Speaker 1: 0:01

Okay, welcome, folks, to another episode of J Bassett's Exposed Vet Productions on this beautiful balmy. Hot, I mean hot August 7, 2025. The year's going by like a rocket. It can't slow down. I don't know why. I've tried to slow it down but you get stuck in the jet wash, I guess, on it and it messes you up.

Speaker 1: 0:24

So today we're going to continue our series on disability at the DBQs and we're going to do the VA calls it the thoracolumbar spine, which basically is a combination of the thoracic spine and the lumbar spine. That's how they reach you. They reach up to the neck, then you've got the other two spinal are put into one, because it's basically the same joints, I guess. And we have no other person that knows this and they can do this besides one lady that knows how to do it, and it's Miss Bethany Spangenberg. Bethany is the principal of Valor Prevet. It's a company that does medical independent opinions and independent medical examinations in some cases, and she writes a very strong IMO and she 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 and she knows the law. So she's going to explain this today in a way that everybody can understand it. Bethany, how are you doing?

Speaker 2: 1:28

I'm doing great In a great place right now, Love the season we're in of life and the kids and we're doing great.

Speaker 1: 1:38

That's great. School started back, yet.

Speaker 2: 1:43

No, we've got one that starts back next week and then two that starts back in a couple weeks.

Speaker 1: 1:50

Okay.

Speaker 2: 1:54

I've got my oldest, my son. He's a soccer guy, he's a junior. This year he was asked to kick for football, so we've got soccer games and football games every week. And then my middle daughter. She's starting middle school and has volleyball. And then my youngest auditioned for a play and she's in play practice and she's going to be in Charlotte Webb.

Speaker 1: 2:27

So, we're running the kids around like crazy, you've got to make the costumes.

Speaker 3: 2:35

Bethany. Take time to enjoy it, because those years go by too quick. So take and cherish every minute of it.

Speaker 1: 2:44

Videotape that play Videotape it.

Speaker 2: 2:51

You know what's terrible is. I mean, it's not terrible, but Nova falls the weekend that they do the play and they do the play five different times, so I have to miss the first two days.

Speaker 1: 3:08

Of the play, or Nova.

Speaker 2: 3:10

Of the play In Nova. My feet are going to be running in and running out at the same pace. I'm just going to focus on getting home.

Speaker 1: 3:21

Where's the conference at this year?

Speaker 2: 3:24

Washington DC. Okay, home, Where's the conference at this year? Washington DC? I'm going to actually try, because my feedback in my headphone is pretty bad, so I'm going to take this off If I could kind of talk into the mic and have you guys still hear me.

Speaker 1: 3:41

We can hear you, you can hear me, okay. Yeah, just pick up just a little bit and go back. Let me see if I can get this to where I can hear you now. Okay, all right, go ahead.

Speaker 2: 4:10

Can you hear me? Okay, you're okay, you're good, okay, so are we ready to get started?

Speaker 1: 4:17

yes, go right ahead.

Speaker 2: 4:24

Go back to the headset, because what I'm doing is the last time. I couldn't share my presentation, so I want to be able to share it like a presentation Okay.

Speaker 2: 4:42

Okay, so while I get this turned over, so we're going to talk about the thoracolumbar and this is for the lower back. The DBQ is 14 pages, is 14 pages. It's about an hour to an hour and a half exam and it is a face-to-face exam. The one thing that I like to point out about this is that the thoracolumbar spine is not how we think of it clinically. This DBQ is purely designed for VA disability, so when veterans talk about their echolumbar spine, it's not how we talk about it in the clinic. So I want to talk a little bit about the anatomy so that you can have an understanding of what the examiners are looking at and what we think clinically. Okay, so here is a picture of the entire spine the cervical spine, the thoracic spine and the lumbar spine, then the sacrum and the coccyx.

Speaker 3: 6:01

So that's also your tailbone.

Speaker 2: 6:03

Now the VA likes to separate it out from the thoracic spine and the lumbar spine, but clinically we typically focus on the lumbar spine and the sacrum. Okay, that's because the nerve root involvement is more, uh, involved in the lumbar spine and the sacrum. There is very little movement in the thoracic spine so there's not a lot of diseases that occur in the thoracic spine. When you get older, the the thoracic spine can be crushed through osteoporosis and through aging. So whenever we look at the thoracic spine, the biggest issues that we see there is the vertebral bodies being crushed from osteoporosis or we see exaggerated curvature in the thoracic spine. Otherwise, the thoracic spine is stable, it is fixed and we don't really focus on the thoracic spine when we're in the clinic and we're active in life.

