Vertebral Fracture or Dislocation (Cervical) C&P Exam Prep

Cervical Forward Flexion (Active)

What it measures: How far forward you can bring your chin toward your chest. Normal is 0-45 degrees.

What to expect: You will be asked to slowly tuck your chin as far down as you can. The examiner will use a goniometer or inclinometer to record the degree of motion achieved. They will also note the degree at which pain begins, even if you can move beyond that point.

Pain considerations: The examiner must document the degree at which pain begins, not just the maximum range. If you experience pain onset at 10 degrees even though you can flex to 25 degrees, state clearly: 'I feel sharp/aching pain in my neck starting at about 10 degrees of flexion.' Under DeLuca v. Brown, pain that limits function must be documented even if it does not restrict end-range motion.

Cervical Extension (Active)

What it measures: How far back you can tilt your head. Normal is 0-45 degrees.

What to expect: You will be asked to slowly tilt your head backward as far as you can. The examiner records the degree achieved. Pain onset degree should also be reported.

Pain considerations: Extension may provoke foraminal compression symptoms in veterans with vertebral fracture residuals. Report any arm tingling, shooting pain, or weakness that occurs during extension testing.

Right and Left Lateral Flexion (Active)

What it measures: How far you can tilt your ear toward each shoulder. Normal is 0-45 degrees each side.

What to expect: You will be asked to tilt your head to the right and left without rotating or shrugging your shoulders. The examiner measures each side separately.

Pain considerations: If lateral flexion toward the injured side is markedly more restricted or painful than the uninjured side, this asymmetry is clinically significant and supports documentation of structural residuals of the fracture or dislocation.

Right and Left Lateral Rotation (Active)

What it measures: How far you can turn your head side to side. Normal is 0-80 degrees each side.

What to expect: You will be asked to turn your head as far right and as far left as possible. The examiner records degrees for each direction.

Pain considerations: Rotation that produces audible crepitus or a grinding sensation should be mentioned aloud during testing so the examiner can document it in the crepitus field of the DBQ.

Passive Range of Motion Testing (Correia Requirements)

What it measures: Range of motion when the examiner moves your neck rather than you moving it yourself. Differences between active and passive ROM are clinically significant.

What to expect: The examiner will gently move your neck through the same planes tested during active ROM while you relax. You should not assist or resist the motion. Any difference between active and passive ranges must be documented.

Pain considerations: If passive ROM provokes the same pain as active ROM, this suggests true structural restriction rather than voluntary guarding and should be communicated to the examiner.

Repetitive Use Testing (DeLuca Factors)

What it measures: Whether your range of motion or pain worsens after performing neck movements three consecutive times, simulating the effect of sustained or repetitive use.

What to expect: After initial ROM testing, the examiner may ask you to repeat the movements. Note any increase in pain, fatigue, or reduced range compared to your first attempt.

Pain considerations: DeLuca factors are legally required to be considered. If the examiner skips repetitive-use assessment, this is a potential basis for a later inadequate examination argument. Proactively describe end-of-day or post-activity worsening.

Neurological Examination - Deep Tendon Reflexes

What it measures: Reflex integrity of cervical nerve roots: biceps (C5-C6), brachioradialis (C6), triceps (C7). Absent or decreased reflexes indicate nerve root pathology.

What to expect: The examiner will tap your tendons at the elbow and forearm with a reflex hammer and compare left to right. Results are recorded as normal, decreased, or absent.

Pain considerations: Reflex testing is objective and does not depend on your report of pain, but be sure to mention any associated symptoms such as weakness or numbness that accompany the reflex abnormality.

Neurological Examination - Sensation

What it measures: Sensory function in the upper and lower extremities, testing for dermatomal patterns consistent with specific cervical nerve root levels.

What to expect: The examiner will use a pin or cotton to test light touch and pin-prick sensation across your arms, hands, and potentially your legs. Decreased or absent sensation in specific dermatomal patterns is documented.

Pain considerations: Sensory changes often accompany the pain associated with cervical fracture/dislocation residuals. Paresthesias (pins and needles) and dysesthesias (burning) in a dermatomal pattern should be described to the examiner in detail, including frequency, distribution, and any triggers.

Muscle Strength Testing

What it measures: Motor strength in upper extremity muscle groups innervated by cervical nerve roots: deltoid/biceps (C5-C6), wrist extensors (C6-C7), triceps/wrist flexors (C7), and intrinsic hand muscles (C8-T1). Graded 0-5/5.

What to expect: The examiner will ask you to push or pull against resistance in specific directions. Each muscle group is graded. Any weakness compared to the opposite side or below normal (5/5) is significant.

