spine
I'm pointing out here.
I have a picture here with howwe see the rib cage.
So this thoracic spine, this iskind of side-by-side comparison
.
We can see the cervical spinehere, the thoracic spine here,
which again we have these ribshere.
(07:47):
Now the ribs and the muscles inbetween the ribs help to
stabilize the thoracic spine.
So there's not a lot of movementhere.
Okay, the lumbar spine we cansee here.
This is the sacrum and this isthe coccyx coccyx, so the sacrum
(08:08):
.
We talk a lot about the SIjoints, so this is the
sacroiliac joint, this is theilium of the hip.
Okay, so we call these the SIjoints.
These are not meant to moveeither, but in women or in
pregnancy that you'll get somemovement in those si joints and
(08:30):
then if you have a leg lengthdiscrepancy you have one leg
shorter than the other thensometimes you will get some
shifting or movement in that sijoint.
Okay, but those si joints arenot made to move.
Now, if I go back, I want youto be able to appreciate this is
the side view of the spine,okay, and this is what it looks
like if I am looking at you fromthe back.
(08:51):
Okay, so this sacrum has a verydistinct shape and you can
appreciate that here on thispicture of the skeleton.
Does that help to understandthe anatomy and what we're
looking at here?
Does that help?
Speaker 1 (09:03):
to understand the anatomy and what we're looking
at here.
Speaker 2 (09:09):
We showed this slide before.
I will say that some of theseslides are very much the same,
but maybe this time I'll saysomething a little bit different
, in a different way, a littlebit clearer, so that you can
have better understanding.
Not all these slides are in thecervical spine, but these some
(09:32):
are redundant, so you canappreciate the anatomy.
So in this picture here we havethe white, which is the
vertebrae, the blue, which arethe discs, and these are
jelly-like discs, and then thered represents the spinal cord
and the spinal nerve rootscoming off of the spinal cord.
Speaker 3 (09:52):
Okay.
Speaker 2 (09:53):
This is a healthy spinal column.
Okay, we can see there's sharpedges here.
The disc is well-shaped andlooks what I call juicy.
Well shaped and looks what Icall juicy.
As these lose their moisture,it's usually with aging or
degeneration or disease, so welike to see these nice and juicy
.
This is a spine with arthritis,so you can start to see some
(10:23):
change in the shape around thedisc and you can see the disc is
not as full.
So if we put them side by sidenow, the one thing to really
appreciate or understand is thatthese discs, as they lose their
moisture, they become moreflexible and you can get more
(10:44):
movement in that area.
The more movement you have in ajoint, the more likely you are
to develop arthritis.
So when it's young and healthyand these discs are firm and
full of fluid, you have lessmovement around these joints and
the spinal column can preserveitself.
As we lose that fluid and weage, these, the spinal vertebrae
(11:07):
here, start to wear and tearand that's where we get the
arthritis.
This is looking down through thespinal column, as if I'm
looking at the top of your head,looking down at the spinal
column.
This is the spinous processthat we feel when we touch the
back of our neck or we push inthe middle of our spine.
(11:27):
Those are those pointy areasthat we feel.
This is the transverse process.
It is there to protect thenerve roots that come off the
spinal cord.
The center here, the materialin the middle, is the spinal
cord itself and these littlewings.
They actually go into the arms,into the ribs and down into the
(11:50):
legs.
Those represent the spinalnerve roots that come off the
spinal cord.
Now, the bony hole that is herethat allows the spinal cord to
go through, that is called thevertebral foramen and then this
is the vertebral body go through.
That is called the vertebralforamen, okay, and then this is
the vertebral body.
If we talk about degenerativediseases in the spine, this
(12:12):
picture shows a healthy, normaldisc okay.
Then as it ages or loses itsmoisture, we get the disc
degeneration.
Then we get more movement.
More movement means that thepressure can disrupt during
movement and cause the disc tobulge or come out of its normal
(12:38):
area.
The disc can protrude onto thenerve space and irritate the
nerve, and that's where we getradiculopathy.
This here depicts just thinningof the disc.
This is a herniated disc.
Each disc has layers and sothis is the outer layer that has
(13:01):
been punctured or torn and theinside material has come out.
And this can also happen whereit isn't more towards the back
and it can irritate the nerveroot.
And then down here at thebottom, as I showed before, is
where we start to get thearthritis buildup from the
(13:22):
degeneration Now I want to pointout specifically in this area
of the spine.
So this is the lumbosacraljunction, where the sacrum meets
the lumbar spine.
If we understand physics, thisparticular area is a fixed.
(13:44):
This particular area is a fixedlike it's fixed, so it doesn't
have a lot of movement.
So your first area of movement,whenever we bend and twist, is
going to be at this l5 s1 and aswe age, the first area that we
start to see degeneration is atthis L5-S1 disc.
(14:05):
So if I'm looking at an x-rayof a 24-25 year old and I know a
little bit about what they dofor a living I may start to see
wear and tear here at the L5-S1disc or here at the L4.
Depending on how your bodystructure is, this is purely
genetics.
You may notice that you havemore pressure, like the the
(14:27):
bending, twisting fulcrum typeof thing at the L4.
So when we see thatdegeneration and the L4, l5,
that is common that's commonlywhere we start to see
degenerative processes in thespine.
So let's say, for some reason Ihave a veteran that had an
injury.
It's a falling type injury andit wasn't like a plop, it was
(14:51):
more of like fell to the side,hurt his back.
I may see something differenthigher up in the lumbar spine.
I might see more arthriticchanges on one side versus the
other and not at the L4, l5 area.
So then that tells me, hey,something happened here, there
was an injury here and thex-rays or the MRIs are
(15:12):
consistent with that.
So knowing how a person agesnormally, you can appreciate the
difference between somebodygetting an injury that causes
changes that we typically don'tsee right.
Any questions so far.
Speaker 1 (15:30):
Okay.
Speaker 2 (15:37):
Diseases of the lumbar spine.
So last week we talked aboutradiculopathy and that's what
this picture shows.
Talked about radiculopathy andthat's what this picture shows.
This picture shows the entirenerve system that goes from the
brain down into the spinal cordand then at each area of the
vertebrae these nerve roots comeout, okay, even down into the
(15:58):
sacrum.
The sacrum has holes in it,you'll see that in the picture
and these nerve roots come downand they control our bowel and
bladder.
So whenever you go and you areseen in the urgent care for back
pain, they always ask aboutbowel and bladder control.
And this is because if there isa nerve or a spinal cord
(16:21):
compression, you start todevelop loss of bladder, loss of
bladder control, loss of bowelcontrol and you get what they
call saddle anesthesia.
So you can see here in thedermatomes.
These dermatomes are where thenerves control the skin.
So you can see here at S2, s3,and even down in this area that
(16:46):
if somebody's having saddleanesthesia sorry, this area you
can see their tush becausethat's the area that touches the
saddle.
If you're on a horseback, it'ssaddle anesthesia.
I have numbness and tingling inthat area and I can't feel this
.
I can't feel that I lost mybowels, I lost my bladder.
(17:07):
Those nerves in that areacontrol very important functions
and so when you go to theurgent care or the emergency
room and they're saying, okay,have you lost control of your
bowel and bladder?
And you say no, then that's agood sign.
If you say yes, that is whatthey call a red flag clinically.
So they have to get yousomewhere that you can have a
(17:29):
higher level of evaluation, orthey need to get you an MRI or
special testing, because theyhave to rule out that you do not
have a compression, an earthcompression, somewhere, causing
you to lose your bowel andbladder.
If that is not fixed orcorrected then you can have
permanent damage.
So that's red flags that weneed to get you to a higher
level of care.
Okay, so we've talked a lotabout the back, the lumbar spine
(17:56):
, the anatomy and the nerves andthere needs to be basic
understanding.
So then that way, as we talkabout this DBQ, you can really
appreciate each portion of thedbq.
So again, I said it's an hourto hour and a half.
Okay, it is face to face.
The first section always startsout about designating the
(18:18):
relationship between the veteranand the examiner, the evidence,
evidence review and thediagnosis.
We always talk about those.
Now for the evidence.
This is the same as it was forthe cervical spine.
You need a statement in supportof claim.
X-rays, mris, ct scans MRIs arepreferred.
(18:42):
Not every clinician looks attheir x-rays and their MRIs are
preferred.
Not every clinician looks attheir x-rays and their MRIs.
But those reports from theradiologist that go level by
level and tell us where thevertebrae or which vertebrae are
impacted, that's important.
If you've had a nerveconduction study, that's
important, and physical therapyrecords are also important.
Oops, a little too fast.
(19:07):
Now when I look at the DBQ here.
There are a lot of diagnoseshere and a veteran can have more
than one disease or conditionof the lumbar spine.
So they have degenerativearthritis, they can have
degenerative disc disease, theycan have lumbosacral strain.
(19:27):
Those different diagnoses don'tgive them a separate rating.
We see that differs from theknee.
So for the knee they can havearthritis, they can have a
meniscal injury and they canhave instability and they get
ratings for all three.
That is not the same as whathappens to the spine.
(19:50):
So when we write a nexus letterfor the spine we'll put all the
diagnoses that pertain to thatveteran's back and put them all
in there.
Because wearing tear of thespine is normally predictable
and progressing in the samemanner.
We normally start out withdegenerative disc disease.
(20:12):
Then we find bony changesbecause there's movement and
then those bony changes andthose discs start to creep upon
the nerve roots and they developradiculopathy.
That is the normal progressionwithout further accident or
injury.
So you can have an accident orinjury when you're in your 20s.
That can deteriorate.
(20:39):
That starts in their 20s andcan deteriorate over time.
But then we can also seebecause you now have these
degenerative changes you're moresusceptible to other injuries,
just like any other joint, andthen we start to see other
things develop and creep up asthe spine degenerates.
So I want you to understandthat just because you have 5
(21:00):
million diagnoses just for theback or related to the back,
doesn't necessarily mean you'regoing to get different ratings
for that Okay.
Now the other thing that youcan appreciate in this list on
the DBQ is that there's nothinghere that says radiculopathy.
Okay, the examiner has to plugin that you have a diagnosis of
radiculopathy.
(21:21):
Okay.
Section two discusses themedical history.
That's where she writes upeverything that you tell them.
Asks about flare-ups.
You should know what causes aflare-up.