Speaker 2: 7:13

So this is just a picture pulling out the thoracic spine and the lumbar spine which the VA wants us to consider. This is actually what we consider in the clinic and what causes most symptoms in our patients. This is actually what we consider in the clinic and what causes most symptoms in our patients and the thoracic spine I'm pointing out here. I have a picture here with how we see the rib cage. So this thoracic spine, this is kind of side-by-side comparison. We can see the cervical spine here, the thoracic spine here, which again we have these ribs here. Now the ribs and the muscles in between the ribs help to stabilize the thoracic spine.

Speaker 2: 7:53

So there's not a lot of movement here. Okay, the lumbar spine we can see here. This is the sacrum and this is the coccyx coccyx, so the sacrum. We talk a lot about the SI joints, so this is the sacroiliac joint, this is the ilium of the hip. Okay, so we call these the SI joints. These are not meant to move either, but in women or in pregnancy that you'll get some movement in those si joints and then if you have a leg length discrepancy you have one leg shorter than the other then sometimes you will get some shifting or movement in that si joint. Okay, but those si joints are not made to move. Now, if I go back, I want you to 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 from the back. Okay, so this sacrum has a very distinct shape and you can appreciate that here on this picture of the skeleton. Does that help to understand the anatomy and what we're looking at here? Does that help?

Speaker 1: 9:03

to understand the anatomy and what we're looking at here.

Speaker 2: 9:09

We showed this slide before. I will say that some of these slides are very much the same, but maybe this time I'll say something a little bit different, in a different way, a little bit clearer, so that you can have better understanding. Not all these slides are in the cervical spine, but these some are redundant, so you can appreciate the anatomy. So in this picture here we have the white, which is the vertebrae, the blue, which are the discs, and these are jelly-like discs, and then the red represents the spinal cord and the spinal nerve roots coming off of the spinal cord.

Speaker 3: 9:52

Okay.

Speaker 2: 9:53

This is a healthy spinal column. Okay, we can see there's sharp edges here. The disc is well-shaped and looks what I call juicy. Well shaped and looks what I call juicy. As these lose their moisture, it's usually with aging or degeneration or disease, so we like to see these nice and juicy. This is a spine with arthritis, so you can start to see some change in the shape around the disc and you can see the disc is not as full. So if we put them side by side now, the one thing to really appreciate or understand is that these discs, as they lose their moisture, they become more flexible and you can get more movement in that area. The more movement you have in a joint, the more likely you are to develop arthritis. So when it's young and healthy and these discs are firm and full of fluid, you have less movement around these joints and the spinal column can preserve itself. As we lose that fluid and we age, these, the spinal vertebrae here, start to wear and tear and that's where we get the arthritis.

Speaker 2: 11:13

This is looking down through the spinal column, as if I'm looking at the top of your head, looking down at the spinal column. This is the spinous process that we feel when we touch the back of our neck or we push in the middle of our spine. Those are those pointy areas that we feel. This is the transverse process. It is there to protect the nerve roots that come off the spinal cord. The center here, the material in the middle, is the spinal cord itself and these little wings. They actually go into the arms, into the ribs and down into the legs. Those represent the spinal nerve roots that come off the spinal cord. Now, the bony hole that is here that allows the spinal cord to go through, that is called the vertebral foramen and then this is the vertebral body go through. That is called the vertebral foramen, okay, and then this is the vertebral body.

Speaker 2: 12:08

If we talk about degenerative diseases in the spine, this picture shows a healthy, normal disc okay. Then as it ages or loses its moisture, we get the disc degeneration. Then we get more movement. More movement means that the pressure can disrupt during movement and cause the disc to bulge or come out of its normal area. The disc can protrude onto the nerve space and irritate the nerve, and that's where we get radiculopathy. This here depicts just thinning of the disc. This is a herniated disc. Each disc has layers and so this is the outer layer that has been punctured or torn and the inside material has come out. And this can also happen where it isn't more towards the back and it can irritate the nerve root. And then down here at the bottom, as I showed before, is where we start to get the arthritis buildup from the degeneration Now I want to point out specifically in this area of the spine.

