19 Del. Admin. Code § 1342-F-3.0

Current through Register Vol. 27, No. 12, June 1, 2024

Section 1342-F-3.0 - Initial Diagnostic Procedures

The Division recommends the following diagnostic procedures be considered, at least initially, the responsibility of the workers' compensation carrier to ensure that an accurate diagnosis and treatment plan can be established. Standard procedures, that should be utilized when initially diagnosing a work-related Cervical pain complaint, are listed below.

3.1HISTORY-TAKING AND PHYSICAL EXAMINATION (Hx & PE) are generally accepted, well established and widely used procedures that establish the foundation/basis for and dictates subsequent stages of diagnostic and therapeutic procedures. When findings of clinical evaluations and those of other diagnostic procedures are not complementing each other, the objective clinical findings should have preference. The medical records should reasonably document the following.

3.1.1History of Present Injury A detailed history, taken in temporal proximity to the time of injury should primarily guide evaluation and treatment.

3.1.2Physical Examination: may include accepted tests and exam techniques applicable to the area being examined:

3.1.2.1 Visual inspection, including posture;

3.1.2.2 Cervical range-of-motion, quality of motion, and presence of muscle spasm. Motion evaluation of specific joints may be indicated. Range-of-motion should not be checked in acute trauma cases until fracture and instability have been ruled out on clinical examination, with or without radiographic evaluation;

3.1.2.3 Examination of thoracic spine

3.1.2.4 Palpation of spinous processes, facets, and muscles noting myofascial tightness, tenderness, and trigger points;

3.1.2.5 Motor and sensory examination of the upper muscle groups with specific nerve root focus, as well as sensation to light touch, pin prick, temperature, position and vibration. More than 2 cm difference in the circumferential measurements of the two upper extremities may indicate chronic muscle wasting; and

3.1.2.6 Deep tendon reflexes. Asymmetry may indicate pathology. Inverted reflexes (e.g. arm flexion or triceps tap) may indicate nerve root or spinal cord pathology at the tested level. Pathologic reflexes include wrist, clonus, grasp reflex, and Hoffman's sign.

3.1.3Spinal Cord Evaluation: In cases where the mechanism of injury, history, or clinical presentation suggests a possible severe injury, additional evaluation is indicated. A full neurological examination for possible spinal cord injury may include:

3.1.3.1 Sharp and light touch, deep pressure, temperature, and proprioceptive sensory function;

3.1.3.2 Strength testing;

3.1.3.3 Anal sphincter tone and/or perianal sensation;

3.1.3.4 Presence of pathological reflexes of the upper and lower extremities; or

3.1.3.5 Evidence of an Incomplete Spinal Cord Injury Syndrome-

3.1.3.5.1 Anterior Cord Syndrome is characterized by the loss of motor function and perception of pain and temperature below the level of the lesion with preservation of touch, vibration, and proprioception. This is typically seen after a significant compressive or flexion injury. Emergent CT or MRI is necessary to look for a possible reversible compressive lesion requiring immediate surgical intervention. The prognosis for recovery is the worst of the incomplete syndromes.

3.1.3.5.2 Brown-Sequard Syndrome is characterized by ipsilateral motor weakness and proprioceptive disturbance with contralateral alteration in pain and temperature perception below the level of the lesion. This is usually seen in cases of penetrating trauma or lateral mass fracture. Surgery is not specifically required, although debridement of the open wound may be.

3.1.3.5.3 Central Cord Syndrome is characterized by sensory and motor disturbance of all limbs, often upper extremity more than lower, and loss of bowel and bladder function with preservation of perianal sensation. This is typically seen in elderly patients with a rigid spine following hyperextension injuries. Surgery is not usually required.

3.1.3.5.4 Posterior Cord Syndrome, a rare condition, is characterized by loss of sensation below the level of the injury, but intact motor function.

3.1.3.6 Spinal cord lesions may be classified according to the American Spine Injury Association (ASIA) impairment scale.

ASIA IMPAIRMENT SCALE

A = Complete: No motor or sensory function is preserved in the sacral segments S4-S5

B = Incomplete: Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5

C = Incomplete: Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3

D = Incomplete: Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a grade of 3 or more

E = Normal: motor and sensory function are normal

A worksheet which details dermatomes and muscle testing required is available from ASIA.

3.1.4Soft Tissue Injury Evaluation: Soft tissue injuries are traumatic injuries to the muscles, ligaments, tendons, and/or connective tissue. The most common mechanism is sudden hyperextension and/or hyperflexion of the neck. Acceleration/deceleration on the lateral plane may also result in one of these syndromes. A true isolated cervical strain is not associated with focal neurological symptoms. The signs and pathophysiology of these injuries are not well understood. Soft tissue injuries may include cervical strain, myofascial syndromes, somatic dysfunction, and fractures.

3.2RADIOGRAPHIC IMAGING of the Cervical spine is a generally accepted, well-established and widely used diagnostic procedure when specific indications based on history and/or physical examination are present The mechanism of injury and specific indications for the radiograph should be listed on the request form to aid the radiologist and x-ray technician. Suggested indications may include:

3.2.1 History of trauma,

3.2.2 Age over 55 years;

3.2.3 Unexplained or persistent Cervical pain for at least 6 weeks or pain that is worse with rest;

3.2.4 Localized pain, fever, constitutional symptoms, or history or exam suggestive of intravenous drug abuse, prolonged steroid use, or osteomyelitis;

3.2.5 Suspected lesion in the Cervical spine due to systemic illness such as a rheumatic/rheumatoid disorder or endocrinopathy. Suspected lesions may require special views;

3.2.6 Past medical history suggestive of pre-existing spinal disease, osteoporosis, spinal instrumentation, or cancer; and

3.2.7 Prior to high-velocity/low amplitude manipulation or Grade IV to V mobilization.

3.3LABORATORY TESTING Laboratory tests are generally accepted, well-established and widely used procedures. They are, however, rarely indicated at the time of initial evaluation, unless there is suspicion of systemic illness, infection, neoplasia, or underlying rheumatologic disorder, connective tissue disorder, or based on history and/or physical examination. Laboratory tests can provide useful diagnostic information. Tests include, but are not limited to:

3.3.1 Complete blood count (CBC) with differential can detect infection, blood dyscrasias, and medication side effects;

3.3.2 Erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), antinuclear antigen (ANA), human leukocyte antigen (HLA), and C-reactive protein (CRP), can be used to detect evidence of a rheumatologic, infectious, or connective tissue disorder;

3.3.3 Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can detect metabolic bone disease;

3.3.4 Urinalysis for bacteria (usually with culture and sensitivity), calcium, phosphorus, hydroxyproline, or hematuria; and

3.3.5 Liver and kidney function may be performed for prolonged anti-inflammatory use or other medications requiring monitoring.

19 Del. Admin. Code § 1342-F-3.0

17 DE Reg. 322 (9/1/2013) (Final)