When veterans report for theirexamination, I like to tell them
okay, so well, some attorneyslike to tell them to go on the
(21:43):
treadmill or go take a five-milewalk or go do something really
that physically exerts itself,and I'm like no, no, no, we're
not trying to cause a heartattack, we're not going to try
to cause any other issues,because we're trying to overwork
the veteran so they can go intothat CMP exam with a flare-up,
because the veteran shouldalways be considered on their
(22:06):
worst day, and that is hard tocreate the worst day when you
are preparing to go into a DBQor an exam.
So what I tell veterans is Isay what is it that triggers
your back pain?
Is it gardening?
Is it trying to weed?
(22:28):
Eat?
Whatever it is that triggersthat flare-up, go ahead and do
that a day or two before yourcmp exam because if you know
that causes a flare-up,typically that flare-up is not
going to recover or bounce backbefore like like.
It'll still be lingeringwhenever you go in for your
competent exam.
(22:48):
And so that way the examinercan see you and you can really
detail, when you're doing theserange of motion testing and
doing the exam, where the painstarts and what kind of things
bother you.
Okay all right.
(23:10):
So section three this is rangeof motion testing.
This is your forward flexionand your extension.
The va considers forwardflexion to be normal at 90
degrees and extension to benormal at 30 degrees.
Okay, this is normally where Ihave.
You know, I I have them standup and bend down and touch their
toes.
If they're unstable, I mighthave them hold a desk or hold a
chair so that way they don'tfall.
(23:31):
Depending on how well they canstand, I may or may not do the
range of motion testing, becauseif they're unstable, if they're
weak in their legs and it's afall risk, because if they're
unstable, if they're weak intheir legs and it's a fall risk,
then I will do my best toestimate or guesstimate what
their range of motion would be,based on the history that they
provide.
And that's acceptable for me todo that.
(23:56):
Lateral flexion Normally what Itell veterans to do is I'll have
them stand with their hands ateach side.
They will slide their hand downand try to touch the side of
their knee and I will capturethe lateral flexion and then I
will have them do the same thingon the other side.
Lateral flexion range of motion, according to the VA, is normal
(24:18):
at 30 degrees.
They're also supposed to becapturing rotation.
This is lumbar rotation.
This is where you're turning atthe waist and sometimes it can
be difficult to capture becausewe also turn at our head and so
we're not trying as examiners,we're not trying to capture the
(24:40):
range of motion at the neck butat the waist.
So some people or some examinershave the veteran put their
hands on their hips or up ontheir sides a little higher than
their hips, and then they'lltry to get them to rotate while
seated, because if you areseated, then you know that your
sacrum is not going to movebecause you're sitting on your,
(25:01):
your butt bone and your sacrumis fixed between the butt bone.
So they'll have them put theirhands basically on their fat
rolls because at least that'swhat I'm doing and I have them
rotate at the waist.
Okay, any questions about that?
Okay?
Speaker 1 (25:26):
all right, the comedy hour what'd you say?
Speaker 2 (25:34):
the comedy hour hey, I gotta make it lively somehow.
This is a lot of data overload,overstimulation.
So for the range of motion, thetakeaway is the examiner is
(25:55):
going to capture a lot ofnumbers.
They're going to do an initialrange of motion.
They're going to document atwhat degree the pain starts.
They're going to do an observedrepeated motion.
So they're going to have you dothe movement three times and
(26:17):
then capture that range ofmotion.
Then there's two parts wherethe examiner is supposed to use
their clinical skills thehistory that the VA provides,
the veteran provides, and theMRIs, the testing, all the other
objective reports discuss whatthey think the limitations would
(26:52):
be during a flare-up and withrepetitive use over time Using a
goniometer.
Of course yes, using thegoniometer.
The guesstimation part issomething that requires clinical
experience.
New practitioners probablycan't provide that.
But what that is is we'retrying to use our clinical
(27:13):
skills to say you know, whatkind of limitation does this
veteran have?
And in the past the VA didn'treally ask the examiner to think
much about that.
And in the past the VA didn'treally ask the examiner to think
much about that.
They didn't ask them to discusspain or where pain started in
range of motion.
When I did these DBQs 12, 13years ago, there was not a place
(27:38):
for me to document where theirpain started.
When I got into the privatesector and started doing these
DBQs as a private examiner and Ilearned from the agent's side
of things, I then started todocument in the comment section
where their pain would startwith each range of motion.
So I'm happy to see that 13 or14 years later they're finally
(28:04):
catching up to what it should be.
So they actually document fivepages.
So it's a lot.
Now the other part to this isthat these DBQs are not designed
for clinical thought process atall.
So when we do an examination,we inspect, we look with our
(28:29):
eyes, we try to find asymmetry,we try to look at movement and
then we push on the musclestructure, then we what we call
palpate Okay, and then we gointo special testing.
The VA has us do it allbackwards, so clinically it
takes longer.
If we go from the start tofinish, a seasoned examiner will
(28:51):
know what they need to do anddo it clinically in their head
and then free, write on a pieceof paper and then plug it back
into the DBQ later.
I don't know why they didn'task a clinical person to write
these DBQs, because that wouldonly make sense to me, because
it would make it moreexpeditious.
But they didn't.
(29:12):
So on page seven the examinergets to look at the veteran's
back and push on the veteran'sback and push on the veteran's
back and they're supposed todiscuss any muscle spasms which
we can feel when we touch, anytenderness.
That is appreciated when theveteran expresses that it hurts,
(29:34):
and they're also supposed to belooking for what we call
guarding.
Guarding can be involuntary,which means that the arthritis
is so bad that the muscles arejust doing what they can to
protect it, or it could bevoluntary, where the pain is so
bad, the veteran's locking upand is not wanting to move.
(29:56):
Okay, the examiner is alsosupposed to observe the veteran
walking sitting.
The examiner is also supposedto observe the veteran walking
sitting, standing and doingtheir normal movements,
transferring from sitting tostanding, standing, to climbing
up on the examination table, andthey're supposed to document
(30:21):
any abnormalities theyappreciate with that.
Any questions?
Speaker 1 (30:27):
All right.
Speaker 2 (30:28):
So the next several sections are for testing of the
nerves in the lower legs.
They're looking at theradiculopathy and trying to
understand the severity of theradiculopathy, but they break it
out up into several sections.
Now we've talked before thatwith the new way that they're
wanting to rate radiculopathy,they would essentially take out
(30:52):
all of these sections except forone.
So in order to understandradiculopathy, there's one, two,
three, four different sectionsand tests that the VA currently
wants us to use in order for theclinician to determine the
severity and location of theradiculopathy.
So the first one, the first onethat the examiner is supposed
(31:17):
to do, is to do strength testing.
They're supposed to assess theflexion of the hip, the knee and
the ankles and determine ifthey are normal, which is full
strength with resistance, andthat means it's a five out of
five.
The scale's highest you can gois a five, and if there's no
(31:38):
muscle movement consistent withparalysis, then that's a zero.
Okay, then the next section,section five, is the reflex exam
.
They're supposed to capture thereflexes at the knee and at the
heel.
Some use a reflex hammer.
(31:59):
I typically use the back of mystethoscope.
Once you do reflexes enough andyou get skillful at it, then
you can use other tools toelicit the reflexes.
Now, a normal reflex is a twoout of four or it's a two.
The way we document it is a twoplus Okay.
If there is hyperactivity,meaning that it's more extreme,
(32:22):
the reflex is more prominent.
That can indicate nerve rootirritation.
And if it's hypo responsive orhypoactive, then it can also
indicate nerve root irritation.
And so it doesn't.
It just varies person to person, it varies nerve by nerve.
There's no consistency to saylike everybody that has this
(32:45):
type of reflex response meansthis.
It's just hey, this isn't right, this isn't normal, we need to
investigate it further.
Section six looks at the sensoryexam which we've talked a
little bit about.
Now it is not typical forexaminers to test S2 and S3.
Okay, s2 and S3 is the sacralnerve 2 and sacral nerve 3.
(33:07):
So if they're doing that, we'dhave a problem.
However, the dermatomes, as youcan see here, t1 through S2,
well, s2 you can test with theback of the legs.
T1 and T2, we normally don'ttest those in the clinic because
we're not assessing forthoracic issues.
(33:30):
The thoracic spine is prettystable In the DBQ.
They don't ask about thethoracic spine and I've had this
.
I've had a veteran come in andsay well, I have arthritis in
the thoracic spine Because thereis very little movement.
(33:50):
Any abnormalities in thethoracic spine are typically not
from the cervical spine andlumbar spine.
It's typically something elsehas gone on, something with your
breathing, something withexternal trauma, but
degenerative wise, we're notgoing to see that in the
thoracic spine.
Now when you talk aboutosteoporosis, which is a
(34:13):
nutritional issue meaning you'renot eating the right like your
body is starting to pull thecalcium from the bones and those
bones weaken because you haveto have calcium in your
bloodstream for cardiac functionThen we see that compression
okay.
So for when we look at thesensory exam for the
thracolumbar DBQ, they only wantsensory testing in the lower
(34:39):
extremities and this is when anexaminer may take a tissue,
piece of toilet paper, cottonball and they'll wipe on the
different dermatomes and ask youto say yes or respond whenever
you feel them touch.
Speaker 1 (34:52):
Okay, what about scoliosis?
Speaker 2 (34:56):
One thing that is different and unique for the
lumbar spine is what we callstraight leg testing is what we
call straight leg testing,straight leg testing.
The idea is is that we arestretching that sciatic nerve or
one of the nerves that is veryprominent in the leg.
Let me go back to it because Iknow you guys will appreciate
(35:16):
the nerve.
Okay, so this is the sciaticnerve.
These nerves come together,they create the sciatic nerve.
It comes under your butt andcomes down into the leg.
Okay, if we do clinically, if welift the leg and you start to
experience pain associated withthat nerve or sensations
(35:40):
associated with that nerve, thenwe can suspect that there's
some type of radiculopathy goingon, depending on the history.
Now, the other thing that canhappen is, because of where the
sciatic nerve lies, there can bemuscle irritation that
irritates that nerve, giving asimilar symptom to radiculopathy
(36:01):
.
So the examiner kind of needsall of these different tests to
put together exactly what iscausing the problem and how
severe the radiculopathy is.
So we can't just base one umone particular test to
(36:24):
understand radiculopathy.
Okay, all right, any questionsabout that?
Speaker 1 (36:38):
No, okay, the only question I had was about
scoliosis.