Speaker 2: 13:31

So this is the lumbosacral junction, where the sacrum meets the lumbar spine. If we understand physics, this particular area is a fixed. This particular area is a fixed like 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 as we age, the first area that we start to see degeneration is at this L5-S1 disc. So if I'm looking at an x-ray of a 24-25 year old and I know a little bit about what they do for a living I may start to see wear and tear here at the L5-S1 disc or here at the L4. Depending on how your body structure is, this is purely genetics. You may notice that you have more pressure, like the the bending, twisting fulcrum type of thing at the L4. So when we see that degeneration and the L4, l5, that is common that's commonly where we start to see degenerative processes in the spine.

Speaker 2: 14:42

So let's say, for some reason I have a veteran that had an injury. It's a falling type injury and it wasn't like a plop, it was more of like fell to the side, hurt his back. I may see something different higher up in the lumbar spine. I might see more arthritic changes 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 the x-rays or the MRIs are consistent with that. So knowing how a person ages normally, you can appreciate the difference between somebody getting an injury that causes changes that we typically don't see right. Any questions so far.

Speaker 1: 15:30

Okay.

Speaker 2: 15:37

Diseases of the lumbar spine. So last week we talked about radiculopathy and that's what this picture shows. Talked about radiculopathy and that's what this picture shows. This picture shows the entire nerve system that goes from the brain down into the spinal cord and then at each area of the vertebrae these nerve roots come out, okay, even down into the sacrum. The sacrum has holes in it, you'll see that in the picture and these nerve roots come down and they control our bowel and bladder.

Speaker 2: 16:06

So whenever you go and you are seen in the urgent care for back pain, they always ask about bowel and bladder control. And this is because if there is a nerve or a spinal cord compression, you start to develop loss of bladder, loss of bladder control, loss of bowel control and you get what they call saddle anesthesia. So you can see here in the dermatomes. These dermatomes are where the nerves control the skin. So you can see here at S2, s3, and even down in this area that if somebody's having saddle anesthesia sorry, this area you can see their tush because that's the area that touches the saddle. If you're on a horseback, it's saddle anesthesia. I have numbness and tingling in that area and I can't feel this. I can't feel that I lost my bowels, I lost my bladder. Those nerves in that area control very important functions and so when you go to the urgent 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 a good sign. If you say yes, that is what they call a red flag clinically. So they have to get you somewhere that you can have a higher level of evaluation, or they need to get you an MRI or special testing, because they have to rule out that you do not have a compression, an earth compression, somewhere, causing you to lose your bowel and bladder. If that is not fixed or corrected then you can have permanent damage. So that's red flags that we need to get you to a higher level of care. Okay, so we've talked a lot about the back, the lumbar spine, the anatomy and the nerves and there needs to be basic understanding. So then that way, as we talk about this DBQ, you can really appreciate each portion of the dbq. So again, I said it's an hour to hour and a half. Okay, it is face to face.

Speaker 2: 18:14

The first section always starts out about designating the relationship between the veteran and the examiner, the evidence, evidence review and the diagnosis. We always talk about those. Now for the evidence. This is the same as it was for the cervical spine. You need a statement in support of claim. X-rays, mris, ct scans MRIs are preferred. Not every clinician looks at their x-rays and their MRIs are preferred. Not every clinician looks at their x-rays and their MRIs. But those reports from the radiologist that go level by level and tell us where the vertebrae or which vertebrae are impacted, that's important. If you've had a nerve conduction study, that's important, and physical therapy records are also important. Oops, a little too fast.

Speaker 2: 19:07

Now when I look at the DBQ here. There are a lot of diagnoses here and a veteran can have more than one disease or condition of the lumbar spine. So they have degenerative arthritis, they can have degenerative disc disease, they can have lumbosacral strain. Those different diagnoses don't give them a separate rating. We see that differs from the knee. So for the knee they can have arthritis, they can have a meniscal injury and they can have instability and they get ratings for all three. That is not the same as what happens to the spine. So when we write a nexus letter for the spine we'll put all the diagnoses that pertain to that veteran's back and put them all in there. Because wearing tear of the spine is normally predictable and progressing in the same manner. We normally start out with degenerative disc disease. Then we find bony changes because there's movement and then those bony changes and those discs start to creep upon the nerve roots and they develop radiculopathy. That is the normal progression without further accident or injury. So you can have an accident or injury when you're in your 20s. That can deteriorate. That starts in their 20s and can deteriorate over time. But then we can also see because you now have these degenerative changes you're more susceptible to other injuries, just like any other joint, and then we start to see other things develop and creep up as the spine degenerates. So I want you to understand that just because you have 5 million diagnoses just for the back or related to the back, doesn't necessarily mean you're going to get different ratings for that Okay. Now the other thing that you can appreciate in this list on the DBQ is that there's nothing here that says radiculopathy. Okay, the examiner has to plug in that you have a diagnosis of radiculopathy. Okay.

