Reference: 38 CFR 4.71a

Back (Thoracolumbar Spine): Evidence & DBQ

What documentation clarifies the criteria

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.

DBQ

What the Back (Thoracolumbar Spine) DBQ records

The DBQ organizes examination findings. It does not guarantee a result. RatingScope's Back record comparison evaluates the General Rating Formula pathway; the separate IVDS incapacitating-episodes formula can be compared alongside it using the interactive tool on this page.

Diagnoses and medical history
Initial active range of motion in degrees
Pain and whether it causes functional loss
Observed repetitive-use testing
Repeated-use-over-time and flare-up findings
Localized tenderness, guarding, muscle spasm, gait, and spinal contour
Muscle strength, reflex, sensory, and radiculopathy findings
Ankylosis and other neurologic abnormalities
IVDS and incapacitating-episode history
Assistive devices, imaging, and functional impact

Preparation

What to have nearby

Latest Back DBQ or examination
Look for forward flexion, the other five motion values, repeated-use findings, flare-up context, gait, contour, and ankylosis.
Physical therapy or specialist notes
These may contain degree measurements, functional observations, neurologic findings, or treatment context.
Imaging and surgical history
These can clarify diagnosis and anatomy, while the listed examination findings remain central to the criteria comparison.
Your description of flare-ups and repeated use
Note what becomes harder, how often it occurs, and whether a clinician documented added limitation. Do not create a degree value yourself.

NextTerminologyPlain-English definitions of the terms used

Keep going

Compare a percentage level and combined-rating math, or review evidence context.

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