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Back conditions (lumbar/thoracolumbar spine) are rated under the General Rating Formula for Diseases and Injuries of the Spine at 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. This covers degenerative disc disease (DDD), strain, fractures, spondylolisthesis, stenosis, and intervertebral disc syndrome (IVDS).
Ratings are primarily based on range of motion (ROM), specifically forward flexion. Per M21-1, Part IV.ii.2.A, the RVSR must also consider functional loss due to pain, weakness, fatigability, and incoordination under the DeLuca factors (DeLuca v. Brown, 8 Vet. App. 202, 1995). Per Sharp v. Shulkin (2017), the examiner MUST estimate ROM during flare-ups. Per Correia v. McDonald (2017), the exam must include active, passive, and weight-bearing ROM testing.
Forward flexion greater than 60 degrees but not greater than 85 degrees; OR combined ROM greater than 120 degrees but not greater than 235 degrees; OR muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour.
Forward flexion greater than 30 degrees but not greater than 60 degrees; OR combined ROM not greater than 120 degrees; OR muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour.
Forward flexion of the thoracolumbar spine 30 degrees or less; OR favorable ankylosis of the entire thoracolumbar spine.
Unfavorable ankylosis of the entire thoracolumbar spine.
Unfavorable ankylosis of the entire spine.
Under 38 C.F.R. § 3.310 | Per M21-1, Part IV.ii.1.C