Speaker 2: 21:24

Section two discusses the medical history. That's where she writes up everything that you tell them. Asks about flare-ups. You should know what causes a flare-up.

Speaker 2: 21:35

When veterans report for their examination, I like to tell them okay, so well, some attorneys like to tell them to go on the treadmill or go take a five-mile walk or go do something really that physically exerts itself, and I'm like no, no, no, we're not trying to cause a heart attack, we're not going to try to cause any other issues, because we're trying to overwork the veteran so they can go into that CMP exam with a flare-up, because the veteran should always be considered on their worst day, and that is hard to create the worst day when you are preparing to go into a DBQ or an exam. So what I tell veterans is I say what is it that triggers your back pain? Is it gardening? Is it trying to weed?

Speaker 2: 22:28

Eat? Whatever it is that triggers that flare-up, go ahead and do that a day or two before your cmp exam because if you know that causes a flare-up, typically that flare-up is not going to recover or bounce back before like like. It'll still be lingering whenever you go in for your competent exam. And so that way the examiner can see you and you can really detail, when you're doing these range of motion testing and doing the exam, where the pain starts and what kind of things bother you.

Speaker 2: 22:58

Okay all right.

Speaker 2: 23:10

So section three this is range of motion testing. This is your forward flexion and your extension. The va considers forward flexion to be normal at 90 degrees and extension to be normal at 30 degrees. Okay, this is normally where I have. You know, I I have them stand up and bend down and touch their toes. If they're unstable, I might have them hold a desk or hold a chair so that way they don't fall. Depending on how well they can stand, I may or may not do the range of motion testing, because if they're unstable, if they're weak in their legs and it's a fall risk, because if they're unstable, if they're weak in their legs and it's a fall risk, then I will do my best to estimate or guesstimate what their range of motion would be, based on the history that they provide. And that's acceptable for me to do that.

Speaker 2: 23:56

Lateral flexion Normally what I tell veterans to do is I'll have them stand with their hands at each side. They will slide their hand down and try to touch the side of their knee and I will capture the lateral flexion and then I will have them do the same thing on the other side. Lateral flexion range of motion, according to the VA, is normal at 30 degrees. They're also supposed to be capturing rotation. This is lumbar rotation. This is where you're turning at the waist and sometimes it can be difficult to capture because we also turn at our head and so we're not trying as examiners, we're not trying to capture the range of motion at the neck but at the waist.

Speaker 2: 24:43

So some people or some examiners have the veteran put their hands on their hips or up on their sides a little higher than their hips, and then they'll try to get them to rotate while seated, because if you are seated, then you know that your sacrum is not going to move because you're sitting on your, your butt bone and your sacrum is fixed between the butt bone. So they'll have them put their hands basically on their fat rolls because at least that's what 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, the takeaway is the examiner is going to capture a lot of numbers. They're going to do an initial range of motion. They're going to document at what degree the pain starts. They're going to do an observed repeated motion. So they're going to have you do the movement three times and then capture that range of motion. Then there's two parts where the examiner is supposed to use their clinical skills the history that the VA provides, the veteran provides, and the MRIs, the testing, all the other objective reports discuss what they think the limitations would be during a flare-up and with repetitive use over time Using a goniometer.

Speaker 2: 26:54

Of course yes, using the goniometer. The guesstimation part is something that requires clinical experience. New practitioners probably can't provide that. But what that is is we're trying to use our clinical skills to say you know, what kind of limitation does this veteran have? And in the past the VA didn't really ask the examiner to think much about that. And in the past the VA didn't really ask the examiner to think much about that. They didn't ask them to discuss pain or where pain started in range of motion.

Speaker 2: 27:32

When I did these DBQs 12, 13 years ago, there was not a place for me to document where their pain started. When I got into the private sector and started doing these DBQs as a private examiner and I learned from the agent's side of things, I then started to document in the comment section where their pain would start with each range of motion. So I'm happy to see that 13 or 14 years later they're finally catching up to what it should be. So they actually document five pages. So it's a lot. Now the other part to this is that these DBQs are not designed for clinical thought process at all. So when we do an examination, we inspect, we look with our eyes, we try to find asymmetry, we try to look at movement and then we push on the muscle structure, then we what we call palpate Okay, and then we go into special testing. The VA has us do it all backwards, so clinically it takes longer. If we go from the start to finish, a seasoned examiner will know what they need to do and do it clinically in their head and then free, write on a piece of paper and then plug it back into the DBQ later. I don't know why they didn't ask a clinical person to write these DBQs, because that would only make sense to me, because it would make it more expeditious. But they didn't.

