La. Admin. Code tit. 40 § I-2005

Current through Register Vol. 50, No. 9, September 20, 2024

Section I-2005 - Initial Diagnostic Procedures

A. The OWCA 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 spine complaint, are listed below.

1. History-taking and physical examination (Hx and PE). These are generally accepted, well-established and widely used procedures that establish the foundation/basis for and dictate subsequent stages of diagnostic and therapeutic procedures. List of medications patient is taking should be included in every history, including over the counter medicines as well as supplements. 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.

a. History of Present Injury. A detailed history, taken in temporal proximity to the time of injury, should primarily guide evaluation and treatment. The history should include pertinent, positive and negative information regarding the following:

i. Mechanism of Injury. This includes details of symptom onset and progression. The mechanism of injury should include a detailed description of the incident and the position of the body before, during, and at the end of the incident. Inclusion of normal work body postures, frequency during the workday and lifting/push/pull requirements, should be included in the absence of a known specific incident;

ii. Location of pain, nature of symptoms, and alleviating/exacerbating factors (e.g. sleep positions). Of particular importance, is whether raising the arm over the head alleviates radicular-type symptoms. The history should include both the primary and secondary complaints (e.g., primary neck pain, secondary arm pain, headaches, and shoulder girdle complaints). The use of a patient completed pain drawing, such as Visual Analog Scale (VAS) is highly recommended, especially during the first two weeks following injury to assure that all work related symptoms are being addressed;

iii. presence and distribution of upper and/or lower extremity numbness, paresthesias, or weakness, especially if precipitated by coughing or sneezing;

iv. alteration of bowel, bladder, or sexual function; and for female patients, alteration in their menstrual cycle;

v. any treatment for current injury and result; and

vi. ability to perform job duties and activities of daily living.

b. Past history:

i. past medical history includes neoplasm, arthritis, and diabetes;

ii. review of systems includes symptoms of rheumatologic, neurologic, endocrine, neoplastic, infectious, and other systemic diseases;

iii. smoking history;

iv. vocational and recreational pursuits;

v. history of depression, anxiety, or other psychiatric illness.

vi. The examiner will screen for concurrent emotional disorders/conditions and, when possible, other known psychosocial predictors of poor outcome;

vii. prior occupational and non-occupational injuries to the same area including specific prior treatment, chronic or recurrent symptoms, and any functional limitations; specific history regarding prior motor vehicle accidents may be helpful.

c. Physical Examination should include accepted tests and exam techniques applicable to the area being examined, including:

i. general and visual inspection, including posture, stance, balance and gait;

ii. palpation of spinous processes, facets, and muscles noting myofacial tightness, tenderness, and trigger points;

iii. 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;

iv. examination of thoracic spine;

v. 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

vi. 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.

d. Relationship to Work: This includes a statement of the probability that the illness or injury is work-related. If further information is necessary to determine work relatedness, the physician should clearly state what additional diagnostic studies or job information is required.

e. Spinal 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:

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

ii. strength testing;

iii. anal sphincter tone and/or perianal sensation;

iv. presence of pathological reflexes of the upper and lower extremities; or

v. evidence of an Incomplete Spinal Cord Injury Syndrome:

(a). 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.

(b). 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.

(c). 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.

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

vi. Spinal cord lesions should 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

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

f. Soft 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. The Quebec Classification is used to categorize soft tissue and more severe cervical injuries.

i. Grade I - neck complaints of pain, stiffness, or tenderness only, without physical signs. Lesion not serious enough to cause muscle spasm. Includes whiplash injury, minor cervical sprains, or strains.

ii. Grade II - neck complaints with musculoskeletal signs, such as limited range-of-motion. Includes muscle spasm related to soft tissue injury, whiplash, cervical sprain, and cervicalgia with headaches, sprained cervical facet joints and ligaments.

iii. Grade III - neck complaints, such as limited range-of-motion, combined with neurologic signs. Includes whiplash, cervicobrachialgia, herniated disc, cervicalgia with headaches.

iv. Grade IV - neck complaints with fracture or dislocation.

2. Radiographic imaging of the cervical spine is a generally accepted, well-established and widely used diagnostic procedure. Basic views are the anteroposterior (AP), lateral, right, and left obliques, swimmer's, and odontoid. CT scans may be necessary to visualize C7 and odontoid in some patients. Lateral flexion and extension views are done to evaluate instability but may have a limited role in the acute setting. MRI or CT is indicated when spinal cord injury is suspected. The mechanism of injury and specific indications for the imaging should be listed on the request form to aid the radiologist and x-ray technician. Alert, non-intoxicated patients, who have isolated cervical complaints without palpable midline cervical tenderness, neurologic findings, or other acute or distracting injuries elsewhere in the body, may not require imaging. The following suggested indications are:

a. history of significant trauma, especially high impact motor vehicle accident, rollover, ejection, bicycle, or recreational vehicle collision or fall from height greater than one meter;

b. age over 65 years;

c. suspicion of fracture, dislocation, instability, or neurologic deficit - Quebec Classification Grade III and IV;

d. unexplained or persistent cervical pain for at least 6 weeks or pain that is worse with rest;

e. localized pain, fever, constitutional symptoms, suspected tumor, history of cancer, or suspected systemic illness such as a rheumatic/rheumatoid disorder or endocrinopathy;

f. 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. Laboratory 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:

a. complete blood count (CBC) with differential can detect infection, blood dyscrasias, and medication side effects;

b. 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;

c. serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can detect metabolic bone disease; and;

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

La. Admin. Code tit. 40, § I-2005

Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation Administration, LR 37:1632 (June 2011), amended by the Louisiana Workforce Commission, Office of Workers Compensation, LR 40:1120 (June 2014), Amended LR 49517 (3/1/2023).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.