Speaker 2 (36:48):
The thoracic spine.
Speaker 1 (36:53):
So what's your question about the scoliosis?
Well, you know he's talkingabout issues with the thoracic
spine.
I mean, scoliosis is probablythe most common problem with the
thoracic spine.
Speaker 2 (37:02):
Yeah, so we can see scoliosis in a couple of ways.
Now, scoliosis is most commonlydevelopmental, but as we age,
degenerative arthritis orchronic inflammation can play a
role in developing scoliosis.
(37:24):
Normally it's not to theseverity that we see with the
developmental issue because ofthe rapid growth in pediatrics,
where the scoliosis in olderindividuals develop because of
degeneration, not that buildupor growth.
It's more of the reverseprocess, but it's the discs have
(37:44):
lost their moisture, so there'smore movement than they're
starting to get the abnormalpressures and it's similar to
ankylosing spondylitis that candevelop and we've talked a
little bit about that last weekand I'll talk about that today.
Thoracic spine issues we seekyphosis, and kyphosis is where
(38:06):
we get that exaggerated humpthat can be from bone changes,
chronic lung disease such asCOPD.
Copd changes the way themuscles control the rib cage and
can actually get what they calla barrel chest, and so instead
of this beautiful oval-shapedchest you get a round,
(38:29):
barrel-shaped chest, and thatcan affect the spine as well.
So is that what you weremeaning?
Speaker 1 (38:36):
Yeah, that's the thing about some folks.
They've got issues like, say,shoulder elevation, diaphragm
paralysis and things like that,where your diaphragm is
paralyzed and it doesn't retractup and down, your shoulder
automatically elevates up,probably a couple inches higher
than the other shoulder In thatprocess.
It actually curves the spine inthe process.
Speaker 2 (38:59):
I should prepare every DBQ with you in mind,
because you are such an atypicalsituation.
We don't see that a lot, butyes, you're absolutely right.
Anything interfering with thediaphragm or the normal lung
function we can see changes inthe thoracic spine.
(39:22):
Same with asthma.
If you have especially childrenthat have chronic asthma issues
and if they're born withrespiratory issues the pediatric
respiratory issues you can seechanges in thoracic spine as
well.
Speaker 3 (39:41):
Bethany, let me ask a question with you saying that,
talking about the lungs, let'stake some of these veterans.
I had one call me last weekthat was around the burn pits
and now he's saying his back isbothering him and his lower back
.
Can chemical exposures whetheror not it be from the lungs, jet
(40:03):
fuel, some of the fire spraysand things that we know that
cause lung problems Can thosealso affect the spine eventually
, over years?
Speaker 2 (40:19):
So clinically, I have not seen toxic chemicals or
burn pits affect the lumbarspine.
What I have seen is those withchronic lung diseases that are
not controlled, such as COPD oruncontrolled asthma.
What I have seen is thatthey're more likely to have what
(40:42):
we call idiopathic compressionfractures of the vertebrae.
Those who have COPD or asthmadon't necessarily get good
oxygen exchange and nutritionexchange, so the body starts to
pull nutrients from the bone andthe bone marrow.
So the bone recovery is not asthe bone structure Like.
(41:08):
Once those elements are takenout, the bone doesn't rebuild
itself very well and so that'swhere we get the vertebrae start
to compress.
Let me go this way thosevertebrae compress and then they
go in and they do what theycall kyphoplasty.
They'll stick cement in thereand stabilize it so it doesn't
compress further.
Because if you have acompletely flattened bone, you
(41:30):
can only imagine what that doesto the nerve roots around it and
the discs around it.
It just creates problems andwe'll look at some x-rays that
show some of that buildup andthat effect.
So to answer your question is Ihave not seen toxic chemicals
directly affect lumbar issues.
We would have to look at it ona case-by-case basis to really
(41:55):
rule out all these other causesbefore we would jump to toxicity
in the lumbar location.
If we know an individual hasburn pit exposure they have
small, like the bronchiolitisand other chronic lung issues in
the lungs from burn pits thenwe may be able to connect
osteoporosis or kyphosis or theidiopathic compression fractures
(42:20):
in the thoracic spine in thethoracic spine.
Again, lung issues, thoracicspine go hand in hand more than
lung issues and lumbar issues.
Speaker 1 (42:31):
Mm-hmm Right, Ask him if he was one of the loaded to
burn pictures, the junk to burn.
Maybe he'd get it connectedthat way.
Speaker 3 (42:41):
Well, you know that was another question.
I mean, I had another gentlemana few weeks ago now and I was a
little leery in speaking withhim.
He was talking about his lowerback protruding disc military
(43:02):
and was assigned to a warehouse.
He was constantly picking up 50, 70, even 80 pound shells and
putting them on loading docksand putting them on some type of
a pallet to be loaded ontotrucks and I asked him.
I said didn't they have devicesto help you load that, okay, and
(43:26):
I said didn't they have devicesto help you load that Mm-hmm?
Okay, and he said no, they hadno devices and he was trying to
connect be okay to connect it ofdoing that for a couple of
years every day to whateventually caused the
deterioration of his spine andproblems that he was having now
(43:53):
and he had been out of themilitary.
Speaker 2 (43:53):
I'm going to say at least 30, 35 years.
So let me show you.
I know we're kind of jumpingaround on this, but I think it's
important that we tackle that.
Let me jump back to one ofthese pictures and I'll tell you
what I don't like about thatbending lifting, and I see this
a lot in roofers, or rooferswhatever, depending on what part
of the country you're from.
(44:15):
So what we see in those who do alot of that lifting from the
ground and coming up a lot ofweighted flexion and extension
is where this is supposed to bestable.
This vertebrae starts to shiftforward and so they call that
(44:38):
spondylolisthesis.
And it's not the disc, it'sactual bone.
So the bones start to shiftbecause this isn't moving, the
sacrum's not moving.
This is the weakest point inflexion and extension.
Depending on genetics it couldbe this one, but this one's
primarily, and so when this boneshifts there's no pulling that
(45:03):
back.
They have to go in and putscrews in and fix the sacrum and
this vertebrae so it doesn'tmove forward and completely
compress these nerve roots.
So you can see here if thiswhole bone pulls forward, this
nerve root is now crushed, pullsforward, this nerve root is now
(45:33):
crushed.
So when I see patients who havethis spondylolisthesis, I
question what kind of occupationdid you do?
What kind of work did you do?
And it's typically that lifting50, 60 pounds, shells or
roofing over time that can causeissues.
And what's terrible is whenpatients get this fixed they'll
still continue to work.
So then guess what happens.
(45:55):
The fulcrum changes.
So now they start to getmovement in the vertebrae above
it and then they have to gettheir fixation or their fix
extended and screws have to gothrough this one.
And then guess what happens ifthey continue to work?
Same thing, so it changes.
It's more physics at that pointfor understanding where the
(46:19):
main pressure for the spine is.
Speaker 1 (46:25):
The vulnerability.
Hold your body weight up.
That's under a lot of pressure.
It holds your body weight upbecause that part down.
Speaker 2 (46:31):
Especially, if not for lifting.
So this is where having goodabs would save your back.
Does that answer your question,ray?
Speaker 3 (46:46):
Yeah, it does.
It makes it very clear because,you know, I was kind of
thinking why it all of a suddenappeared so many years later.
But the way you just explainedit, it takes time for that to
develop over a period of time,over a period of time.
So it very could have startedfor those two years of lifting
(47:08):
that amount of weight daily, youknow, I'm going to guess at
least four to six hours a day.
Speaker 1 (47:16):
Great For your question about the shells he
lifts in.
Now all shells in the field arehand-handled.
We go into a pallet the 155s iswhat you're talking about
because that's the way to theshells and that was the most
commonly used shell.
In the closed environment, sayin the factories, or they reload
the shells.
They've got lifting plugs thatscrew on where the fuse goes in.
(47:39):
They can pick them.
They got chain hoists andthings like that to pick them up
, but in the field it's all byhand.
Speaker 2 (47:50):
Well, hopefully they have occupational or lifting
training, lift with your leg.
So this was just wrapping up onthe radiculopathy how they take
all those sections for theexaminer to determine the
severity of the radiculopathy.
So it's not just one thing welook at, especially in the
(48:11):
clinic, and then from here we'regoing to order our own MRIs or
CT scans, depending on what theyfeel is appropriate.
But in the CMP realm they don'thave that option.
So if you have those MRIs orEMGs, that further supports the
story or tells the story.
Supports the story or tells thestory.
So I'm going to jump to thenext section, which is about
(48:39):
ankylosis.
Now, last week we talked aboutthis how what happens is
inflammation around the discsand around the vertebrae start
to create rebuilding of bone.
That's actually what happens indegenerative arthritis.
We get inflammation in thatarea because of stressors.
Then the body starts to try torepair or lessen those stressors
(49:01):
on that area.
When ankylosing spondylitiscomes, there's a couple of
things that can cause it.
Spondylitis comes, there's acouple of things that can cause
it.
You can have infectious reasonsand that causes the cells to
turn over a lot quicker andthat's where you get the fusion
of the bones and the discs arepretty much gone.
You can also have it occur indegenerative arthritis.
(49:24):
I've seen a few of these Forreason why others develop
degenerative changes quickerthan others.
I don't know.
If we figure it out, I'm surewe'll make lots of money
somewhere, but it can alsohappen because of degeneration.
The other thing that I think isimportant and this applies to
(49:45):
both cervical and lumbar spineis when somebody gets a surgical
fixation, like they go in andthey get fused, or they get the
bars on the side and the screwsin the side, like we were
talking about with thespondylolisthesis, where those
vertebrae shift.
Okay, that can be anunfavorable or a favorable
(50:14):
spinal position and those needto be considered in the rating
schedule.
So if somebody has an extendedlumbar hardware, they should be
advocating for the ankylosisrating schedule and I actually
have a picture of one to showyou.
(50:36):
But they must.
The clinician the VA C&Pexaminer is not the person
that's going to go in and lookat the x-rays.
It's going to be your privateclinicians or your treating
clinicians that are going to seethese images.
So they need to document intheir private treatment records
or in the primary care recordsor specialist needs to document
(50:57):
that if they have an unfavorableor an unfavorable position of
their spinal being fixed ortheir spine being fixed, then it
has to come from somewhereoutside the CMP exam, because
the CMP examiners are nottrained to do this.