Pain considerations: Weakness due to pain inhibition (pain preventing you from generating full force) is distinct from true neurological weakness. Tell the examiner which type you are experiencing: 'My strength is reduced because the movement causes pain' versus 'My arm feels genuinely weak even without pain.'

Muscle Atrophy Measurement

What it measures: Bilateral arm circumference in centimeters to document muscle wasting from disuse or denervation secondary to the cervical condition.

What to expect: The examiner may measure both arms with a tape measure at a standardized location. A difference greater than 1-2 cm between sides is clinically significant.

Pain considerations: Disuse atrophy due to chronic pain avoidance patterns is a legitimate form of functional impairment under 38 CFR 4.40 and should be communicated to the examiner.

100%

Unfavorable ankylosis of the entire spine. Under the General Rating Formula, this represents complete loss of spinal motion with ankylosis in an unfavorable position.

From 38 CFR: 38 CFR 4.71a General Rating Formula for Diseases and Injuries of the Spine: 100% - Unfavorable ankylosis of the entire spine.

50%

Unfavorable ankylosis of the cervical spine. The cervical spine is fused or effectively immobile in a non-neutral or functionally compromised position.

From 38 CFR: 38 CFR 4.71a General Rating Formula: 50% - Unfavorable ankylosis of the cervical spine.

30%

Forward flexion of the cervical spine 15 degrees or less; OR favorable ankylosis of the cervical spine.

From 38 CFR: 38 CFR 4.71a General Rating Formula: 30% - Forward flexion of the cervical spine 15 degrees or less; or favorable ankylosis of the cervical spine.

20%

Forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; OR the combined range of motion of the cervical spine not greater than 170 degrees; OR muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis.

From 38 CFR: 38 CFR 4.71a General Rating Formula: 20% - Forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or the combined range of motion of the cervical spine not greater than 170 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis.

10%

Forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; OR the combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; OR muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; OR vertebral body fracture with loss of 50% or more of the height.

From 38 CFR: 38 CFR 4.71a General Rating Formula: 10% - Forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or the combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height.

Pain - Location, Character, and Frequency

How to describe it: Be specific about where your pain is located (base of skull, mid-cervical, lower cervical), what it feels like (sharp, stabbing, aching, burning, throbbing), what makes it better or worse, and how often you experience it. Distinguish between pain at rest, pain with motion, and pain that radiates.

Example: On my worst days, I wake up with a 7-8 out of 10 pain at the base of my skull and mid-neck that radiates down my right arm to my elbow. I cannot turn my head to the right without a sharp stabbing pain, and I have to turn my entire body to look sideways. The pain is constant and is only partially relieved by my medication.

Examiner listens for: The examiner is filling in DBQ fields for pain on motion, pain at rest, pain on weight-bearing, frequency of pain, and severity. They need to document whether pain is mild, moderate, or severe and whether it causes functional loss. They are also populating the DeLuca fields for functional loss beyond the measured ROM.

Avoid: Do not say 'it's not that bad' or 'I manage okay' if your pain significantly limits your daily function. Do not describe only your best days. The examiner is required to rate your typical and worst-day presentation.

Range of Motion and Stiffness

How to describe it: Describe the degree to which your neck movement is limited in each direction and how this affects specific tasks. Mention morning stiffness duration, end-of-day worsening, and specific activities you can no longer perform or must modify.

Example: On bad days, I can barely tuck my chin to my chest - maybe 10-15 degrees before severe pain stops me. I cannot look over my shoulder while driving. I sleep with a cervical pillow and still wake up stiff for 1-2 hours. By midafternoon, after sitting at a desk, I am almost unable to move my neck at all.

Examiner listens for: The examiner is documenting active ROM in all planes with degree measurements, pain onset degrees, and whether passive ROM exceeds active ROM. They are also noting whether ROM decreases after repetitive use - this is a DeLuca requirement that directly affects your rating.

Avoid: Do not perform your maximum range of motion on the exam day if that maximum is not representative of your average or worst-day function. If the examiner asks 'can you move your neck?' do not demonstrate only what is comfortable - demonstrate your true daily limitation and verbally describe your range on bad days.

Radiculopathy - Arm Pain, Numbness, and Weakness

How to describe it: Describe any symptoms that travel from your neck into your shoulders, arms, or hands. Include which arm(s) are affected, what the sensation feels like (electric shock, burning, numbness, tingling, heaviness), which fingers are affected, and whether it is constant or intermittent.

Example: Several times a week, I get a shooting electric pain from the base of my neck down my right arm into my index finger and thumb. My right hand goes numb when I hold the phone or drive for more than 10 minutes. I have dropped objects and cannot open jars with my right hand. The pain is a 6 out of 10 and wakes me from sleep.