Speaker 2: 29:12

So on page seven the examiner gets to look at the veteran's back and push on the veteran's back and push on the veteran's back and they're supposed to discuss any muscle spasms which we can feel when we touch, any tenderness. That is appreciated when the veteran expresses that it hurts, and they're also supposed to be looking for what we call guarding. Guarding can be involuntary, which means that the arthritis is so bad that the muscles are just doing what they can to protect it, or it could be voluntary, where the pain is so bad, the veteran's locking up and is not wanting to move. Okay, the examiner is also supposed to observe the veteran walking sitting. The examiner is also supposed to observe the veteran walking sitting, standing and doing their normal movements, transferring from sitting to standing, standing, to climbing up on the examination table, and they're supposed to document any abnormalities they appreciate 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 the radiculopathy and trying to understand the severity of the radiculopathy, but they break it out up into several sections. Now we've talked before that with the new way that they're wanting to rate radiculopathy, they would essentially take out all of these sections except for one. So in order to understand radiculopathy, there's one, two, three, four different sections and tests that the VA currently wants us to use in order for the clinician to determine the severity and location of the radiculopathy. So the first one, the first one that the examiner is supposed to do, is to do strength testing. They're supposed to assess the flexion of the hip, the knee and the ankles and determine if they are normal, which is full strength with resistance, and that means it's a five out of five. The scale's highest you can go is a five, and if there's no muscle movement consistent with paralysis, then that's a zero. Okay, then the next section, section five, is the reflex exam. They're supposed to capture the reflexes at the knee and at the heel. Some use a reflex hammer. I typically use the back of my stethoscope. Once you do reflexes enough and you get skillful at it, then you can use other tools to elicit the reflexes. Now, a normal reflex is a two out of four or it's a two. The way we document it is a two plus Okay. If there is hyperactivity, meaning that it's more extreme, the reflex is more prominent. That can indicate nerve root irritation. And if it's hypo responsive or hypoactive, 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 say like everybody that has this type of reflex response means this. It's just hey, this isn't right, this isn't normal, we need to investigate it further.

Speaker 2: 32:52

Section six looks at the sensory exam which we've talked a little bit about. Now it is not typical for examiners to test S2 and S3. Okay, s2 and S3 is the sacral nerve 2 and sacral nerve 3. So if they're doing that, we'd have a problem. However, the dermatomes, as you can see here, t1 through S2, well, s2 you can test with the back of the legs. T1 and T2, we normally don't test those in the clinic because we're not assessing for thoracic issues.

Speaker 2: 33:30

The thoracic spine is pretty stable In the DBQ. They don't ask about the thoracic spine and I've had this. I've had a veteran come in and say well, I have arthritis in the thoracic spine Because there is very little movement. Any abnormalities in the thoracic spine are typically not from the cervical spine and lumbar spine. It's typically something else has gone on, something with your breathing, something with external trauma, but degenerative wise, we're not going to see that in the thoracic spine. Now when you talk about osteoporosis, which is a nutritional issue meaning you're not eating the right like your body is starting to pull the calcium from the bones and those bones weaken because you have to have calcium in your bloodstream for cardiac function Then we see that compression okay. So for when we look at the sensory exam for the thracolumbar DBQ, they only want sensory testing in the lower extremities and this is when an examiner may take a tissue, piece of toilet paper, cotton ball and they'll wipe on the different dermatomes and ask you to 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 call straight leg testing is what we call straight leg testing, straight leg testing. The idea is is that we are stretching that sciatic nerve or one of the nerves that is very prominent in the leg. Let me go back to it because I know you guys will appreciate the nerve. Okay, so this is the sciatic nerve. These nerves come together, they create the sciatic nerve. It comes under your butt and comes down into the leg.

