“Medical equivalence” and the effects of treatment and obesity may also result in Social Security disability.
Two added spinal disorders were among the changes to the Social Security musculoskeletal disability “Listings” which became effective February 2002. Arachnoiditis and pseudoclaudication, as defined and discussed in the Listings at 20 Code of Federal Regulations (CFR), Part 404, Subpart P, Appendix 1, 1.00 and 1.04, are now considered disabling for Social Security disability benefits purposes.
The Listings describe all medical conditions considered disabling as a matter of law. An individual who presents medical evidence that he or she suffers with a disorder which meets or medically equals the conditions described in the Listings is considered legally disabled and qualified to receive Social Security disability benefits.
Spinal arachnoiditis (Listing 1.04B) is characterized by adhesive thickening of the arachnoid membrane which may cause intermittent ill-defined burning pain and sensory dysesthesia. It also may cause neurogenic bladder or bowel incontinence when the cauda equina is involved.
While the cause is not always clear, there may be evidence of spinal stenosis or a history of spinal trauma or meningitis. Diagnosis must be confirmed by description at time of surgery, microscopic examination of biopsied tissue or findings on medically acceptable imaging.
To meet the Listing, arachnoiditis must be manifested by severe burning or painful dysesthesia, resulting in the need to change position or posture more than once every two hours.
Pseudoclaudication, also known as intermittent neurogenic claudication, involves entrapment of the nerves of the cauda equina due to enlarged facets, shortened pedicles, thickening of the yellow ligament (ligamentum flavum) and posterior arches producing sagittal narrowing.
The symptoms of pseudoclaudication are produced when the cauda equina is further compromised by walking and hyperextension. These symptoms include pain and weakness in the lower extremities when walking, relieved by rest. Patients describe neurologic symptoms such as numbness, coldness, burning, fatigue, incoordination or cramping or discomfort of the lower extremities.
Weakness is not common, although many complain of inability to walk due to pain. Pain is worsened by standing or walking short distances, relieved by rest. Urinary incontinence and other visceral disturbances may also occur.
Neurologic symptoms may occur on flexion or extension of the spine, but no pain occurs on straight leg raising. Physical examination should include evaluation of the curvature of the spine, with mobility and flexibility. Vascular examination is important to distinguish from vascular claudication. Unlike vascular claudication, in pseudoclaudication pulses will be present.
The best test is to observe whether the patient adopts a flexed position after standing or walking for a few minutes.
Sensory loss and weakness may be seen. Deep tendon reflexes may be decreased or absent. Weakness of dorsiflexion of the foot with disappearance of ankle jerk has also been found.
Although pseudoclaudication is determined largely through clinical history and physical examination, a definitive diagnosis will require imaging studies often showing hypertrophy of the lamina, pedicles, apophyseal joints with thickened ligamentum flavum and pinching of the posterior aspects of the lumbar canal.*
In summary, pseudoclaudication resulting from lumbar spinal stenosis (Listing 1.04C) must be established by findings on appropriate medically acceptable imaging. Also, it must be manifested by chronic non-radicular pain and weakness, resulting in an inability to ambulate effectively.
The Social Security code defines inability to ambulate effectively as extreme limitation of the ability to walk, interfering very seriously with an individual’s ability to initiate, sustain or complete activities independently. Such limitation to lower extremity functioning requires the use of handheld assistive devices (walker, two crutches, or two canes) that limit the functioning of both upper extremities.
A person unable to ambulate effectively will not be able to: 1) sustain a reasonable walking pace over a sufficient distance to be able to carry out the activities of daily living; 2) walk a block at a reasonable pace on rough or uneven surfaces; 3) use standard transportation; 4) carry out routine ambulatory activities such as shopping or banking; or 5) climb a few steps at a reasonable pace using a single hand rail. A person may be deemed unable to ambulate effectively even if able to walk independently about one’s own home without the use of assistive devices.
Physical findings must be based on objective observation during the examination and not simply the individual’s report (allegation). Because abnormal physical findings may be intermittent, their presence over a period of time must be established by a record of ongoing management and evaluation.
Lower extremity atrophy must be documented by circumferential measurements of both thighs and lower legs at stated points above and below the knees.
Patient with Condition Equal to a Listing is also Disabled
These and other specific musculoskeletal conditions in the Listings are only examples of common musculoskeletal disorders that are severe enough to prevent a person from engaging in gainful activity. If an individual has a medically determinable impairment which is not listed, an impairment that does not meet the requirements of a Listing, or a combination of impairments (no one of which meets a listing), Social Security will consider medical “equivalence.” That is, if the individual has a medically determinable impairment or combination of impairments equal to a “listed” impairment in severity and duration, the individual will be deemed disabled.
Effects of Obesity and Treatment
Obesity is a medically determinable impairment often associated with disturbance of the musculoskeletal system. The combined effects of obesity with musculoskeletal impairments can be greater than the effects of each considered separately. When evaluating whether an individual is disabled, Social Security will consider the combined effects of obesity and musculoskeletal disorder(s), as to any additional and cumulative effects of obesity on ability to function.
Social Security will also consider the effects of treatment in evaluating a condition’s impact on an individual’s ability to function. For example, side effects from pain medication may cause drowsiness, dizziness or disorientation. These and the adverse effects of surgery and other treatments on ability to function will be considered individually on a case-by-case basis.
While herniated discs (herniated nucleus pulposus) seem to be the most widely recognized, they are not the only disabling disorder of the spine. Your patient with chronic low back pain may qualify for Social Security disability if his or her functioning is impaired in any of the above described ways.
This article was prepared by Arthur W. Stevens III and Peter Yeager
* Medical information on pseudoclaudication: National Organization of Social Security Claimants’ Representatives, Social Security Practice Guide, Matthew Bender & Co., Inc.,3/2002, Vol. 4, pp. 29-79 & -80.