They're not trained to look atthe x-rays.
So and I'll explain that alittle bit better in a few
(51:21):
clinical application slides thisone I covered a little bit
already, but every diagnosis onthis falls underneath the
intervertebral disc syndrome, orIVDS.
Anybody that saw me at the VAfor CMP exams from 2011 to 2013,
nobody had IVDS.
Because I don't know what thatwas.
(51:42):
I didn't know what that was.
They didn't teach us what itwas.
This is old medicine.
I didn't know what it was.
Recently they defined it so,and I'm sure a lot of other CMP
examiners who are beingtransparent can say the same
thing.
Now this is where we get intothe x-rays.
Let me see here where we're inthe DBQ.
(52:08):
So let me actually jump to theDBQ.
We talked about IVDS.
Then the next session sectiontalks about assistive devices.
Those who have a severeradiculopathy can develop what
they call drop foot, that's whenthe ankle.
They're not able to pull theirtoes up and they have weakness
(52:28):
in that.
Sometimes they wear a plasticbrace called an AFO to help them
keep that foot up and have themambulate more regularly.
Drop foot is common.
As radiculopathy gets worse,then people even diabetic.
Even diabetic nerve damage canresult in AFOs.
(52:50):
Afo is a loss of use.
So if you're a veteran that hasa drop foot that has an AFO,
you need to be asking for SMCfor loss of use.
Okay, and that goes along.
(53:12):
The loss of use goes along.
Speaker 3 (53:13):
I could tell you all about that there you go.
Speaker 2 (53:18):
Section 8, excuse me, section 13 is exactly that.
It's talking about the loss ofuse and that SMC consideration
there.
Then there's a section therefor other important findings.
Then section 15 looks atdiagnosis, excuse me, diagnostic
testing.
(53:39):
So MRIs are best and again,providers do not visually look
at the imaging, they depend onwhat the radiologist says Me
being outside in the civiliansector, I always look at my
x-rays.
So if we look at this x-ray,this is actually a good x-ray.
This is relatively healthy.
(53:59):
We have good disc space.
The alignment looks pretty good.
We have a little bit ofspurring here which we can see.
It's stressors, wear and tearof some sort.
But this looks like bones of ahealthy person.
This is a little bit ofinstability.
(54:19):
So this is actually what theycall a flexion x-ray and if in
the clinic we're worried aboutinstability of some of the
vertebrae, then we can ask thex-ray department to do flexion
and extension x-rays.
So you can see here what thisinstability does to this space
(54:42):
back here.
So it narrows it and this couldbe why the individual is having
some of the symptoms thatthey're having.
Okay, but I wouldn'tnecessarily call this a
spondylolisthesis.
But this is the same idea wherethe bone itself is actually
(55:02):
shifting forward.
Okay, okay, now this case thatI'm showing next.
I'll go fast because I knowwe're almost out of time here,
but this case is actually veryimportant.
This is somebody that I workedwith 10 plus years ago and this
is when I was in the civilianside and I was advocating for
(55:25):
this individual to get thehighest compensable rating ever,
and this is because of how theyare in an unfavorable position
of their spinal fusion.
This is absolutely terrible,terrible.
(55:55):
This is in my opinion and I'mnot a surgeon but I've never
seen anything like this in mylife.
I don't know why the surgeonwould do what they did, but when
it comes to medical malpractice, the standards are higher and
your time is limited.
In the state of Ohio, you haveone year from the date of
discovery to sue someone formedical malpractice.
Now this veteran kept going backto this surgeon and kept going
(56:18):
back to the surgeon and finallyshe's like I'm not getting any
better.
This lady was working at thepool, trying to work with the
back like this at the pool,trying to work with the back
like this.
If she falls and gets anymovement in this space
whatsoever, she's a dead woman.
So if the examiner doesn't lookat this x-ray, they're not
(56:46):
going to be able to appreciatethe degree and severity of this
spine.
This was bad.
Now I'm going to flip throughquickly just the rating schedule
, so that way it's in the video.
These are going to the redarrow there.
(57:10):
These two red arrows are goingto be your most common claims
and then, to finish up, the DBQ.
They ask for the functionalimpact and that should be in
your statement, open remarks andthen the examiner's
(57:32):
certification and signature.
I know that's a lot.
Any questions?
Speaker 1 (57:41):
Scrambled brain there for a few minutes.
I think you covered it well,yeah, and you covered it full
fully.
Yeah, and you covered it fullfully.
People listening if you watchthis and you see the information
like that, you've got issueswith your back and with your
spine itself.
You need to keep an eye on whatyou've got and what you've been
(58:02):
diagnosed with.
If you've got a spinal disease,just make sure that you get it
fixed as soon as you can,because that can lead to other
problems, especially walking,because every time you move it
slips.
Speaker 3 (58:18):
Well, if you put it off, thinking you're big and
strong and healthy, and it justhurts, you've got to be careful
because you're going to end upin a wheelchair or with, like
you said, loss of use of a footand have to wear an AFO.
So, yeah, pay attention to it.
Speaker 1 (58:37):
If you've got that issue.
I don't care if you're KingKong.
You have a slip like that andit's going to put you down.
Speaker 2 (58:44):
Generally speaking, when it comes from the clinical
side of things, I typicallyrecommend to put off spinal
surgery as long as you can.
However, in some cases youcan't, so you really need to get
a second opinion Always get asecond opinion when it comes to
spine surgeries and when itcomes to the spondylolisthesis,
(59:05):
where you have that shifting.
If you're a roofer or roofingand that's your occupation, you
need to find another one,because it's just going to get
worse and worse and eventuallyyou're not going to be able to
walk.
Speaker 1 (59:20):
Go to school, become an accountant, be a pressure
pusher, do something.
Stay off the roof.
Speaker 2 (59:26):
That heavy lifting and moving that back needs to go
away.
Speaker 1 (59:35):
Okay, well, we covered a whole lot of territory
tonight, I think.
We went up and down the WestCoast and back down and over to
Vegas and pulled a couple oflefties and went back to the
West Coast.
We covered a lot of it, a lotof roads, a lot of miles.
But now we've got to pick asubject for next time, then
we'll figure it out.
Speaker 2 (59:55):
I think I have one.
Speaker 1 (59:56):
Come on, buddy, okay.
Speaker 2 (59:58):
Chronic fatigue syndrome Appreciate it.
Speaker 1 (01:00:00):
Thank you, okay, chronic fatigue syndrome.
You heard the guy, so that'swhat we're going to do next time
.
Chronic fatigue syndrome.
That's something I need tocheck into too.
But with that, I want to thankBethany for coming on.
You can reach Bethany at she's.
She's just go to Valor.
That's Valor4Vetcom, that'sValor4, the number four vetcom.
(01:00:20):
And if you need help with anIMO or anything like that, just
go ahead and punch in theinformation.
She's got a portal and she'llpick you up and they'll be in
contact With that.
This is John, on behalf of MrRay Cobb and Beth Expanian-Burr.
(01:00:41):
We'll be setting off for now.
Bye, guys.
Okay, welcome, folks, to another episode of J
Bassett's Exposed VetProductions on this beautiful
balmy.
Hot, I mean hot August 7, 2025.
The year's going by like arocket.
It can't slow down.
I don't know why.
I've tried to slow it down butyou get stuck in the jet wash, I
(00:22):
guess, on it and it messes youup.
So today we're going to continueour series on disability at the
DBQs and we're going to do theVA calls it the thoracolumbar
spine, which basically is acombination of the thoracic
spine and the lumbar spine.
That's how they reach you.
They reach up to the neck, thenyou've got the other two spinal
(00:43):
are put into one, because it'sbasically the same joints, I
guess.
And we have no other personthat knows this and they can do
this besides one lady that knowshow to do it, and it's Miss
Bethany Spangenberg.
Bethany is the principal ofValor Prevet.
It's a company that doesmedical independent opinions and
(01:07):
independent medicalexaminations in some cases, and
she writes a very strong IMO andshe backs it up with years of
knowledge and experience.
And I hate to say it, folks,she's also a non-practicing
accredited VA appeals agent andshe knows the law.
So she's going to explain thistoday in a way that everybody
can understand it.
Bethany, how are you doing?
Speaker 2 (01:28):
I'm doing great In a great place right now, Love the
season we're in of life and thekids and we're doing great.
Speaker 1 (01:38):
That's great.
School started back, yet.
Speaker 2 (01:43):
No, we've got one that starts back next week and
then two that starts back in acouple weeks.
Speaker 1 (01:50):
Okay.
Speaker 2 (01:54):
I've got my oldest, my son.
He's a soccer guy, he's ajunior.
This year he was asked to kickfor football, so we've got
soccer games and football gamesevery week.
And then my middle daughter.
She's starting middle schooland has volleyball.
(02:15):
And then my youngest auditionedfor a play and she's in play
practice and she's going to bein Charlotte Webb.
Speaker 1 (02:27):
So, we're running the kids around like crazy, you've
got to make the costumes.
Speaker 3 (02:35):
Bethany.
Take time to enjoy it, becausethose years go by too quick.
So take and cherish everyminute of it.
Speaker 1 (02:44):
Videotape that play Videotape it.
Speaker 2 (02:51):
You know what's terrible is.
I mean, it's not terrible, butNova falls the weekend that they
do the play and they do theplay five different times, so I
have to miss the first two days.
Speaker 1 (03:08):
Of the play, or Nova.
Speaker 2 (03:10):
Of the play In Nova.
My feet are going to be runningin and running out at the same
pace.
I'm just going to focus ongetting home.
Speaker 1 (03:21):
Where's the conference at this year?
Speaker 2 (03:24):
Washington DC.
Okay, home, Where's theconference at this year?
Washington DC?
I'm going to actually try,because my feedback in my
headphone is pretty bad, so I'mgoing to take this off If I
could kind of talk into the micand have you guys still hear me.
Speaker 1 (03:41):
We can hear you, you can hear me, okay.
Yeah, just pick up just alittle bit and go back.
Let me see if I can get this towhere I can hear you now.
Okay, all right, go ahead.
Speaker 2 (04:10):
Can you hear me?
Okay, you're okay, you're good,okay, so are we ready to get
started?
Speaker 1 (04:17):
yes, go right ahead.
Speaker 2 (04:24):
Go back to the headset, because what I'm doing
is the last time.
I couldn't share mypresentation, so I want to be
able to share it like apresentation Okay.
