Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Thoracic Disc Disorder with Myelopathy


Related Terms

  • Thoracic Disc Displacement with Myelopathy
  • Thoracic Spinal Cord Compression

Differential Diagnosis

Specialists

  • Neurologist
  • Neurosurgeon
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist

Comorbid Conditions

Factors Influencing Duration

The severity and extent of the condition, underlying conditions, response to surgical treatment, and presence of surgical complications may influence length of disability.

Medical Codes

ICD-9-CM:
722.72 - Thoracic Disc Disorder with Myelopathy

Overview

© Reed Group
Thoracic disc disorder with myelopathy involves bulging or displacement of discs between the vertebrae of the thoracic spine (thoracic intervertebral disc herniation) with accompanying spinal cord compression. Myelopathy is an inclusive term referring to any disease of the spinal canal. The thoracic region specifies the middle portion of the spine. The following are examples of myelopathy: carcinomatous myelopathy (spinal cord degeneration associated with cancer); compressive myelopathy (spinal cord changes from the pressure of hematomas or masses); and radiation myelopathy (spinal cord destruction from radiation sources such as x-ray therapy). When the spinal cord destruction is caused as a complication of disease, the specific myelopathy signifies that origin; for example, diabetic myelopathy. Myelopathy describes the clinical findings associated with compression of the spinal cord that results in impairment of nerve function and may cause partial or complete paralysis of the lower extremities (paraplegia), with impairment of bowel and bladder function.

Thoracic disc herniations are uncommon as a cause of spinal cord compression causing myelopathy. Disc herniation in the thoracic spine accounts for less than 1% of all symptomatic disc herniations (Malanga). Most symptomatic thoracic disc herniations occur in the lower thoracic region, with 75% occurring in the lower four disc levels of the thoracic spine (T8-T12) (Vollmer). Approximately 80% of cases occur without a history of trauma and are due to degenerative changes, including disc calcification or ligament ossification (Malanga).

Incidence and Prevalence: The incidence of thoracic disc injuries is 1 in 1 million individuals annually, accounting for 0.25% to 0.75% of all herniated discs (Hannani).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Thoracic disc disorder with myelopathy occurs twice as frequently in males as in females. Eighty percent of thoracic disc herniations occur between the third and fifth decades of life (Vollmer). Individuals who participate in sports such as golf that involve twisting movements are at increased risk for thoracic disc disorders. In general, individuals who are obese and who smoke, or those who have a sedentary lifestyle (poor physical fitness) are at an increased risk for degenerative disc disease and disc injury in all parts of the spine.

Source: Medical Disability Advisor



Diagnosis

History: Pain in the thoracic region may be reported, indicating possible degenerative disc disease, fracture, tumor, or infection. When cord compression is present, the individual may report lack of sensation in the legs, restricted movement (which may be described by the individual as weakness) or spasticity of the lower extremities, and bowel or bladder dysfunction. (If the individual reports shooting pains down the legs, that implies nerve root impingement rather than cord compression.) If the condition has been progressive over a period of time, urinary urgency and incontinence are common, and symptoms are present in one-third of individuals (Malanga).

A history of prior spinal injury or disc disease may be reported by younger individuals, but in most cases a longer history of symptoms (more than 6 to 12 months) without trauma is reported.

Progressive disturbance in gait may be reported due to increasing weakness and poor sensation in the legs; these findings may be acute or slowly progressive and chronic. Symptoms usually affect one leg more than the other. Motor changes alone are reported in 6% of individuals (Malanga). Pins-and-needles sensations (paresthesias) in the legs are common, and sensory changes (usually numbness) alone are reported in 15% of individuals (Malanga).

Physical exam: The entire region of the thoracic spine may be palpated to identify muscle spasm. Hips, knees, and ankles may be examined and range of motion evaluated. A complete motor and sensory examination may be performed, including reflex testing. The exam may reveal sensory and motor disturbances in the legs. Reflexes in the legs may be overactive (hyperreflexia). Clonus, a reflex tremor that can be set in motion by reflex testing, and abnormal toe extension on stimulation of the bottom of the foot (Babinski reflex) may be present in myelopathy; these findings are consistent with spinal cord compression. Changes in abdominal reflexes and cremasteric reflex (checking for symmetry) can help diagnose myelopathy.

Tests: Plain x-rays may show calcification in a thoracic disc, but that disc may not be causing the symptoms. MRI, CT scan, and / or CT myelography are used to evaluate the anatomy of the thoracic spine and to identify cord compression related to degenerative changes, disc herniation, or other conditions (e.g., tumor).

Source: Medical Disability Advisor



Treatment

Cord compression with myelopathy requires immediate attention. This diagnosis is most often treated surgically if the neurologic deficit is severe or progressive. Several surgical approaches are available to decompress the spinal cord, including discectomy with or without fusion, using either the partial rib removal (costotransversectomy) approach or going through the chest (transthoracic approach). Video-assisted thoracic surgery (VATS) can be used to remove central thoracic disc herniations without thoracotomy or fusion.

