Reference: 38 CFR 4.71a

Back (Thoracolumbar Spine): Evidence & DBQ

What documentation clarifies the criteria

Primary sources:38 CFR 4.71a spine criteria and range-of-motion notesOfficial VA Back (Thoracolumbar Spine) DBQ

Evidence

Evidence that may clarify the published criteria

Back DBQ

Shows measured motion, repeated-use findings, flare-up context, guarding, spasm, gait, contour, ankylosis, neurologic findings, and other examination details in one structured record.

A DBQ is useful structured evidence, but RatingScope does not decide what evidence VA must accept.

Clinical examination notes

May document degree measurements, tenderness, spasm, guarding, gait, spinal contour, diagnosis, treatment, and neurologic observations.

A diagnosis or treatment history alone does not identify a percentage pathway.

Repeated-use and flare-up findings

May clarify whether pain, weakness, fatigability, or repeated movement adds documented functional loss or a different degree value.

RatingScope does not convert a symptom description into an unrecorded range-of-motion value.

Imaging reports

May clarify diagnosis, anatomy, fracture, degeneration, stenosis, or surgical changes.

MRI or X-ray severity does not by itself determine the General Rating Formula percentage.

Neurologic findings

May clarify radiating pain, numbness, weakness, reflex changes, or nerve involvement that should be understood separately from the back motion pathway.

A related neurologic finding is not automatically service connected or separately evaluated.

Personal descriptions of daily function

Can explain how bending, standing, walking, sitting, lifting, repeated use, or flare-ups affect daily activities.

Personal descriptions add context but do not replace clinical measurements required by a measurement-based criterion.

Official VA Forms & DBQs

Downloadable DBQs & Supporting Claim Forms

Take the public DBQ to your private physician or review it prior to your C&P examination.

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