Okay, so while I get this turnedover, so we're going to talk
(04:51):
about the thoracolumbar and thisis for the lower back.
The DBQ is 14 pages, is 14pages.
It's about an hour to an hourand a half exam and it is a
face-to-face exam.
The one thing that I like topoint out about this is that the
(05:17):
thoracolumbar spine is not howwe think of it clinically.
This DBQ is purely designed forVA disability, so when veterans
talk about their echolumbarspine, it's not how we talk
(05:38):
about it in the clinic.
So I want to talk a little bitabout the anatomy so that you
can have an understanding ofwhat the examiners are looking
at and what we think clinically.
Okay, so here is a picture ofthe entire spine the cervical
spine, the thoracic spine andthe lumbar spine, then the
(06:00):
sacrum and the coccyx.
Speaker 3 (06:01):
So that's also your tailbone.
Speaker 2 (06:03):
Now the VA likes to separate it out from the
thoracic spine and the lumbarspine, but clinically we
typically focus on the lumbarspine and the sacrum.
Okay, that's because the nerveroot involvement is more, uh,
involved in the lumbar spine andthe sacrum.
(06:24):
There is very little movementin the thoracic spine so there's
not a lot of diseases thatoccur in the thoracic spine.
When you get older, the thethoracic spine can be crushed
through osteoporosis and throughaging.
(06:45):
So whenever we look at thethoracic spine, the biggest
issues that we see there is thevertebral bodies being crushed
from osteoporosis or we seeexaggerated curvature in the
thoracic spine.
Otherwise, the thoracic spineis stable, it is fixed and we
(07:05):
don't really focus on thethoracic spine when we're in the
clinic and we're active in life.
So this is just a picturepulling out the thoracic spine
and the lumbar spine which theVA wants us to consider.
This is actually what weconsider in the clinic and what
causes most symptoms in ourpatients.
This is actually what weconsider in the clinic and what
(07:26):
causes most symptoms in ourpatients and the thoracic spine
I'm pointing out here.
I have a picture here with howwe see the rib cage.
So this thoracic spine, this iskind of side-by-side comparison
.
We can see the cervical spinehere, the thoracic spine here,
which again we have these ribshere.
(07:47):
Now the ribs and the muscles inbetween the ribs help to
stabilize the thoracic spine.
So there's not a lot of movementhere.
Okay, the lumbar spine we cansee here.
This is the sacrum and this isthe coccyx coccyx, so the sacrum
(08:08):
.
We talk a lot about the SIjoints, so this is the
sacroiliac joint, this is theilium of the hip.
Okay, so we call these the SIjoints.
These are not meant to moveeither, but in women or in
pregnancy that you'll get somemovement in those si joints and
(08:30):
then if you have a leg lengthdiscrepancy you have one leg
shorter than the other thensometimes you will get some
shifting or movement in that sijoint.
Okay, but those si joints arenot made to move.
Now, if I go back, I want youto be able to appreciate this is
the side view of the spine,okay, and this is what it looks
like if I am looking at you fromthe back.
(08:51):
Okay, so this sacrum has a verydistinct shape and you can
appreciate that here on thispicture of the skeleton.
Does that help to understandthe anatomy and what we're
looking at here?
Does that help?
Speaker 1 (09:03):
to understand the anatomy and what we're looking
at here.
Speaker 2 (09:09):
We showed this slide before.
I will say that some of theseslides are very much the same,
but maybe this time I'll saysomething a little bit different
, in a different way, a littlebit clearer, so that you can
have better understanding.
Not all these slides are in thecervical spine, but these some
(09:32):
are redundant, so you canappreciate the anatomy.
So in this picture here we havethe white, which is the
vertebrae, the blue, which arethe discs, and these are
jelly-like discs, and then thered represents the spinal cord
and the spinal nerve rootscoming off of the spinal cord.
Speaker 3 (09:52):
Okay.
Speaker 2 (09:53):
This is a healthy spinal column.
Okay, we can see there's sharpedges here.
The disc is well-shaped andlooks what I call juicy.
Well shaped and looks what Icall juicy.
As these lose their moisture,it's usually with aging or
degeneration or disease, so welike to see these nice and juicy
.
This is a spine with arthritis,so you can start to see some
(10:23):
change in the shape around thedisc and you can see the disc is
not as full.
So if we put them side by sidenow, the one thing to really
appreciate or understand is thatthese discs, as they lose their
moisture, they become moreflexible and you can get more
(10:44):
movement in that area.
The more movement you have in ajoint, the more likely you are
to develop arthritis.
So when it's young and healthyand these discs are firm and
full of fluid, you have lessmovement around these joints and
the spinal column can preserveitself.
As we lose that fluid and weage, these, the spinal vertebrae
(11:07):
here, start to wear and tearand that's where we get the
arthritis.
This is looking down through thespinal column, as if I'm
looking at the top of your head,looking down at the spinal
column.
This is the spinous processthat we feel when we touch the
back of our neck or we push inthe middle of our spine.
(11:27):
Those are those pointy areasthat we feel.
This is the transverse process.
It is there to protect thenerve roots that come off the
spinal cord.
The center here, the materialin the middle, is the spinal
cord itself and these littlewings.
They actually go into the arms,into the ribs and down into the
(11:50):
legs.
Those represent the spinalnerve roots that come off the
spinal cord.
Now, the bony hole that is herethat allows the spinal cord to
go through, that is called thevertebral foramen and then this
is the vertebral body go through.
That is called the vertebralforamen, okay, and then this is
the vertebral body.
If we talk about degenerativediseases in the spine, this
(12:12):
picture shows a healthy, normaldisc okay.
Then as it ages or loses itsmoisture, we get the disc
degeneration.
Then we get more movement.
More movement means that thepressure can disrupt during
movement and cause the disc tobulge or come out of its normal
(12:38):
area.
The disc can protrude onto thenerve space and irritate the
nerve, and that's where we getradiculopathy.
This here depicts just thinningof the disc.
This is a herniated disc.
Each disc has layers and sothis is the outer layer that has
(13:01):
been punctured or torn and theinside material has come out.
And this can also happen whereit isn't more towards the back
and it can irritate the nerveroot.
And then down here at thebottom, as I showed before, is
where we start to get thearthritis buildup from the
(13:22):
degeneration Now I want to pointout specifically in this area
of the spine.
So this is the lumbosacraljunction, where the sacrum meets
the lumbar spine.
If we understand physics, thisparticular area is a fixed.
(13:44):
This particular area is a fixedlike it's fixed, so it doesn't
have a lot of movement.
So your first area of movement,whenever we bend and twist, is
going to be at this l5 s1 and aswe age, the first area that we
start to see degeneration is atthis L5-S1 disc.
(14:05):
So if I'm looking at an x-rayof a 24-25 year old and I know a
little bit about what they dofor a living I may start to see
wear and tear here at the L5-S1disc or here at the L4.
Depending on how your bodystructure is, this is purely
genetics.
You may notice that you havemore pressure, like the the
(14:27):
bending, twisting fulcrum typeof thing at the L4.
So when we see thatdegeneration and the L4, l5,
that is common that's commonlywhere we start to see
degenerative processes in thespine.
So let's say, for some reason Ihave a veteran that had an
injury.
It's a falling type injury andit wasn't like a plop, it was
(14:51):
more of like fell to the side,hurt his back.
I may see something differenthigher up in the lumbar spine.
I might see more arthriticchanges on one side versus the
other and not at the L4, l5 area.
So then that tells me, hey,something happened here, there
was an injury here and thex-rays or the MRIs are
(15:12):
consistent with that.
So knowing how a person agesnormally, you can appreciate the
difference between somebodygetting an injury that causes
changes that we typically don'tsee right.
Any questions so far.
Speaker 1 (15:30):
Okay.
Speaker 2 (15:37):
Diseases of the lumbar spine.
So last week we talked aboutradiculopathy and that's what
this picture shows.
Talked about radiculopathy andthat's what this picture shows.
This picture shows the entirenerve system that goes from the
brain down into the spinal cordand then at each area of the
vertebrae these nerve roots comeout, okay, even down into the
(15:58):
sacrum.
The sacrum has holes in it,you'll see that in the picture
and these nerve roots come downand they control our bowel and
bladder.
So whenever you go and you areseen in the urgent care for back
pain, they always ask aboutbowel and bladder control.
And this is because if there isa nerve or a spinal cord
(16:21):
compression, you start todevelop loss of bladder, loss of
bladder control, loss of bowelcontrol and you get what they
call saddle anesthesia.
So you can see here in thedermatomes.
These dermatomes are where thenerves control the skin.
So you can see here at S2, s3,and even down in this area that
(16:46):
if somebody's having saddleanesthesia sorry, this area you
can see their tush becausethat's the area that touches the
saddle.
If you're on a horseback, it'ssaddle anesthesia.
I have numbness and tingling inthat area and I can't feel this
.
I can't feel that I lost mybowels, I lost my bladder.
(17:07):
Those nerves in that areacontrol very important functions
and so when you go to theurgent care or the emergency
room and they're saying, okay,have you lost control of your
bowel and bladder?
And you say no, then that's agood sign.
If you say yes, that is whatthey call a red flag clinically.
So they have to get yousomewhere that you can have a
(17:29):
higher level of evaluation, orthey need to get you an MRI or
special testing, because theyhave to rule out that you do not
have a compression, an earthcompression, somewhere, causing
you to lose your bowel andbladder.
If that is not fixed orcorrected then you can have
permanent damage.
So that's red flags that weneed to get you to a higher
level of care.
Okay, so we've talked a lotabout the back, the lumbar spine
(17:56):
, the anatomy and the nerves andthere needs to be basic
understanding.
So then that way, as we talkabout this DBQ, you can really
appreciate each portion of thedbq.
So again, I said it's an hourto hour and a half.
Okay, it is face to face.
The first section always startsout about designating the
(18:18):
relationship between the veteranand the examiner, the evidence,
evidence review and thediagnosis.
We always talk about those.
Now for the evidence.
This is the same as it was forthe cervical spine.
You need a statement in supportof claim.
X-rays, mris, ct scans MRIs arepreferred.
(18:42):
Not every clinician looks attheir x-rays and their MRIs are
preferred.
Not every clinician looks attheir x-rays and their MRIs.
But those reports from theradiologist that go level by
level and tell us where thevertebrae or which vertebrae are
impacted, that's important.
