Wednesday, August 29, 2012

My back condition prevents me from working: Can I get SSD benefits?

Studies have shown that 8 out of 10 Americans will experience back pain at some point in their lives. For most people, such pain can be treated with a massage, a trip to the chiropractor, physical therapy, or anti-inflammatory medicine. For some, however, back pain could be a sign of serious conditions, which can eventually lead to significant disability. In fact, some people are so disabled by back problems that they are no longer able to work. These people often face financial hardships and apply for Social Security Disability (SSD) benefits only to be rejected because their conditions do not meet the specific medical criteria necessary to receive SSD benefits. In this post, I will review some of the specific back conditions eligible for SSD benefits.

Medical Listing
Claimants can be found eligible for SSD benefits if they can demonstrate that their medical condition meets all the requirements of a medical listing. This listing is a very detailed comprehensive description of the exact criteria that must be met to qualify a specific condition for SSD consideration. All of this information can be quickly and easily found on the SSA.GOV website. The problem, however, is that the criteria provided is heavily laden with medical terminology, making it nearly impossible for lay people to understand. It took me many days with a medical dictionary and discussions with physician friends and colleagues to get a clear understanding of this very technical terminology. I will try to explain the criteria for a medical listing for a back condition without resorting to all of this medical language to the extent that is possible.
It is important to note that a person can be found eligible for SSD benefits even if their condition does not meet a medical listing.  I will discuss this further in another post.  This post will focus on getting SSD benefits for a back condition based on meeting a medical listing.

Back Conditions Specifically Recognized by the SSA
In describing the medical listing for back problems on its website, the SSA lists several specific conditions that it recognizes. These are important to understand:

1. Herniated Nucleus Palposus: This is what in lay language is called a slipped disk. The spine is composed of interlocking bones (vertebrae) spaced apart by softer cushions called discs. These discs are made of a hard outer surface called the annulus fibrosis which surrounds a soft central component called the nucleus palposus. Occasionally, the outer covering gets worn down allowing the nucleus palposus to bulge out from the spine. Sometimes the nucleus palposus can bulge out so far as to “herniate” or fall onto the nerves of the spinal cord which travel right behind it. This pressure on the nerves can cause back pain, sciatica (pain travelling down one or both legs) as well as weakness or numbness of the legs. Depending on the location along the spinal cord, the damage to nerves can cause problems with walking, urinating, or having bowel movements.

2. Spinal Stenosis: The nerves of the spinal cord travel within a canal formed by the vertebrae of the spine. Sometimes this canal is too narrow (stenosis), placing pressure on the nerves. This narrowness could be something that you are born with or can be due to a variety of problems ranging from trauma to bone spurs. Regardless of the cause, the pressure on the nerves damages them, leading to symptoms similar to those of a herniated nucleus palposus.

3. Facet Arthritis: As I previously mentioned, the spinal cord travels in a canal created by the bones of the spine. At each level of the spinal cord, the two bones surrounding the cord to form the canal are kept together by small joints called facet joints. These joints allow for movement of the spine. As a result, they can face some significant wear and tear leading to arthritis. When the arthritis is mild or moderate, it can cause back pain and stiffness. When it is severe, facet arthritis can create swelling of the area, which puts pressure on the nerves and causes nerve damage and the associated symptoms I previously mentioned.

4. Degenerative Disc Disease: As I mentioned previously, the vertebrae of the spine are cushioned by discs that sit between them. These discs provide padding so the bones don’t rub against each other during movement. With time and use, these disks wear down, allowing the vertebrae to rub against each other. This rubbing can cause severe pain particularly with sitting, twisting, or bending.

5. Osteoarthritis: Osteoarthritis, and specifically Spinal Arthritis, is the generic term for the Facet Arthritis described above.

6. Vertebral Fracture: Like an arm or leg, the bones of the spinal column can also break due to trauma. Such breaks or fractures can cause significant pain. Occasionally the fracture can also cause damage to the nerves of the spinal cord with the associated symptoms I previously mentioned.

7. Spinal Arachnoiditis: No, this has nothing to do with spiders. The Arachnoid Mater is a covering of the brain and the spinal cord. Sometimes this covering can get inflamed due to chemicals, infections, trauma, chronic compression, or surgery. This inflammation, called Arachnoiditis, can subsequently lead to the formation of scar tissue, which can make the nerves of the spinal cord stick together and get damaged. Symptoms caused by this condition include pain and tingling of the legs, trouble controlling the legs, pain with sitting, and, depending on the location of the injury, trouble with urination or bowel movements.

Criteria For Eligibility for SSD by meeting a medical listing
Simply being diagnosed with one of the above conditions is not enough to meet a medical listing for SSD. In order to meet a medical listing, claimants with one of these spinal conditions must also demonstrate that the condition led to impairment of a nerve or the spinal cord in ONE of the following scenarios
1. Compression of a spinal nerve (through slipped disk, facet arthritis, vertebral fracture, degenerative disk disease etc.) as demonstrated by ALL of the following:

a. Neuroanatomic distribution of pain: every nerve of the spinal cord is responsible for making specific muscles move and for making specific areas of the body “feel.” As a result, doctors can often determine which spinal nerve is injured based on which muscles are not working and which parts of the body are numb. In order to meet a medical listing, the SSA requires that the area of pain and weakness described by the claimant should correspond to the expected neuroanatomic distribution of a damaged nerve or nerves as seen on an imaging test(MRI, etc.).