Source: Medical Disability Advisor



Prognosis

Without surgery, individuals with symptomatic thoracic disc disease and mild neurologic deficit may improve with conservative treatment and time, but cord compression with myelopathy requires immediate attention to prevent permanent neurologic compromise. With surgery, 87% of individuals will have alleviation of pain, 95% will have improvement in hyperreflexia, and 76% will have improvement in urinary symptoms (Vollmer). However, clinical outcomes after thoracic disc surgery are not as good as after cervical or lumbar disc surgery, and approximately 11% of individuals undergoing surgical procedures for thoracic disc problems experience no relief of symptoms (Vollmer). There is also a higher rate of permanent neurologic complication with surgery on the thoracic disc, compared to cervical and lumbar discs. Surgery is reserved for cases with severe or progressive neurologic deficit.

Source: Medical Disability Advisor



Rehabilitation

Individuals with thoracic disc disorders with myelopathy in most cases will be managed surgically (Shiokawa). Rehabilitation will focus on a postoperative protocol, to be determined by the surgeon. Before rehabilitation can begin, a careful assessment of the degree of involvement of the central nervous system is necessary. This should include signs of upper motor neuron involvement such as tone irregularities, sensory and motor changes, as well as signs of bowel and bladder dysfunction.

The primary focus of rehabilitation is to restore function in activities of daily living and to teach individuals how to manage their symptoms.

While managing pain, therapists instruct individuals in gentle exercises to the trunk and other involved body parts. Due to the variability in individual response, the treating practitioner must pay careful attention to tolerance to treatment. General conditioning exercises of the trunk and limbs may be initiated when indicated and progressed as tolerated. Therapists should initiate postural training as soon as tolerated by the individual, and progress to strengthening, balance, and stabilization exercises of the trunk. If there is lower extremity involvement, gait training, stretching, and strengthening exercises are indicated. In addition to undergoing supervised rehabilitation, the individual should be instructed in a home exercise program to be practiced daily and continued independently after the completion of rehabilitation. Individuals should also be instructed in how to care for and protect the back through proper body mechanics.

An occupational therapist may play an important role in the training and / or adaptations of activities of daily living and work for individuals that present with residual neurological deficits. An ergonomic evaluation can provide information regarding the avoidance or modification of activities and positions at work that may aggravate the symptoms or to adapt the work place.

For further information about management of this condition and rehabilitation outcome, please refer to "Thoracic Disc Disease and Myelopathy" (Belanger).

FREQUENCY OF REHABILITATION VISITS
Surgical
SpecialistThoracic Disc Disorder with Myelopathy
Physical TherapistUp to 25 visits within 10 weeks
Note on Surgical Guidelines: Rehab usually begins after tissue healing, about 6 to 8 weeks after surgery.
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Possible complications of this condition include paralysis, infection, and bowel and bladder dysfunction (i.e., loss of sphincter control, fecal and urinary incontinence). Prolonged pain from the thoracotomy (surgical approach) is not uncommon. Surgical complications may occur, including infection, leakage of cerebrospinal fluid, and poor wound closure.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Prolonged standing, walking, or climbing may need to be restricted, if nerve damage to the legs persists. The accommodation may be temporary or permanent. Activities of lifting and carrying may have to be modified due to leg weakness.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Does individual report mid-back pain? Does it travel along a rib?
  • Does individual have any weakness, spasticity, or lack of sensation in a leg?
  • Does individual have any bowel or bladder abnormalities?
  • Does individual have any paresthesias?
  • Has individual had a fall landing on the buttocks or feet with a twisting of the spine?
  • Does individual have any degenerative changes in the area?
  • On exam, does individual have mid-back pain? Are reflexes overactive? Is Babinski's sign present? Are other reflexes abnormal?
  • Has individual had plain x-rays, CT with myelography, and / or MRI?
  • Have conditions with similar symptoms been ruled out?

Regarding treatment:

  • Has individual undergone a discectomy with or without fusion?
  • Is individual participating in postoperative rehabilitation?

Regarding prognosis:

  • Is individual active in rehabilitation?
  • Is individual's employer able to accommodate any necessary restrictions?
  • Does individual have any conditions that may affect ability to recover?
  • Has individual had any complications such as paralysis, incontinence, infection, bowel or bladder dysfunction, or disc calcification?

Source: Medical Disability Advisor



References

Cited

Belanger, T. A., and S. E. Emery. "Thoracic Disc Disease and Myelopathy." The Adult and Pediatric Spine. Eds. J. W. Frymoyer and S. W. Wiesel. 3rd ed. 2 vols. Philadelphia: Lippincott, Williams & Wilkins, 2004. 855-864.

Hannani, Kambiz. "Thoracic Disc Injuries." eMedicine. Eds. Craig C. Young, et al. 21 Dec. 2007. Medscape. 11 Feb. 2009 <emedicine.medscape.com/article/96168-overview>.

Malanga, Gerard A. "Thoracic Discogenic Pain Syndrome." eMedicine. Eds. Craig C. Young, et al. 8 Jan. 2009. Medscape. 11 Feb. 2009 <emedicine.medscape.com/article/96284-overview>.

Shiokawa, K., et al. "Clinical Analysis and Prognostic Study of Ossified Ligamentum Flavum of the Thoracic Spine." Journal Neurosurgery Spine 94 1 (2001): 221-226. National Center for Biotechnology Information. National Library of Medicine. 15 Dec. 2008 <PMID: 11302624>.

Vollmer, Dennis G. "Transthoracic Approaches to Thoracic Disc Herniations." Neurosurgical Focus 9 4 (2000): Medscape. WebMD, LLC. 27 Oct. 2004 <http://www.medscape.com/viewarticle/405649_1>.

Source: Medical Disability Advisor






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