If you've had a nerveconduction study, that's
important, and physical therapyrecords are also important.
Oops, a little too fast.
(19:07):
Now when I look at the DBQ here.
There are a lot of diagnoseshere and a veteran can have more
than one disease or conditionof the lumbar spine.
So they have degenerativearthritis, they can have
degenerative disc disease, theycan have lumbosacral strain.
(19:27):
Those different diagnoses don'tgive them a separate rating.
We see that differs from theknee.
So for the knee they can havearthritis, they can have a
meniscal injury and they canhave instability and they get
ratings for all three.
That is not the same as whathappens to the spine.
(19:50):
So when we write a nexus letterfor the spine we'll put all the
diagnoses that pertain to thatveteran's back and put them all
in there.
Because wearing tear of thespine is normally predictable
and progressing in the samemanner.
We normally start out withdegenerative disc disease.
(20:12):
Then we find bony changesbecause there's movement and
then those bony changes andthose discs start to creep upon
the nerve roots and they developradiculopathy.
That is the normal progressionwithout further accident or
injury.
So you can have an accident orinjury when you're in your 20s.
That can deteriorate.
(20:39):
That starts in their 20s andcan deteriorate over time.
But then we can also seebecause you now have these
degenerative changes you're moresusceptible to other injuries,
just like any other joint, andthen we start to see other
things develop and creep up asthe spine degenerates.
So I want you to understandthat just because you have 5
(21:00):
million diagnoses just for theback or related to the back,
doesn't necessarily mean you'regoing to get different ratings
for that Okay.
Now the other thing that youcan appreciate in this list on
the DBQ is that there's nothinghere that says radiculopathy.
Okay, the examiner has to plugin that you have a diagnosis of
radiculopathy.
(21:21):
Okay.
Section two discusses themedical history.
That's where she writes upeverything that you tell them.
Asks about flare-ups.
You should know what causes aflare-up.
When veterans report for theirexamination, I like to tell them
okay, so well, some attorneyslike to tell them to go on the
(21:43):
treadmill or go take a five-milewalk or go do something really
that physically exerts itself,and I'm like no, no, no, we're
not trying to cause a heartattack, we're not going to try
to cause any other issues,because we're trying to overwork
the veteran so they can go intothat CMP exam with a flare-up,
because the veteran shouldalways be considered on their
(22:06):
worst day, and that is hard tocreate the worst day when you
are preparing to go into a DBQor an exam.
So what I tell veterans is Isay what is it that triggers
your back pain?
Is it gardening?
Is it trying to weed?
(22:28):
Eat?
Whatever it is that triggersthat flare-up, go ahead and do
that a day or two before yourcmp exam because if you know
that causes a flare-up,typically that flare-up is not
going to recover or bounce backbefore like like.
It'll still be lingeringwhenever you go in for your
competent exam.
(22:48):
And so that way the examinercan see you and you can really
detail, when you're doing theserange of motion testing and
doing the exam, where the painstarts and what kind of things
bother you.
Okay all right.
(23:10):
So section three this is rangeof motion testing.
This is your forward flexionand your extension.
The va considers forwardflexion to be normal at 90
degrees and extension to benormal at 30 degrees.
Okay, this is normally where Ihave.
You know, I I have them standup and bend down and touch their
toes.
If they're unstable, I mighthave them hold a desk or hold a
chair so that way they don'tfall.
(23:31):
Depending on how well they canstand, I may or may not do the
range of motion testing, becauseif they're unstable, if they're
weak in their legs and it's afall risk, because if they're
unstable, if they're weak intheir legs and it's a fall risk,
then I will do my best toestimate or guesstimate what
their range of motion would be,based on the history that they
provide.
And that's acceptable for me todo that.
(23:56):
Lateral flexion Normally what Itell veterans to do is I'll have
them stand with their hands ateach side.
They will slide their hand downand try to touch the side of
their knee and I will capturethe lateral flexion and then I
will have them do the same thingon the other side.
Lateral flexion range of motion, according to the VA, is normal
(24:18):
at 30 degrees.
They're also supposed to becapturing rotation.
This is lumbar rotation.
This is where you're turning atthe waist and sometimes it can
be difficult to capture becausewe also turn at our head and so
we're not trying as examiners,we're not trying to capture the
(24:40):
range of motion at the neck butat the waist.
So some people or some examinershave the veteran put their
hands on their hips or up ontheir sides a little higher than
their hips, and then they'lltry to get them to rotate while
seated, because if you areseated, then you know that your
sacrum is not going to movebecause you're sitting on your,
(25:01):
your butt bone and your sacrumis fixed between the butt bone.
So they'll have them put theirhands basically on their fat
rolls because at least that'swhat I'm doing and I have them
rotate at the waist.
Okay, any questions about that?
Okay?
Speaker 1 (25:26):
all right, the comedy hour what'd you say?
Speaker 2 (25:34):
the comedy hour hey, I gotta make it lively somehow.
This is a lot of data overload,overstimulation.
So for the range of motion, thetakeaway is the examiner is
(25:55):
going to capture a lot ofnumbers.
They're going to do an initialrange of motion.
They're going to document atwhat degree the pain starts.
They're going to do an observedrepeated motion.
So they're going to have you dothe movement three times and
(26:17):
then capture that range ofmotion.
Then there's two parts wherethe examiner is supposed to use
their clinical skills thehistory that the VA provides,
the veteran provides, and theMRIs, the testing, all the other
objective reports discuss whatthey think the limitations would
(26:52):
be during a flare-up and withrepetitive use over time Using a
goniometer.
Of course yes, using thegoniometer.
The guesstimation part issomething that requires clinical
experience.
New practitioners probablycan't provide that.
But what that is is we'retrying to use our clinical
(27:13):
skills to say you know, whatkind of limitation does this
veteran have?
And in the past the VA didn'treally ask the examiner to think
much about that.
And in the past the VA didn'treally ask the examiner to think
much about that.
They didn't ask them to discusspain or where pain started in
range of motion.
When I did these DBQs 12, 13years ago, there was not a place
(27:38):
for me to document where theirpain started.
When I got into the privatesector and started doing these
DBQs as a private examiner and Ilearned from the agent's side
of things, I then started todocument in the comment section
where their pain would startwith each range of motion.
So I'm happy to see that 13 or14 years later they're finally
(28:04):
catching up to what it should be.
So they actually document fivepages.
So it's a lot.
Now the other part to this isthat these DBQs are not designed
for clinical thought process atall.
So when we do an examination,we inspect, we look with our
(28:29):
eyes, we try to find asymmetry,we try to look at movement and
then we push on the musclestructure, then we what we call
palpate Okay, and then we gointo special testing.
The VA has us do it allbackwards, so clinically it
takes longer.
If we go from the start tofinish, a seasoned examiner will
(28:51):
know what they need to do anddo it clinically in their head
and then free, write on a pieceof paper and then plug it back
into the DBQ later.
I don't know why they didn'task a clinical person to write
these DBQs, because that wouldonly make sense to me, because
it would make it moreexpeditious.
But they didn't.
(29:12):
So on page seven the examinergets to look at the veteran's
back and push on the veteran'sback and push on the veteran's
back and they're supposed todiscuss any muscle spasms which
we can feel when we touch, anytenderness.
That is appreciated when theveteran expresses that it hurts,
(29:34):
and they're also supposed to belooking for what we call
guarding.
Guarding can be involuntary,which means that the arthritis
is so bad that the muscles arejust doing what they can to
protect it, or it could bevoluntary, where the pain is so
bad, the veteran's locking upand is not wanting to move.
(29:56):
Okay, the examiner is alsosupposed to observe the veteran
walking sitting.
The examiner is also supposedto observe the veteran walking
sitting, standing and doingtheir normal movements,
transferring from sitting tostanding, standing, to climbing
up on the examination table, andthey're supposed to document
(30:21):
any abnormalities theyappreciate with that.
Any questions?
Speaker 1 (30:27):
All right.
Speaker 2 (30:28):
So the next several sections are for testing of the
nerves in the lower legs.
They're looking at theradiculopathy and trying to
understand the severity of theradiculopathy, but they break it
out up into several sections.
Now we've talked before thatwith the new way that they're
wanting to rate radiculopathy,they would essentially take out
(30:52):
all of these sections except forone.
So in order to understandradiculopathy, there's one, two,
three, four different sectionsand tests that the VA currently
wants us to use in order for theclinician to determine the
severity and location of theradiculopathy.
So the first one, the first onethat the examiner is supposed
(31:17):
to do, is to do strength testing.
They're supposed to assess theflexion of the hip, the knee and
the ankles and determine ifthey are normal, which is full
strength with resistance, andthat means it's a five out of
five.
The scale's highest you can gois a five, and if there's no
(31:38):
muscle movement consistent withparalysis, then that's a zero.
Okay, then the next section,section five, is the reflex exam
.
They're supposed to capture thereflexes at the knee and at the
heel.
Some use a reflex hammer.
(31:59):
I typically use the back of mystethoscope.
Once you do reflexes enough andyou get skillful at it, then
you can use other tools toelicit the reflexes.
Now, a normal reflex is a twoout of four or it's a two.
The way we document it is a twoplus Okay.
If there is hyperactivity,meaning that it's more extreme,
(32:22):
the reflex is more prominent.
That can indicate nerve rootirritation.
And if it's hypo responsive orhypoactive, then it can also
indicate nerve root irritation.
And so it doesn't.
It just varies person to person, it varies nerve by nerve.
There's no consistency to saylike everybody that has this
(32:45):
type of reflex response meansthis.
It's just hey, this isn't right, this isn't normal, we need to
investigate it further.
Section six looks at the sensoryexam which we've talked a
little bit about.
Now it is not typical forexaminers to test S2 and S3.
Okay, s2 and S3 is the sacralnerve 2 and sacral nerve 3.
(33:07):
So if they're doing that, we'dhave a problem.
However, the dermatomes, as youcan see here, t1 through S2,
well, s2 you can test with theback of the legs.
T1 and T2, we normally don'ttest those in the clinic because
we're not assessing forthoracic issues.
(33:30):
The thoracic spine is prettystable In the DBQ.
They don't ask about thethoracic spine and I've had this
.
I've had a veteran come in andsay well, I have arthritis in
the thoracic spine Because thereis very little movement.
(33:50):
Any abnormalities in thethoracic spine are typically not
from the cervical spine andlumbar spine.
