West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-38 - Treatment Guidelines: Herniated Lumbar Disc

Current through Register Vol. XLI, No. 28, July 12, 2024
38.1. Injured workers under treatment by
				their own physician who fail to improve after two to four weeks - refer to a
				qualified orthopedic surgeon or neurosurgeon for consultation and/or treatment.
Herniations occur most commonly through a posterolateral
				  defect, but midline herniations may occur. Resulting compression of the spinal
				  nerve root causes inflammation and pain, usually along the anatomic course of
				  the nerve. In the lumbar spine, this most often occurs at the L4 and L5 disc
				  levels, causing pressure on the corresponding L5 and S1 nerve roots. As a
				  result of both mechanical and biochemical changes around the nerve root, the
				  injured worker will experience pain, paresthesia, and possibly weakness in the
				  leg or legs usually below the knee. The rare herniations at the L1, L2 and L3
				  levels are usually associated with pain, paresthesia, and weakness above the
				  knee. Back pain may or may not be a presenting complaint with any herniated
				  lumbar disc.
38.2. The
				appropriate diagnostic criteria consist of:
Back pain is usually the first symptom and may or may not
				  abate as the pain and paresthesias begin to radiate down the leg. The leg pain
				  is often described as a sharp, shooting pain that radiates along the anatomic
				  course of the nerve from proximal to distal. The onset may be sudden or
				  insidious. The injured worker often has difficulty getting up from sitting or
				  supine positions and commonly leans or lists to one side or the other. Motion
				  of the spine is limited due to pain and muscle spasm. The neurological
				  examination may be normal if the compressed nerve is still functional, or it
				  may yield objective evidence of impaired nerve function (e.g. atrophy,
				  weakness, sensory alteration or diminished reflex) depending upon the nerve
				  root affected. Signs of nerve root tension (e.g. positive straight leg raising)
				  may also be present.
When the L4 disc herniates, it usually causes pressure on
				  the L5 nerve root resulting in weakness of the great toe extensor or other
				  dorsiflexor muscles of the foot and sensory loss along the medial aspect of the
				  foot to the great toe, but it is usually not associated with reflex
				  abnormality. When the L5 disc herniates, it usually causes pressure on the S1
				  nerve root, resulting in a sensory deficit in the posterior calf area and
				  lateral aspect of the foot in addition to a diminished Achilles' reflex and
				  occasional weakness of the plantar flexors of the foot.
38.3. Diagnostic test and examination
				considerations are as follows:
a. Clinical
				diagnosis is supported by these studies:
1.
				Plain spine radiographs (and on rare occasions bone scans) to rule out other
				conditions such as tumor, infection, fracture and congenital anomalies, if not
				previously done;
2. MRI;
				and
3. Myelography with CT
				scans.