When Radiculopathy Appears in the Claim File
The claim is approximately six months old, the injured individual is 49 years old, 5’11”, 325 pounds. The presenting complaint was low back pain after a relatively routine lifting type of event. The initial physical examination noted tenderness to palpation in the lower lumbar region, straight leg raising is reported to be negative, there is no specific motor or sensory losses identified.
Up until the most recent clinical record, the complaints of pain were limited to the lower lumbar region. Now there is a complaint of pain into the lower extremity, and a diagnosis of radiculopathy has been assigned.
For many of my contemporaries who manage Workers’ Compensation files, the sudden appearance of this additional diagnosis raises concerns on a number of fronts. Multiple additional extensive testing, injection protocols, potential surgical interventions, and prolonged disability find themselves attached to this assessment.
Is the Diagnosis Supported by Objective Medical Evidence?
However, prior to this angst being pursued, the very first question that must be resolved is if there is, in fact, an objectively established diagnosis of radiculopathy. Is there appropriate medical documentation that supports the presence of this diagnosis, and is this particular pathology a function of the date of injury?
Radicular Pain Is Not the Same as Radiculopathy
One must understand that a verifiable radiculopathy is different from pain radiating in a radicular pattern. These two clinical states are not the same, and unfortunately too many clinicians, attorneys, and patients feel these terms are interchangeable. This is the first issue to be resolved.
By clinical definition, radiculopathy is a neurologic condition caused by an irritation of a nerve root or compression of a nerve root. A simple complaint of pain in the upper or lower extremity is a symptom and not the basis for a diagnosis. Symptoms do not establish a diagnosis of radiculopathy.
Objective Findings Must Support the Diagnosis
The clinical record should note the difference between separate subjective complaints and objective neurologic evidence. All too often we see complaints that are a function of an attempt to expand the extent of the compensable injury. The clinical record that is assigned to this diagnosis should include an exact description of the distribution of the pain complaints, notation of any dermatomal sensory loss, and what specific motor function losses are noted. The key element here is that these findings need to be in a specific nerve root distribution. An individual who has pathology at L2/L3 but symptoms in an L5 distribution does not have a verifiable radiculopathy that is a function of the identified event.
Add to this, the clinical examination should document reflex changes where the involved root has a testable reflex (L4 at the knee, S1 at the ankle). Additionally, if electrodiagnostic testing has been completed, and this testing is optional, the findings should correlate anatomically.
The Importance of Prior Clinical Examinations
Understanding this was the first assessment of the diagnosis, findings that come and go without explanation, or that do not match one nerve root, are a reason to question the diagnosis. If these specific physical examination findings are not consistent, there is a clear clinical indication to exclude this diagnosis as part of the compensable injury.
Imaging Findings Don’t Establish Causation
Speaking of inclusion into the compensable diagnoses, one must refer to prior clinical examinations subsequent to the date of injury and prior to the awarding of this particular diagnosis. If the previous records demonstrate normal strength, normal sensation, symmetric deep tendon reflexes, and particularly no neurologic deficits on examination, this would be an objective basis to exclude this particular assessment from the problem list. With this information, the foundation to support the diagnosis of radiculopathy can be weakened considerably.
However, in evaluating these low back pain complaints, an MRI was obtained, documenting disc bulges, protrusions, foraminal narrowing, and degenerative disc disease. As we all know, with age, specific body parts wear out. The findings noted are long-standing, pre-existing, and most probably unrelated comorbidities. If there is a radiculopathy secondary to these findings, without any objective evidence of aggravation (STIR/T2 weighted studies), this is clearly not a function of the compensable event.
Questions Every Claims Professional Should Ask
Each of these findings is common in asymptomatic adults[1]. As noted, imaging provides evidence of anatomy and, at times, pathology. However, it does not answer the critical causation questions. The presence of an imaging abnormality does not establish that the finding arose from the date of injury or that it explains the claimant’s symptoms. Those determinations require consideration of the injury mechanism, objective examination findings, the evolution of clinical assessments, and any intervening factors that may have led to the additional diagnosis.
Here is a checklist of questions you should ask:
- Were neurologic deficits documented?
- What objective findings support the diagnosis?
- Are symptoms consistent with a specific nerve root pattern?
- Does the mechanism of injury plausibly explain nerve root involvement?
- Are symptoms present immediately after injury or only months later?
- Are there significant pre-existing degenerative findings?
- Is the diagnosis based primarily on subjective complaints?
Establishing the Relationship to the Compensable Injury
To be clear, I am not saying that radiculopathy is not present; what I am saying is that it must be a function of the identified event. Moreover, there needs to be specific objective clinical data to support the presence of this diagnosis as a part of the compensable injury as opposed to an ordinary disease of life or degenerative process. One must not be afraid of this terminology, particularly when you have the basis to address this finding objectively and clinically to establish if it is related.
[1] Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology. 2015;36(4):811-816.