It's typically something elsehas gone on, something with your
breathing, something withexternal trauma, but
degenerative wise, we're notgoing to see that in the
thoracic spine.
Now when you talk aboutosteoporosis, which is a
(34:13):
nutritional issue meaning you'renot eating the right like your
body is starting to pull thecalcium from the bones and those
bones weaken because you haveto have calcium in your
bloodstream for cardiac functionThen we see that compression
okay.
So for when we look at thesensory exam for the
thracolumbar DBQ, they only wantsensory testing in the lower
(34:39):
extremities and this is when anexaminer may take a tissue,
piece of toilet paper, cottonball and they'll wipe on the
different dermatomes and ask youto say yes or respond whenever
you feel them touch.
Speaker 1 (34:52):
Okay, what about scoliosis?
Speaker 2 (34:56):
One thing that is different and unique for the
lumbar spine is what we callstraight leg testing is what we
call straight leg testing,straight leg testing.
The idea is is that we arestretching that sciatic nerve or
one of the nerves that is veryprominent in the leg.
Let me go back to it because Iknow you guys will appreciate
(35:16):
the nerve.
Okay, so this is the sciaticnerve.
These nerves come together,they create the sciatic nerve.
It comes under your butt andcomes down into the leg.
Okay, if we do clinically, if welift the leg and you start to
experience pain associated withthat nerve or sensations
(35:40):
associated with that nerve, thenwe can suspect that there's
some type of radiculopathy goingon, depending on the history.
Now, the other thing that canhappen is, because of where the
sciatic nerve lies, there can bemuscle irritation that
irritates that nerve, giving asimilar symptom to radiculopathy
(36:01):
.
So the examiner kind of needsall of these different tests to
put together exactly what iscausing the problem and how
severe the radiculopathy is.
So we can't just base one umone particular test to
(36:24):
understand radiculopathy.
Okay, all right, any questionsabout that?
Speaker 1 (36:38):
No, okay, the only question I had was about
scoliosis.
Speaker 2 (36:48):
The thoracic spine.
Speaker 1 (36:53):
So what's your question about the scoliosis?
Well, you know he's talkingabout issues with the thoracic
spine.
I mean, scoliosis is probablythe most common problem with the
thoracic spine.
Speaker 2 (37:02):
Yeah, so we can see scoliosis in a couple of ways.
Now, scoliosis is most commonlydevelopmental, but as we age,
degenerative arthritis orchronic inflammation can play a
role in developing scoliosis.
(37:24):
Normally it's not to theseverity that we see with the
developmental issue because ofthe rapid growth in pediatrics,
where the scoliosis in olderindividuals develop because of
degeneration, not that buildupor growth.
It's more of the reverseprocess, but it's the discs have
(37:44):
lost their moisture, so there'smore movement than they're
starting to get the abnormalpressures and it's similar to
ankylosing spondylitis that candevelop and we've talked a
little bit about that last weekand I'll talk about that today.
Thoracic spine issues we seekyphosis, and kyphosis is where
(38:06):
we get that exaggerated humpthat can be from bone changes,
chronic lung disease such asCOPD.
Copd changes the way themuscles control the rib cage and
can actually get what they calla barrel chest, and so instead
of this beautiful oval-shapedchest you get a round,
(38:29):
barrel-shaped chest, and thatcan affect the spine as well.
So is that what you weremeaning?
Speaker 1 (38:36):
Yeah, that's the thing about some folks.
They've got issues like, say,shoulder elevation, diaphragm
paralysis and things like that,where your diaphragm is
paralyzed and it doesn't retractup and down, your shoulder
automatically elevates up,probably a couple inches higher
than the other shoulder In thatprocess.
It actually curves the spine inthe process.
Speaker 2 (38:59):
I should prepare every DBQ with you in mind,
because you are such an atypicalsituation.
We don't see that a lot, butyes, you're absolutely right.
Anything interfering with thediaphragm or the normal lung
function we can see changes inthe thoracic spine.
(39:22):
Same with asthma.
If you have especially childrenthat have chronic asthma issues
and if they're born withrespiratory issues the pediatric
respiratory issues you can seechanges in thoracic spine as
well.
Speaker 3 (39:41):
Bethany, let me ask a question with you saying that,
talking about the lungs, let'stake some of these veterans.
I had one call me last weekthat was around the burn pits
and now he's saying his back isbothering him and his lower back
.
Can chemical exposures whetheror not it be from the lungs, jet
(40:03):
fuel, some of the fire spraysand things that we know that
cause lung problems Can thosealso affect the spine eventually
, over years?
Speaker 2 (40:19):
So clinically, I have not seen toxic chemicals or
burn pits affect the lumbarspine.
What I have seen is those withchronic lung diseases that are
not controlled, such as COPD oruncontrolled asthma.
What I have seen is thatthey're more likely to have what
(40:42):
we call idiopathic compressionfractures of the vertebrae.
Those who have COPD or asthmadon't necessarily get good
oxygen exchange and nutritionexchange, so the body starts to
pull nutrients from the bone andthe bone marrow.
So the bone recovery is not asthe bone structure Like.
(41:08):
Once those elements are takenout, the bone doesn't rebuild
itself very well and so that'swhere we get the vertebrae start
to compress.
Let me go this way thosevertebrae compress and then they
go in and they do what theycall kyphoplasty.
They'll stick cement in thereand stabilize it so it doesn't
compress further.
Because if you have acompletely flattened bone, you
(41:30):
can only imagine what that doesto the nerve roots around it and
the discs around it.
It just creates problems andwe'll look at some x-rays that
show some of that buildup andthat effect.
So to answer your question is Ihave not seen toxic chemicals
directly affect lumbar issues.
We would have to look at it ona case-by-case basis to really
(41:55):
rule out all these other causesbefore we would jump to toxicity
in the lumbar location.
If we know an individual hasburn pit exposure they have
small, like the bronchiolitisand other chronic lung issues in
the lungs from burn pits thenwe may be able to connect
osteoporosis or kyphosis or theidiopathic compression fractures
(42:20):
in the thoracic spine in thethoracic spine.
Again, lung issues, thoracicspine go hand in hand more than
lung issues and lumbar issues.
Speaker 1 (42:31):
Mm-hmm Right, Ask him if he was one of the loaded to
burn pictures, the junk to burn.
Maybe he'd get it connectedthat way.
Speaker 3 (42:41):
Well, you know that was another question.
I mean, I had another gentlemana few weeks ago now and I was a
little leery in speaking withhim.
He was talking about his lowerback protruding disc military
(43:02):
and was assigned to a warehouse.
He was constantly picking up 50, 70, even 80 pound shells and
putting them on loading docksand putting them on some type of
a pallet to be loaded ontotrucks and I asked him.
I said didn't they have devicesto help you load that, okay, and
(43:26):
I said didn't they have devicesto help you load that Mm-hmm?
Okay, and he said no, they hadno devices and he was trying to
connect be okay to connect it ofdoing that for a couple of
years every day to whateventually caused the
deterioration of his spine andproblems that he was having now
(43:53):
and he had been out of themilitary.
Speaker 2 (43:53):
I'm going to say at least 30, 35 years.
So let me show you.
I know we're kind of jumpingaround on this, but I think it's
important that we tackle that.
Let me jump back to one ofthese pictures and I'll tell you
what I don't like about thatbending lifting, and I see this
a lot in roofers, or rooferswhatever, depending on what part
of the country you're from.
(44:15):
So what we see in those who do alot of that lifting from the
ground and coming up a lot ofweighted flexion and extension
is where this is supposed to bestable.
This vertebrae starts to shiftforward and so they call that
(44:38):
spondylolisthesis.
And it's not the disc, it'sactual bone.
So the bones start to shiftbecause this isn't moving, the
sacrum's not moving.
This is the weakest point inflexion and extension.
Depending on genetics it couldbe this one, but this one's
primarily, and so when this boneshifts there's no pulling that
(45:03):
back.
They have to go in and putscrews in and fix the sacrum and
this vertebrae so it doesn'tmove forward and completely
compress these nerve roots.
So you can see here if thiswhole bone pulls forward, this
nerve root is now crushed, pullsforward, this nerve root is now
(45:33):
crushed.
So when I see patients who havethis spondylolisthesis, I
question what kind of occupationdid you do?
What kind of work did you do?
And it's typically that lifting50, 60 pounds, shells or
roofing over time that can causeissues.
And what's terrible is whenpatients get this fixed they'll
still continue to work.
So then guess what happens.
(45:55):
The fulcrum changes.
So now they start to getmovement in the vertebrae above
it and then they have to gettheir fixation or their fix
extended and screws have to gothrough this one.
And then guess what happens ifthey continue to work?
Same thing, so it changes.
It's more physics at that pointfor understanding where the
(46:19):
main pressure for the spine is.
Speaker 1 (46:25):
The vulnerability.
Hold your body weight up.
That's under a lot of pressure.
It holds your body weight upbecause that part down.
Speaker 2 (46:31):
Especially, if not for lifting.
So this is where having goodabs would save your back.
Does that answer your question,ray?
Speaker 3 (46:46):
Yeah, it does.
It makes it very clear because,you know, I was kind of
thinking why it all of a suddenappeared so many years later.
But the way you just explainedit, it takes time for that to
develop over a period of time,over a period of time.
So it very could have startedfor those two years of lifting
(47:08):
that amount of weight daily, youknow, I'm going to guess at
least four to six hours a day.
Speaker 1 (47:16):
Great For your question about the shells he
lifts in.
Now all shells in the field arehand-handled.
We go into a pallet the 155s iswhat you're talking about
because that's the way to theshells and that was the most
commonly used shell.
In the closed environment, sayin the factories, or they reload
the shells.
They've got lifting plugs thatscrew on where the fuse goes in.
(47:39):
They can pick them.
They got chain hoists andthings like that to pick them up
, but in the field it's all byhand.
Speaker 2 (47:50):
Well, hopefully they have occupational or lifting
training, lift with your leg.
So this was just wrapping up onthe radiculopathy how they take
all those sections for theexaminer to determine the
severity of the radiculopathy.
So it's not just one thing welook at, especially in the
(48:11):
clinic, and then from here we'regoing to order our own MRIs or
CT scans, depending on what theyfeel is appropriate.
But in the CMP realm they don'thave that option.
So if you have those MRIs orEMGs, that further supports the
story or tells the story.