b. Limitation of motion of the spine: pain or stiffness of the back which significantly limits a claimant from bending or twisting .

c. Motor Loss: As I mentioned before, each nerve of the spinal cord is responsible for specific muscles. When the nerve is damaged, doctors often see a decrease in size (atrophy) and weakness of the muscles corresponding to that nerve. To meet a medical listing, a claimant should demonstrate weakness and atrophy of the muscles corresponding to damaged spinal nerve as seen on imaging tests.

d. Sensory Loss: Each nerve of the spinal cord also provides sensation, which is the ability to feel something. With nerve damage, this ability to feel the corresponding parts of the body is also decreased. Again, the area of decreased sensation documented for a claimant needs to match an appropriate nerve seen to be damaged on an imaging test.

e. Loss of reflexes: The health of certain nerves of the spinal cord is also determined by a test of reflexes. This is the test performed by doctors when they hit your knee with a hammer and look for your leg to jump. Some areas of damage to the spinal cord can cause these reflexes to either be more or less noticeable. As always, such changes in reflexes need to correspond to the appropriate damaged spinal nerve as evidenced through imaging.

f. Positive straight leg raising test: This criteria applies only for those claimants with lower back problems. This test is performed with the claimant lying down and sitting up. The doctor lifts each leg with the knee straight. If pain shooting down the raised leg occurs during this procedure, the test is considered positive , signaling a significant back problem.

2. Spinal Arachnoiditis: As I describe above, this condition is an inflammation of the covering of the spinal cord. In order to meet a medical listing for SSD, spinal arachnoiditis needs to be clearly documented in the claimant’s medical record through at least ONE of the following:
a. Operative Report: Documentation of the condition in an operative report in which a surgeon performing back surgery on the claimant clearly states that evidence of spinal arachnioiditis was seen once the spinal cord was visualized during the surgery

b. Pathology Report: Verification on a pathology report that spinal arachnoiditis was found during a biopsy of the spinal cord.

c. Imaging: The presence of spinal arachnoiditis needs to be demonstrated on a medically appropriate imaging test like and MRI.
In addition to the documentation of the presence of the condition in the medical record, the claimant must also demonstrate that spinal arachnoiditis causes:
a. Dyesthesia: This is an abnormal sensation that feels like burning under the skin which subsequently causes the claimant to need a

b. Repeated Change of Posture or Position: The burning sensation caused by spinal arachnoiditis can often cause people with the condition to constantly change their position so as to avoid it. For the purpose of a medical listing, the claimant needs to demonstrate that he needs to change position at least every 2 hours due to this burning sensation caused by the condition.


3. Lumbar Spinal Stenosis: As I mentioned previously, spinal stenosis is a condition which causes compression of the nerves of the spinal cord due to the fact that the bony canal in which the spinal cord travels is too narrow. To meet a medical listing, claimants with spinal stenosis need to demonstrate the following:
a. Verification of the condition with appropriate medical imaging

b. Pseudoclaudication: This is a constellation of symptoms caused by spinal stenosis which includes weakness as well as chronic pain that does NOT follow the distribution of a single particular nerve or group of nerves but, rather, is diffuse. In order to meet a medical listing, a claimant must demonstrate that the pseudoclaudication from the spinal stenosis subsequently causes an

c. Inability to ambulate: The SSA has a specific definition for this: Inability to ambulate effectively means an extreme limitation of the ability to walk; i.e., an impairment(s) that interferes very seriously with the individual's ability to independently initiate, sustain, or complete activities. Ineffective ambulation is defined generally as having insufficient lower extremity functioning to permit independent ambulation without the use of a hand-held assistive device(s) that limits the functioning of both upper extremities. Basically, the SSA is saying that to meet the medical listing for spinal stenosis, a claimant must demonstrate that the condition prevents him or her from walking without the aid of a walker. The SSA then goes on to elaborate:  Therefore, examples of ineffective ambulation include, but are not limited to, the inability to walk without the use of a walker, two crutches or two canes, the inability to walk a block at a reasonable pace on rough or uneven surfaces, the inability to use standard public transportation, the inability to carry out routine ambulatory activities, such as shopping and banking, and the inability to climb a few steps at a reasonable pace with the use of a single hand rail. The ability to walk independently about one's home without the use of assistive devices does not, in and of itself, constitute effective ambulation.  Hence, the claimant must demonstrate that the spinal stenosis completely prevents him or her from getting around independently.
A Few Words On Documentation

As you can see, the criteria for a medical listing for back disorders are quite extensive and detailed. In my practice however, I have noticed that most people get denied a medical listing for back problems not because they do not meet the criteria but, rather, because their medical records are not adequate. All of the specific details I mentioned in the above criteria for medical listing need to be present in the medical records. For example, it is not enough to present documentation of a doctor’s visit in which the doctor states that the claimant complains of back pain. Rather, a detailed physical exam must be included which demonstrates the appropriate objective findings I previously mentioned like numbness, weakness, atrophy, positive leg raises, etc. In addition, particularly for back disorders, reports of appropriate imaging tests (like MRI) in the claimant’s medical record are crucial. It is so disappointing to see someone disabled from a back disorder be denied SSD benefits or need to go through an extensive appeals or reapplication process because of a lack of medical records. Understanding the criteria for a medical listing and appropriately presenting this criteria through extensive and appropriate medical records can be the difference between winning and losing an SSD claim for a back disorder.

This is NOT legal advice.  This blog provides general information about Social Security Disability cases.  To discuss your particular circumstances and claim, please contact a lawyer in your area.

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