Speaker 2: 35:26

Okay, if we do clinically, if we lift the leg and you start to experience pain associated with that nerve or sensations associated with that nerve, then we can suspect that there's some type of radiculopathy going on, depending on the history. Now, the other thing that can happen is, because of where the sciatic nerve lies, there can be muscle irritation that irritates that nerve, giving a similar symptom to radiculopathy. So the examiner kind of needs all of these different tests to put together exactly what is causing the problem and how severe the radiculopathy is. So we can't just base one um one particular test to understand radiculopathy. Okay, all right, any questions about 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 talking about issues with the thoracic spine. I mean, scoliosis is probably the 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 commonly developmental, but as we age, degenerative arthritis or chronic inflammation can play a role in developing scoliosis. Normally it's not to the severity that we see with the developmental issue because of the rapid growth in pediatrics, where the scoliosis in older individuals develop because of degeneration, not that buildup or growth. It's more of the reverse process, but it's the discs have lost their moisture, so there's more movement than they're starting to get the abnormal pressures and it's similar to ankylosing spondylitis that can develop and we've talked a little bit about that last week and I'll talk about that today. Thoracic spine issues we see kyphosis, and kyphosis is where we get that exaggerated hump that can be from bone changes, chronic lung disease such as COPD. Copd changes the way the muscles control the rib cage and can actually get what they call a barrel chest, and so instead of this beautiful oval-shaped chest you get a round, barrel-shaped chest, and that can affect the spine as well. So is that what you were meaning?

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 retract up and down, your shoulder automatically elevates up, probably a couple inches higher than the other shoulder In that process. It actually curves the spine in the process.

Speaker 2: 38:59

I should prepare every DBQ with you in mind, because you are such an atypical situation. We don't see that a lot, but yes, you're absolutely right. Anything interfering with the diaphragm or the normal lung function we can see changes in the thoracic spine. Same with asthma. If you have especially children that have chronic asthma issues and if they're born with respiratory issues the pediatric respiratory issues you can see changes in thoracic spine as well.

Speaker 3: 39:41

Bethany, let me ask a question with you saying that, talking about the lungs, let's take some of these veterans. I had one call me last week that was around the burn pits and now he's saying his back is bothering him and his lower back. Can chemical exposures whether or not it be from the lungs, jet fuel, some of the fire sprays and things that we know that cause lung problems Can those also affect the spine eventually, over years?

Speaker 2: 40:19

So clinically, I have not seen toxic chemicals or burn pits affect the lumbar spine. What I have seen is those with chronic lung diseases that are not controlled, such as COPD or uncontrolled asthma. What I have seen is that they're more likely to have what we call idiopathic compression fractures of the vertebrae. Those who have COPD or asthma don't necessarily get good oxygen exchange and nutrition exchange, so the body starts to pull nutrients from the bone and the bone marrow. So the bone recovery is not as the bone structure Like.

Speaker 2: 41:08

Once those elements are taken out, the bone doesn't rebuild itself very well and so that's where we get the vertebrae start to compress. Let me go this way those vertebrae compress and then they go in and they do what they call kyphoplasty. They'll stick cement in there and stabilize it so it doesn't compress further. Because if you have a completely flattened bone, you can only imagine what that does to the nerve roots around it and the discs around it. It just creates problems and we'll look at some x-rays that show some of that buildup and that effect.

Speaker 2: 41:42

So to answer your question is I have not seen toxic chemicals directly affect lumbar issues. We would have to look at it on a case-by-case basis to really rule out all these other causes before we would jump to toxicity in the lumbar location. If we know an individual has burn pit exposure they have small, like the bronchiolitis and other chronic lung issues in the lungs from burn pits then we may be able to connect osteoporosis or kyphosis or the idiopathic compression fractures in the thoracic spine in the thoracic spine. Again, lung issues, thoracic spine 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 connected that way.

Speaker 3: 42:41

Well, you know that was another question. I mean, I had another gentleman a few weeks ago now and I was a little leery in speaking with him. He was talking about his lower back protruding disc military and was assigned to a warehouse. He was constantly picking up 50, 70, even 80 pound shells and putting them on loading docks and putting them on some type of a pallet to be loaded onto trucks and I asked him.

Speaker 3: 43:21

I said didn't they have devices to help you load that, okay, and I said didn't they have devices to help you load that Mm-hmm? Okay, and he said no, they had no devices and he was trying to connect be okay to connect it of doing that for a couple of years every day to what eventually caused the deterioration of his spine and problems that he was having now and he had been out of the military.

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 jumping around on this, but I think it's important that we tackle that. Let me jump back to one of these pictures and I'll tell you what I don't like about that bending lifting, and I see this a lot in roofers, or roofers whatever, depending on what part of the country you're from.

