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How Do Doctors Assess The Level Of WPI For Spinal Injury Claims? | Garling & Co

Tuesday, June 13, 2017

If you have sustained an injury to your spine such as a neck or low back injury, then you are entitled to make a claim for lump sum compensation for permanent impairment.

To determine the amount of lump sum compensation payable for your spinal injury, you are referred to a medical specialist to assess the level of whole person impairment.

The level of whole person impairment is determined in accordance with the following: -

  1. The American Medical Association Guidelines for the Evaluation of Permanent Impairment (Edition 5) “AMA 5”.
  2. The NSW Workers Compensation Guidelines for the Evaluation of Permanent Impairment (April 2016) “The Guidelines”.

The Guidelines are produced by the State Insurance Regulatory Authority and they amend the AMA 5 Guides.

The Guidelines take precedence over AMA 5.

The Guidelines indicate that the doctor when assessing the level of permanent impairment of the spine, must use a diagnosis related estimate or DRE method.

The spinal injury assessment should include a comprehensive, accurate history, a review of all pertinent medical records available at the assessment, a comprehensive description of the individual’s current symptoms and their relationship to activities of daily living (ADL), careful and thorough physical examinations and all findings of relevant laboratory, imaging, diagnosis and axillary tests available at the assessment. Imaging findings that are used to support the impairment rating should be consistent with symptoms and findings on examination.

The DRE method is used for assessing permanent impairment in respect of the cervical spine region, thoracic spine region and lumbar spine region.

If for example there is an injury to the lumbar spine, then the doctor must choose the category of DRE impairment. The categories range from Category I to Category V.

In respect of lumbar and thoracic spine injury, the following whole person impairment’s apply in respect of each category:

  • DRE Category I – 0% whole person impairment
  • DRE Category II - 5-8% whole person impairment
  • DRE Category III - 15-18% whole person impairment
  • DRE Category IV - 20-23% whole person impairment
  • DRE Category V - 25-28% whole person impairment

In relation to the cervical spine, the impairment percentages are as follows:

  • DRE Category I – 0% whole person impairment
  • DRE Category II - 5-8% whole person impairment
  • DRE Category III - 15-18% whole person impairment
  • DRE Category IV - 25-28% whole person impairment
  • DRE Category V - 35-38% whole person impairment

The medical assessment must determine which category of DRE impairment an injury meets on the basis of the findings on examination. The doctors look for the following objective findings:

  • Muscle spasm
  • Muscle guarding
  • Asymmetry of spinal motion
  • Non-verifiable radicular pain
  • Absent reflexes
  • Atrophy
  • Weakness and loss of sensation
  • Radiculopathy
  • Alteration of motion segment integrity
  • Cauda equina syndrome

 

DRE CATEGORY I

You will be assessed as having a 0% whole person impairment if there are no significant clinical findings, no observed muscle guarding or spasm, no neurological impairment, no structural integrity and no other indication of spinal injury or fracture.

 

DRE CATEGORY II

You will be assessed in this category if on examination the doctor finds some muscle guarding or spasm, some asymmetric loss of range of motion, non-verifiable radicular complaints, or some non-verifiable radicular complaints or a fracture of the spine with 25% or less compression of the vertebral body.

 

DRE CATEGORY III

You are assessed as Category III if you have signs of radiculopathy, loss of relevant reflexes, loss of muscle strength or atrophy of the muscle, history of herniated discs with objective findings of radiculopathy or a fracture of between 20-50% of one of the vertebral bodies.

 

DRE CATEGORY IV

You are assessed in Category IV if you have loss of motion segment integrity, this usually occurs following a fusion or arthrodesis surgery. You may also be Category IV if you have a 50% compression of one vertebral body or greater.

 

DRE CATEGORY V

You will be assessed as DRE Category V if you meet both the criteria contained in Category III and Category IV or additionally a 50% compression of greater of one vertebral body with neurological compromise.

 

ADDITIONAL WHOLE PERSON IMPAIRMENT

In addition to the impairment allowable for each category, further impairment is added for the effects of surgery. Spinal surgery with no residual symptoms attract a further whole person impairment of between 1-3%. Spinal surgery with residual symptoms attract an additional whole person impairment of between 2-3%. Second operations can attract between a further 1-2% whole person impairment each.

Disc replacement surgery is the equivalent of a spinal fusion.

The implementation of a spinal cord stimulator or similar device does not attract any additional whole person impairment.

 

CONCLUSION

Spinal injuries are the most common types of injury. To obtain an assessment of greater than 10% for a spine injury only will require signs of radiculopathy such as sensory loss, loss of reflexes and loss of muscle strength or atrophy. These are objective findings found by the medical practitioner on examination.

Alternatively, a worker must have undergone a fusion or disc replacement surgery to qualify for the higher Category IV impairment to obtain a greater than 20% whole person impairment.

The level of whole person impairment is crucial in determining a worker’s ongoing entitlement to workers compensation.

Refer to our previous article on whole person impairment claims to find out what benefits you are entitled to receive depending on the level of whole person impairment assessed.

It is important therefore to obtain the highest whole person impairment possible for your spinal injury.

When and how to make a claim for whole person impairment is critical as you only have one chance to obtain lump sum compensation for whole person impairment and if you get it wrong, it can have serious consequences on your ongoing entitlements to workers compensation.

You need to speak to an accredited specialist in personal injury and an expert in workers compensation to obtain the highest possible whole person impairment for your spinal injury.

Please call Matthew Garling of Garling & Co Lawyers on (02) 8518 1120 or email Matthew at mgarling@garlingandco.com.au for further information.

GARLING & CO 2017

 

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