Examiner listens for: The examiner is determining whether a radiculopathy diagnosis is warranted. They need dermatomal distribution of symptoms (C5-C6 - thumb/index finger; C7 - middle finger; C8-T1 - ring/little finger), correlation with reflex and strength findings, and the severity level (mild, moderate, severe) for separate rating under 38 CFR 4.71a. A separately rated radiculopathy can add 20-60% on top of the cervical spine rating.

Avoid: Do not dismiss arm symptoms as 'just occasional tingling.' Radiculopathy is separately ratable and can substantially increase your overall rating. If you have any radiating pain, numbness, or weakness in your arms or hands, describe it in detail even if the examiner does not specifically ask.

Flare-Ups - Frequency, Duration, and Triggers

How to describe it: Describe episodes where your cervical symptoms significantly worsen beyond your baseline. Include how often flare-ups occur, how long they last, what triggers them (activity, weather, stress, sleep position), and what you are unable to do during a flare-up.

Example: I have flare-ups about twice a month that last 3-5 days. During these episodes I cannot drive, work at my computer, or sleep through the night. I have had to call in sick to work multiple times and have spent entire days in bed with ice packs on my neck. The flare-ups are triggered by prolonged sitting, cold weather, or any sudden head movement.

Examiner listens for: The examiner must document your description of flare-ups in the DBQ flare-up narrative field. Flare-up frequency and duration directly affect the intervertebral disc syndrome incapacitating episode rating and the overall functional loss assessment. Under M21-1, your description of flare-ups, even if not occurring during the exam, must be recorded.

Avoid: Do not assume your flare-ups are too minor to mention because you are not currently in one during the exam. The VA rating system is designed to capture your worst-case function, not your best day. Flare-ups that temporarily increase your limitation to a higher rating level must be communicated and documented.

Fatigue, Weakness, and Lack of Endurance (DeLuca Factors)

How to describe it: Explain how your cervical condition causes fatigue of the neck and upper extremities with sustained activity, and how your functional capacity deteriorates over the course of a day or with repeated movements.

Example: By midday, holding my head upright is exhausting. My neck muscles fatigue after 30-45 minutes of computer work. I have to lie down for 30 minutes to relieve the fatigue and pain before I can resume activity. By evening, I have almost no ability to turn my head and my arms feel heavy and weak.

Examiner listens for: The DBQ has specific checkboxes for fatigability, weakness, lack of endurance, and incoordination as sources of functional loss. These are the DeLuca factors. The examiner must document each of these if present. These factors can support a higher rating even when the observed ROM measurement does not cross a threshold.

Avoid: Do not focus only on pain while neglecting to mention fatigue and endurance limitations. Many veterans receive lower ratings because they only describe pain on motion but fail to articulate the fatigue and weakness that develop with sustained activity or by end of day.

Functional Impact on Daily Life and Work

How to describe it: Describe the specific ways your cervical condition affects your ability to perform work tasks, household activities, personal care, driving, exercise, and social activities. Use concrete examples with time limits and frequency.

Example: I can no longer work at my previous job as a construction supervisor because I cannot look up to supervise overhead work or turn my head quickly to monitor equipment. I can only sit at a computer for 20 minutes before pain forces me to stop. I cannot wash dishes without neck pain. I cannot exercise. My wife assists me with tasks that require looking upward. I wake up 3-4 times per night from neck pain.

Examiner listens for: The examiner must document functional impact in the DBQ functional loss section. This includes interference with sitting, standing, locomotion disturbance, deformity, swelling, and other functional manifestations. The nexus between your cervical condition and occupational/daily living impairment is critical to the rating.

Avoid: Do not give vague answers like 'it limits me somewhat.' Give specific activities, time limits, and the consequences of exceeding those limits. Specific examples are far more valuable to a rater than general statements.

Segmental Instability and Structural Findings

How to describe it: If you have been told you have instability, abnormal motion, or structural deformity at your fracture site, describe any symptoms of instability such as a sensation of the neck giving way, clicking or grinding sounds, or the need to support your head with your hands.

Example: I can feel my neck shift or give way when I turn too quickly. I hear and feel a grinding/clicking in my neck with most movements. I have to use a cervical collar during flare-ups to stabilize my neck. My chiropractor and spine surgeon have told me my fracture site shows chronic instability on imaging.

Examiner listens for: The examiner has a specific DBQ checkbox for segmental instability (field 39). This finding may independently support a higher rating level or support a favorable ankylosis finding. Structural instability is directly relevant to DC 5235 and should be communicated with supporting imaging history.

Avoid: Do not assume the examiner has reviewed your imaging reports. Reference specific MRI, CT, or x-ray findings from your treatment records that document fracture residuals, subluxation, or instability. Say: 'My MRI from [date] at [facility] showed [finding] at [level].'