Speaker 2: 44:15

So what we see in those who do a lot of that lifting from the ground and coming up a lot of weighted flexion and extension is where this is supposed to be stable. This vertebrae starts to shift forward and so they call that spondylolisthesis.

Speaker 2: 44:38

And it's not the disc, it's actual bone. So the bones start to shift because this isn't moving, the sacrum's not moving. This is the weakest point in flexion and extension. Depending on genetics it could be this one, but this one's primarily, and so when this bone shifts there's no pulling that back. They have to go in and put screws in and fix the sacrum and this vertebrae so it doesn't move forward and completely compress these nerve roots. So you can see here if this whole bone pulls forward, this nerve root is now crushed, pulls forward, this nerve root is now crushed.

Speaker 2: 45:33

So when I see patients who have this spondylolisthesis, I question what kind of occupation did you do? What kind of work did you do? And it's typically that lifting 50, 60 pounds, shells or roofing over time that can cause issues. And what's terrible is when patients get this fixed they'll still continue to work. So then guess what happens. The fulcrum changes. So now they start to get movement in the vertebrae above it and then they have to get their fixation or their fix extended and screws have to go through this one. And then guess what happens if they continue to work? Same thing, so it changes. It's more physics at that point for understanding where the 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 up because that part down.

Speaker 2: 46:31

Especially, if not for lifting. So this is where having good abs 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 sudden appeared so many years later. But the way you just explained it, it takes time for that to develop over a period of time, over a period of time. So it very could have started for those two years of lifting that amount of weight daily, you know, 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 are hand-handled. We go into a pallet the 155s is what you're talking about because that's the way to the shells and that was the most commonly used shell. In the closed environment, say in the factories, or they reload the shells. They've got lifting plugs that screw on where the fuse goes in. They can pick them. They got chain hoists and things like that to pick them up, but in the field it's all by hand.

Speaker 2: 47:50

Well, hopefully they have occupational or lifting training, lift with your leg. So this was just wrapping up on the radiculopathy how they take all those sections for the examiner to determine the severity of the radiculopathy. So it's not just one thing we look at, especially in the clinic, and then from here we're going to order our own MRIs or CT scans, depending on what they feel is appropriate. But in the CMP realm they don't have that option. So if you have those MRIs or EMGs, that further supports the story or tells the story. Supports the story or tells the story. So I'm going to jump to the next section, which is about ankylosis. Now, last week we talked about this how what happens is inflammation around the discs and around the vertebrae start to create rebuilding of bone. That's actually what happens in degenerative arthritis. We get inflammation in that area because of stressors. Then the body starts to try to repair or lessen those stressors on that area. When ankylosing spondylitis comes, there's a couple of things that can cause it. Spondylitis comes, there's a couple of things that can cause it. You can have infectious reasons and that causes the cells to turn over a lot quicker and that's where you get the fusion of the bones and the discs are pretty much gone. You can also have it occur in degenerative arthritis. I've seen a few of these For reason why others develop degenerative changes quicker than others. I don't know. If we figure it out, I'm sure we'll make lots of money somewhere, but it can also happen because of degeneration. The other thing that I think is important and this applies to both cervical and lumbar spine is when somebody gets a surgical fixation, like they go in and they get fused, or they get the bars on the side and the screws in the side, like we were talking about with the spondylolisthesis, where those vertebrae shift. Okay, that can be an unfavorable or a favorable spinal position and those need to be considered in the rating schedule. So if somebody has an extended lumbar hardware, they should be advocating for the ankylosis rating schedule and I actually have a picture of one to show you. But they must. The clinician the VA C&P examiner is not the person that's going to go in and look at the x-rays. It's going to be your private clinicians or your treating clinicians that are going to see these images. So they need to document in their private treatment records or in the primary care records or specialist needs to document that if they have an unfavorable or an unfavorable position of their spinal being fixed or their spine being fixed, then it has to come from somewhere outside the CMP exam, because the CMP examiners are not trained to do this. They're not trained to look at the x-rays. So and I'll explain that a little bit better in a few clinical application slides this one I covered a little bit already, but every diagnosis on this falls underneath the intervertebral disc syndrome, or IVDS. Anybody that saw me at the VA for CMP exams from 2011 to 2013, nobody had IVDS. Because I don't know what that was. I didn't know what that was. They didn't teach us what it was. 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 being transparent can say the same thing. Now this is where we get into the x-rays. Let me see here where we're in the DBQ. So let me actually jump to the DBQ. We talked about IVDS. Then the next session section talks about assistive devices.

