Spinal fusion

Medical records showing measured range of motion are central to rating spinal fusion. A VA or private examiner should record forward flexion of the thoracolumbar spine and cervical spine in degrees, rounded to the nearest five degrees, as well as extension, lateral flexion, and lateral rotation so that combined range of motion can be calculated. These measurements are compared against normal values: normal thoracolumbar combined motion is 240 degrees and normal cervical combined motion is 340 degrees.

Records documenting muscle spasm, guarding, or localized tenderness help support a 10% or 20% rating, particularly if the examiner notes an abnormal gait or abnormal spinal contour such as scoliosis or abnormal kyphosis. For higher ratings, imaging or clinical findings that confirm ankylosis and describe whether it is favorable or unfavorable are important.

If unfavorable ankylosis is claimed, records should document functional consequences such as restricted jaw opening, difficulty walking due to limited line of vision, diaphragmatic breathing, or neurologic symptoms from nerve root stretching. Your own statements describing how pain, stiffness, or limited motion affect your work and daily activities can help show the real-world impact of your symptoms.