Supports the story or tells thestory.
So I'm going to jump to thenext section, which is about
(48:39):
ankylosis.
Now, last week we talked aboutthis how what happens is
inflammation around the discsand around the vertebrae start
to create rebuilding of bone.
That's actually what happens indegenerative arthritis.
We get inflammation in thatarea because of stressors.
Then the body starts to try torepair or lessen those stressors
(49:01):
on that area.
When ankylosing spondylitiscomes, there's a couple of
things that can cause it.
Spondylitis comes, there's acouple of things that can cause
it.
You can have infectious reasonsand that causes the cells to
turn over a lot quicker andthat's where you get the fusion
of the bones and the discs arepretty much gone.
You can also have it occur indegenerative arthritis.
(49:24):
I've seen a few of these Forreason why others develop
degenerative changes quickerthan others.
I don't know.
If we figure it out, I'm surewe'll make lots of money
somewhere, but it can alsohappen because of degeneration.
The other thing that I think isimportant and this applies to
(49:45):
both cervical and lumbar spineis when somebody gets a surgical
fixation, like they go in andthey get fused, or they get the
bars on the side and the screwsin the side, like we were
talking about with thespondylolisthesis, where those
vertebrae shift.
Okay, that can be anunfavorable or a favorable
(50:14):
spinal position and those needto be considered in the rating
schedule.
So if somebody has an extendedlumbar hardware, they should be
advocating for the ankylosisrating schedule and I actually
have a picture of one to showyou.
(50:36):
But they must.
The clinician the VA C&Pexaminer is not the person
that's going to go in and lookat the x-rays.
It's going to be your privateclinicians or your treating
clinicians that are going to seethese images.
So they need to document intheir private treatment records
or in the primary care recordsor specialist needs to document
(50:57):
that if they have an unfavorableor an unfavorable position of
their spinal being fixed ortheir spine being fixed, then it
has to come from somewhereoutside the CMP exam, because
the CMP examiners are nottrained to do this.
They're not trained to look atthe x-rays.
So and I'll explain that alittle bit better in a few
(51:21):
clinical application slides thisone I covered a little bit
already, but every diagnosis onthis falls underneath the
intervertebral disc syndrome, orIVDS.
Anybody that saw me at the VAfor CMP exams from 2011 to 2013,
nobody had IVDS.
Because I don't know what thatwas.
(51:42):
I didn't know what that was.
They didn't teach us what itwas.
This is old medicine.
I didn't know what it was.
Recently they defined it so,and I'm sure a lot of other CMP
examiners who are beingtransparent can say the same
thing.
Now this is where we get intothe x-rays.
Let me see here where we're inthe DBQ.
(52:08):
So let me actually jump to theDBQ.
We talked about IVDS.
Then the next session sectiontalks about assistive devices.
Those who have a severeradiculopathy can develop what
they call drop foot, that's whenthe ankle.
They're not able to pull theirtoes up and they have weakness
(52:28):
in that.
Sometimes they wear a plasticbrace called an AFO to help them
keep that foot up and have themambulate more regularly.
Drop foot is common.
As radiculopathy gets worse,then people even diabetic.
Even diabetic nerve damage canresult in AFOs.
(52:50):
Afo is a loss of use.
So if you're a veteran that hasa drop foot that has an AFO,
you need to be asking for SMCfor loss of use.
Okay, and that goes along.
(53:12):
The loss of use goes along.
Speaker 3 (53:13):
I could tell you all about that there you go.
Speaker 2 (53:18):
Section 8, excuse me, section 13 is exactly that.
It's talking about the loss ofuse and that SMC consideration
there.
Then there's a section therefor other important findings.
Then section 15 looks atdiagnosis, excuse me, diagnostic
testing.
(53:39):
So MRIs are best and again,providers do not visually look
at the imaging, they depend onwhat the radiologist says Me
being outside in the civiliansector, I always look at my
x-rays.
So if we look at this x-ray,this is actually a good x-ray.
This is relatively healthy.
(53:59):
We have good disc space.
The alignment looks pretty good.
We have a little bit ofspurring here which we can see.
It's stressors, wear and tearof some sort.
But this looks like bones of ahealthy person.
This is a little bit ofinstability.
(54:19):
So this is actually what theycall a flexion x-ray and if in
the clinic we're worried aboutinstability of some of the
vertebrae, then we can ask thex-ray department to do flexion
and extension x-rays.
So you can see here what thisinstability does to this space
(54:42):
back here.
So it narrows it and this couldbe why the individual is having
some of the symptoms thatthey're having.
Okay, but I wouldn'tnecessarily call this a
spondylolisthesis.
But this is the same idea wherethe bone itself is actually
(55:02):
shifting forward.
Okay, okay, now this case thatI'm showing next.
I'll go fast because I knowwe're almost out of time here,
but this case is actually veryimportant.
This is somebody that I workedwith 10 plus years ago and this
is when I was in the civilianside and I was advocating for
(55:25):
this individual to get thehighest compensable rating ever,
and this is because of how theyare in an unfavorable position
of their spinal fusion.
This is absolutely terrible,terrible.
(55:55):
This is in my opinion and I'mnot a surgeon but I've never
seen anything like this in mylife.
I don't know why the surgeonwould do what they did, but when
it comes to medical malpractice, the standards are higher and
your time is limited.
In the state of Ohio, you haveone year from the date of
discovery to sue someone formedical malpractice.
Now this veteran kept going backto this surgeon and kept going
(56:18):
back to the surgeon and finallyshe's like I'm not getting any
better.
This lady was working at thepool, trying to work with the
back like this at the pool,trying to work with the back
like this.
If she falls and gets anymovement in this space
whatsoever, she's a dead woman.
So if the examiner doesn't lookat this x-ray, they're not
(56:46):
going to be able to appreciatethe degree and severity of this
spine.
This was bad.
Now I'm going to flip throughquickly just the rating schedule
, so that way it's in the video.
These are going to the redarrow there.
(57:10):
These two red arrows are goingto be your most common claims
and then, to finish up, the DBQ.
They ask for the functionalimpact and that should be in
your statement, open remarks andthen the examiner's
(57:32):
certification and signature.
I know that's a lot.
Any questions?
Speaker 1 (57:41):
Scrambled brain there for a few minutes.
I think you covered it well,yeah, and you covered it full
fully.
Yeah, and you covered it fullfully.
People listening if you watchthis and you see the information
like that, you've got issueswith your back and with your
spine itself.
You need to keep an eye on whatyou've got and what you've been
(58:02):
diagnosed with.
If you've got a spinal disease,just make sure that you get it
fixed as soon as you can,because that can lead to other
problems, especially walking,because every time you move it
slips.
Speaker 3 (58:18):
Well, if you put it off, thinking you're big and
strong and healthy, and it justhurts, you've got to be careful
because you're going to end upin a wheelchair or with, like
you said, loss of use of a footand have to wear an AFO.
So, yeah, pay attention to it.
Speaker 1 (58:37):
If you've got that issue.
I don't care if you're KingKong.
You have a slip like that andit's going to put you down.
Speaker 2 (58:44):
Generally speaking, when it comes from the clinical
side of things, I typicallyrecommend to put off spinal
surgery as long as you can.
However, in some cases youcan't, so you really need to get
a second opinion Always get asecond opinion when it comes to
spine surgeries and when itcomes to the spondylolisthesis,
(59:05):
where you have that shifting.
If you're a roofer or roofingand that's your occupation, you
need to find another one,because it's just going to get
worse and worse and eventuallyyou're not going to be able to
walk.
Speaker 1 (59:20):
Go to school, become an accountant, be a pressure
pusher, do something.
Stay off the roof.
Speaker 2 (59:26):
That heavy lifting and moving that back needs to go
away.
Speaker 1 (59:35):
Okay, well, we covered a whole lot of territory
tonight, I think.
We went up and down the WestCoast and back down and over to
Vegas and pulled a couple oflefties and went back to the
West Coast.
We covered a lot of it, a lotof roads, a lot of miles.
But now we've got to pick asubject for next time, then
we'll figure it out.
Speaker 2 (59:55):
I think I have one.
Speaker 1 (59:56):
Come on, buddy, okay.
Speaker 2 (59:58):
Chronic fatigue syndrome Appreciate it.
Speaker 1 (01:00:00):
Thank you, okay, chronic fatigue syndrome.
You heard the guy, so that'swhat we're going to do next time
.
Chronic fatigue syndrome.
That's something I need tocheck into too.
But with that, I want to thankBethany for coming on.
You can reach Bethany at she's.
She's just go to Valor.
That's Valor4Vetcom, that'sValor4, the number four vetcom.
(01:00:20):
And if you need help with anIMO or anything like that, just
go ahead and punch in theinformation.
She's got a portal and she'llpick you up and they'll be in
contact With that.
This is John, on behalf of MrRay Cobb and Beth Expanian-Burr.
(01:00:41):
We'll be setting off for now.
Bye, guys.
Popular Podcasts
New Heights with Jason & Travis Kelce
Football’s funniest family duo — Jason Kelce of the Philadelphia Eagles and Travis Kelce of the Kansas City Chiefs — team up to provide next-level access to life in the league as it unfolds. The two brothers and Super Bowl champions drop weekly insights about the weekly slate of games and share their INSIDE perspectives on trending NFL news and sports headlines. They also endlessly rag on each other as brothers do, chat the latest in pop culture and welcome some very popular and well-known friends to chat with them. Check out new episodes every Wednesday. Follow New Heights on the Wondery App, YouTube or wherever you get your podcasts. You can listen to new episodes early and ad-free, and get exclusive content on Wondery+. Join Wondery+ in the Wondery App, Apple Podcasts or Spotify. And join our new membership for a unique fan experience by going to the New Heights YouTube channel now!
The Breakfast Club
The World's Most Dangerous Morning Show, The Breakfast Club, With DJ Envy, Jess Hilarious, And Charlamagne Tha God!
Fudd Around And Find Out
UConn basketball star Azzi Fudd brings her championship swag to iHeart Women’s Sports with Fudd Around and Find Out, a weekly podcast that takes fans along for the ride as Azzi spends her final year of college trying to reclaim the National Championship and prepare to be a first round WNBA draft pick. Ever wonder what it’s like to be a world-class athlete in the public spotlight while still managing schoolwork, friendships and family time? It’s time to Fudd Around and Find Out!