Speaker 2: 52:18

Those who have a severe radiculopathy can develop what they call drop foot, that's when the ankle. They're not able to pull their toes up and they have weakness in that. Sometimes they wear a plastic brace called an AFO to help them keep that foot up and have them ambulate more regularly. Drop foot is common. As radiculopathy gets worse, then people even diabetic. Even diabetic nerve damage can result in AFOs. Afo is a loss of use. So if you're a veteran that has a drop foot that has an AFO, you need to be asking for SMC for loss of use. Okay, and that goes along. 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 of use and that SMC consideration there. Then there's a section there for other important findings. Then section 15 looks at diagnosis, excuse me, diagnostic testing. So MRIs are best and again, providers do not visually look at the imaging, they depend on what the radiologist says Me being outside in the civilian sector, I always look at my x-rays.

Speaker 2: 53:54

So if we look at this x-ray, this is actually a good x-ray. This is relatively healthy. We have good disc space. The alignment looks pretty good. We have a little bit of spurring here which we can see. It's stressors, wear and tear of some sort. But this looks like bones of a healthy person. This is a little bit of instability. So this is actually what they call a flexion x-ray and if in the clinic we're worried about instability of some of the vertebrae, then we can ask the x-ray department to do flexion and extension x-rays. So you can see here what this instability does to this space back here. So it narrows it and this could be why the individual is having some of the symptoms that they're having. Okay, but I wouldn't necessarily call this a spondylolisthesis. But this is the same idea where the bone itself is actually shifting forward.

Speaker 2: 55:04

Okay, okay, now this case that I'm showing next. I'll go fast because I know we're almost out of time here, but this case is actually very important. This is somebody that I worked with 10 plus years ago and this is when I was in the civilian side and I was advocating for this individual to get the highest compensable rating ever, and this is because of how they are in an unfavorable position of their spinal fusion. This is absolutely terrible, terrible. This is in my opinion and I'm not a surgeon but I've never seen anything like this in my life. I don't know why the surgeon would 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 have one year from the date of discovery to sue someone for medical malpractice.

Speaker 2: 56:14

Now this veteran kept going back to this surgeon and kept going back to the surgeon and finally she's like I'm not getting any better. This lady was working at the pool, trying to work with the back like this at the pool, trying to work with the back like this. If she falls and gets any movement in this space whatsoever, she's a dead woman. So if the examiner doesn't look at this x-ray, they're not going to be able to appreciate the degree and severity of this spine. This was bad. Now I'm going to flip through quickly just the rating schedule, so that way it's in the video. These are going to the red arrow there. These two red arrows are going to be your most common claims and then, to finish up, the DBQ. They ask for the functional impact and that should be in your statement, open remarks and then the examiner's certification and signature. I know that's a lot. Any questions?

Speaker 1: 57:41

Scrambled brain there for a few minutes.

Speaker 1: 57:43

I think you covered it well, yeah, and you covered it full fully. Yeah, and you covered it full fully. People listening if you watch this and you see the information like that, you've got issues with your back and with your spine itself. You need to keep an eye on what you've got and what you've been 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 just hurts, you've got to be careful because you're going to end up in a wheelchair or with, like you said, loss of use of a foot and 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 King Kong. You have a slip like that and it's going to put you down.

Speaker 2: 58:44

Generally speaking, when it comes from the clinical side of things, I typically recommend to put off spinal surgery as long as you can. However, in some cases you can't, so you really need to get a second opinion Always get a second opinion when it comes to spine surgeries and when it comes to the spondylolisthesis, where you have that shifting. If you're a roofer or roofing and that's your occupation, you need to find another one, because it's just going to get worse and worse and eventually you'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 West Coast and back down and over to Vegas and pulled a couple of lefties and went back to the West Coast. We covered a lot of it, a lot of roads, a lot of miles. But now we've got to pick a subject 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: 1:00:00

Thank you, okay, chronic fatigue syndrome. You heard the guy, so that's what we're going to do next time. Chronic fatigue syndrome. That's something I need to check into too. But with that, I want to thank Bethany for coming on. You can reach Bethany at she's. She's just go to Valor. That's Valor4Vetcom, that's Valor4, the number four vetcom. And if you need help with an IMO or anything like that, just go ahead and punch in the information. She's got a portal and she'll pick you up and they'll be in contact With that. This is John, on behalf of Mr Ray Cobb and Beth Expanian-Burr. We'll be setting off for now. Bye, guys.